This chapter examines the changes in economic inequalities in the UK and internationally along with the links between poverty and inequality. We outline the way in which health and illness are distributed in the population and the psychosocial factors that operate to create and maintain health inequalities. Poverty and economic inequality are intrinsically and instrumentally related. Both are relevant to deprivation, violate human dignity, hinder social and health goals, and fluctuate in populations in a correlated manner. Health and illness are socially patterned in the same way as we saw for the experience of poverty, and are related to social class and status. Health and ill-health are determined not only by biological mechanisms, but also by a series of upstream factors which are material, psychological, social, and political – that is, by the ‘causes of the causes’. The examination of poverty, economic inequality and health inequalities reveal psychological, social, economic, and political factors that can help us to develop a firmer understanding of the social exclusion of people with mental health conditions as well as important aspects of public mental health.

This chapter examines the ways in which people with mental health conditions who also belong to other excluded groups may be particularly disadvantaged, in general and by mental health services. People with mental health conditions are at risk of social exclusion, but many from certain social identity groups are particularly at risk: for example, women, people from black and minority ethnic groups, and those from sexual minorities. In addition, certain groups of people are defined by their exclusion from society, such as refugees and asylum seekers, prisoners, and the homeless. The occurrence of mental health conditions in these groups is much higher than in the general population and they will often face barriers to accessing essential material resources and adequate healthcare. The presence of mental health conditions and group characteristics intersect to exacerbate the degree of exclusion experienced by the people in these groups. Some combinations may result in particularly profound states of deprivation and destitution. These severe and multiple forms of exclusion have been named ‘deep social exclusion’ or ‘people with multiple and complex needs’, two examples of which are seen in ‘multiple exclusion homelessness’ and people with multiple diagnoses.

This chapter provides an overview of the methodological challenges in researching social inclusion amongst people with mental health conditions and gives examples of interventions that have been shown to be effective in addressing social exclusion including pre-school parenting programmes, early intervention, peer support, recovery colleges, self-care, self-management, and self-directed care. As with all clinical practice, the starting point is the establishment of a therapeutic relationship that encompasses empathy, understanding, hope, and a willingness to help, along with a recovery orientation encompassing collaborative and strengths-based approaches. Much of this does not require a major reorganisation of services, but rather a refocusing and reprioritisation of existing tools and clinical skills, alongside commitment by mental health organisations to ensure their structures facilitate service-user involvement in the planning and delivery of services

This chapter pulls together the findings presented in Section 2 on the extent of social exclusion in people with mental health conditions and the possible causal links between social exclusion and mental ill-heath and health, to build a descriptive model linking these. The evidence supports the contention that people with mental health conditions are excluded from participation in many areas of society and that there are clear social inequalities in mental ill-health. Although this is the case across all forms of mental health conditions, some groups are more at risk of exclusion than others. To build a picture of the relationship between mental health conditions and social exclusion we need to take into consideration the nature of the mental health conditions, material disadvantages, stigma and discrimination, and the effects of the wider community and society. The dynamic nature of exclusion must be considered, including its effects across the life course and generations and the interaction of the factors affecting exclusion. There are the strong contextual effects of material factors, summarised by the association of poor health with income inequality, suggesting that above a certain level economic growth does not produce an increase in population health and may be damaging.

This chapter introduces Section 2 of the book and briefly examines the social inequalities that are risk factors for mental health conditions. Not only do we find that inequalities are associated with the prevalence of mental ill-health, the most disadvantaged also tend to have reduced access to mental health and social services, and, when they do access help, the quality of their experiences and outcomes are often poorer. The chapters in Section 2 examine the social exclusion of people with mental health conditions in five areas of reduced participation: exclusion from material resources, productive activity, social relations and neighbourhoods, civic participation, and health and health services.

This chapter covers the development of social policies and the modern Welfare State. Welfare states represent recognition that the key welfare needs of the country will be met by the state through the provision of income transfers and key public services. Their development has been closely associated with the expansion of citizenship and human rights. In the UK the Poor Law was a long-lasting historical core on which the nation’s welfare state was built, and was associated with the important infrastructure of local authorities, health systems, and education along with the provision of payments in times of need. A well-functioning welfare state is important for the wellbeing of the population and has valuable redistributive roles. They provide social investment in children’s early lives and guard against social risks such as unemployment and poverty. They have the potential to assist economic growth and to provide the infrastructure and support for human capital, such as through the creation of a ‘healthy workforce’. Generally, the more egalitarian states perform better on a range of well-being measures. They remain a central pillar of the maintenance and improvement of the quality of life of people with disabilities associated with mental health conditions.

