Mental health policy and practice across Europe: an overview

36 Mental health policy and practice
basic rights, or where that recognition exists, lack of access to the political and
legal systems necessary to make those rights a reality. This approach can be
pursued along the theme of discrimination and lack of enforceable rights
(Burchardt et al. 2002). Although in some countries, for example the United
Kingdom, this is not a common approach to social exclusion, it has been
explored in some studies (Leslie 1997; Sayce 2000) and is the most appropriate
concept for pursuing the issue of social exclusion in relation to individuals
experiencing mental health problems. For that reason, this is the dominant
concept of social exclusion employed in this chapter. An issue that is only
briefly touched upon here but deserves highlighting is the idea of agency or
power; that is, who is doing the excluding. This has clear ramifications for
individuals with mental health problems who may find themselves unable to
make decisions about their life and their medical treatment, as well as being
vulnerable to more major abuses of basic human rights in many countries.
The next important question is: what is the relationship between social exclusion
and individuals with mental health problems? According to a report by the
United Kingdom government’s Social Exclusion Unit (2004), people with mental
health problems are at increased risk of becoming socially excluded, and
similarly, people who experience social exclusion are at increased risk of experiencing
a mental health problem. It is likely that causality works in both directions
and compounds the experience. Empirical evidence from the United
Kingdom shows an association between disadvantage, variously measured, and
higher frequencies of common mental disorders. Prevalence rates were shown
to be higher in social groups exhibiting less education, unemployment and
lower income and material assets (Fryers et al. 2003). A review of the international
evidence also supports the notion that material poverty is a risk factor
for a negative outcome among people with mental health problems (Saraceno
and Barbui 1997). Both the experience of (mental) health problems and of social
exclusion are mediated by a range of factors, which can function both inter- and
intra-generationally (Hobcraft 2002) and include: discrimination, unemployment,
poverty, stress, lack of access to services and reduced social networks.
Exclusion from citizenship
This chapter addresses both social exclusion and the discrimination – distinguishing
between human differences and treating some groups unfavourably
as a result – that amplifies, compounds and results in social exclusion. People
with psychiatric impairments are among the most excluded of all European
citizens (see Sayce 2000; European Foundation for the Improvement of Living
and Working Conditions 2003). Social exclusion is a particularly powerful
descriptor of the experience of mental health service users/survivors. It has been
defined in terms of:
the inter-locking and mutually compounding problems of impairment,
discrimination, diminished social role, lack of economic and social participation
and disability. Among the factors at play are lack of status, joblessness,
lack of opportunities to establish a family, small or non-existent social