The term ‘social exclusion’ appears to have originated in France in the 1970s and had a significant influence on European social policy before being taken up by the UK’s New Labour Government in the 1990s. This chapter outlines the concepts of social exclusion and some of the competing discourses associated with the term. Several notable definitions of the term are discussed before we settle on the CASE definition of ‘An individual is socially excluded if he or she does not participate in key activities of the society in which he or she lives’. The concepts of social exclusion may provide added value to discussing the more traditional concepts of poverty and deprivation. It is a relational concept and thus is of importance for developing a social psychiatric perspective. The relationship between Social Exclusion and Social Inclusion is complex and they are not necessarily polar opposites; rather, they may be viewed as a continuum, but a continuum of several dimensions which may differ over time and place. The chapter sets out a framework for examining the social exclusion of people with mental health conditions.

Groups who are socially excluded often lack a voice, something that holds for people with mental health conditions, especially if these are serious and enduring or if they are part of a socio-economically deprived group or a group that is marginalised because of their social identity. This chapter examines the involvement of people with mental health conditions in political and civic activities and the extent to which their human and civil rights are violated. Whilst there is a lack of studies examining the involvement of people with mental health conditions in these areas, there is nevertheless good reason to believe that they are excluded in this domain. Taking a global view of people with mental health conditions there are clear examples of violations of human and civil rights across the world’s continents. These violations take many forms and cover the following domains of exclusion: poverty, education, employment, personal, family and social relations, violence and persecution, health and access to essential services. Worldwide, people with mental and psychosocial disabilities face injustice and are not free from cruel, inhuman, degrading treatment, and punishment; they also lack the right to participate in the economic, cultural, and social life of their communities.

This chapter outlines concepts related to social exclusion that are relevant to people with mental health conditions. These concepts highlight the political and civil nature of exclusion (citizenship, equality and human rights, choice); the importance of material (poverty and deprivation), social (social capital, stigma, and discrimination) and individual factors (participation, choice, and agency); and a means of identifying and describing causal factors for social exclusion (agency and process, dynamic dimensions, multifactorial causes, life course, and longitudinal perspectives). It also covers personal recovery, which provides a bridge between the literature on social exclusion and that on mental health conditions.

This chapter examines the importance of family, social networks, social capital, and personal safety to people with mental health conditions and how these are often missing from their lives and replaced by social isolation and loneliness. For people with mental health conditions, social contacts and levels of support play a role in the genesis of their conditions as well as their recovery. People with mental ill-health often lack access to some forms of social capital but may benefit from the buffering effects of other forms. Social interaction may be curtailed by the subjective experiences of the mental health conditions, but also from the stigma and discrimination experienced by people with mental health conditions as personal experience of or fear of crime, aggression, and persecution. These are experiences that can set up a vicious cycle of loneliness and depression and exclusion for social contacts and important sources of support. These mental health and social conditions are unevenly distributed and exacerbated by the nature of the physical and social conditions of neighbourhoods. Whilst communities can be supportive, they may also present unacceptable risks to vulnerable groups in the form of crimes and victimisation.

Here we examine governmental policies that affect how people with mental health conditions are treated in society. The development of UK mental health services has been closely associated with the evolution of social policies, the increasing role of the state in the provisions for the population’s well-being, and the ‘Welfare State’. The provision of poor relief, dating from the Elizabethan Poor Law to its Victorian revision, has dominated the care of people with mental health conditions, both within and outside of institutions. Until the nineteenth century, the British state played a minimal role in the care of mental ill-health, and the 1800s witnessed a substantial growth in publicly funded asylums. These County Asylums were Poor Law institutions and remained so into the twentieth century. The UK’s modern mental health services arose from the Beveridge welfare state reforms but carried with them much of the baggage of the Victorian Poor Laws. The close relationship between the welfare state and mental health services illustrates the importance of social policy provision relating to income, employment, housing, education, health, and personal social services, to the broader provision of services for people with mental health conditions and the running of effective mental health services.