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 Social Inclusion and Mental
Health
Second Edition

bli h d li b C b id i i
 I am delighted to welcome this new edition as essential reading for everyone working/
involved in health and social care, not just mental health services. The text expands our
understanding of the means of social exclusion, its poisonous legacy on children and
adults, and how we might change the single, main driver of mental health conditions –
poverty. The book goes beyond theoretical frameworks and the language of exclusion
(inequalities and disparities belong to different political tribes) – it brings exclusion into
the world of service users and health professionals. We learn that exclusion is not merely
economic, but race and disability (to name just two) compound multiple disadvantages. I
wish I had read a social science primer like this book at the start of my career, and can
only hope it will be taken up by the next generations.
Peter Byrne, Consultant Liaison Psychiatrist, Royal London Hospital; Co-director of
RCPsych Public Mental Health Implementation Centre
Without action, the poor may well ‘always be with us’. But as this book makes so clear,
poverty (whether defined in terms of lacking material resources, access to occupational
and leisure opportunities, civil participation, or even supportive social networks) is
partly a consequence of exclusion arising from political, economic, and social structures
but all too often through deliberate actions of individual self-interest, prejudice, and
discrimination.
This book provides a comprehensive and persuasive account of the forces at play and
more importantly what we, collectively, professionally and individually can do to tackle
the social and economic barriers that people with mental health conditions face in daily
life. This is an outstanding book that should be read by all mental health professionals as
a fundamental text for their profession.
Tom K J Craig, Professor Emeritus of Social Psychiatry, King’s College London
The second edition of this impressive volume is timely, as in the United Kingdom and
Europe we confront poverty, a conflict in Europe, and a major energy crisis, whereby
more people will not eat well and use drugs and alcohol and high fat and salt foods will go
up. We can anticipate greater levels of poor health and health crises. The central
messages of this manifesto cut through political instability and poor health literacy,
and give all policymakers and politicians an opportunity to improve the health of the
nation and reduce health inequalities. I especially enjoyed the nuanced exposition of how
as a society we fail to tackle social determinants of poor health at our peril. Poverty and
social adversity, especially child maltreatment, lead to premature mortality and poorer
life chances and quality of life, including the development of mental illnesses.
Furthermore, those with mental illness encounter prejudice, stigma, and discrimination,
all of which mean people with mental illnesses face precarity and structural violence that
deprives them of equal rights to benefit from societal opportunities and care systems. We
need systemic preventive and care interventions. This book is a clarion call to all. We
must do better to prevent mental illness, tackle social determinants, reduce stigma and
discrimination, and promote inclusive public care systems in which those with mental
illness realise their rights as citizens. Inclusive policy and practice are at the heart of
actions that might transform dystopian complacency in mental healthcare and public
mental health.
Kamaldeep Bhui, Professor of Psychiatry, University of Oxford

bli h d li b C b id i i
 Social Inclusion
and Mental Health
Second Edition
Jed Boardman
King’s College London

Helen Killaspy
University College London

Gill Mezey
St George’s Hospital Medical School, University of London

bli h d li b C b id i i
 University Printing House, Cambridge CB2 8BS, United Kingdom
One Liberty Plaza, 20th Floor, New York, NY 10006, USA
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Cambridge University Press is part of the University of Cambridge.

It furthers the University’s mission by disseminating knowledge in the pursuit of
education, learning, and research at the highest international levels of excellence.

www.cambridge.org
Information on this title: www.cambridge.org/9781911623595
DOI: 10.1017/9781911623601
© Royal College of Psychiatrists 2010, 2023
This publication is in copyright. Subject to statutory exception
and to the provisions of relevant collective licensing agreements,
no reproduction of any part may take place without the written
permission of Cambridge University Press.
First published 2010
Second edition 2023
A catalogue record for this publication is available from the British Library.
ISBN 978-1-911-62359-5 Paperback
Cambridge University Press has no responsibility for the persistence or accuracy of
URLs for external or third-party internet websites referred to in this publication
and does not guarantee that any content on such websites is, or will remain,
accurate or appropriate.

....................................................................................................
Every effort has been made in preparing this book to provide accurate and up-to-date information that
is in accord with accepted standards and practice at the time of publication. Although case histories are
drawn from actual cases, every effort has been made to disguise the identities of the individuals involved.
Nevertheless, the authors, editors, and publishers can make no warranties that the information
contained herein is totally free from error, not least because clinical standards are constantly changing
through research and regulation. The authors, editors, and publishers therefore disclaim all liability for
direct or consequential damages resulting from the use of material contained in this book. Readers are
strongly advised to pay careful attention to information provided by the manufacturer of any drugs or
equipment that they plan to use.

bli h d li b C b id i i
 Contents
Foreword to Second Edition vii
Foreword to First Edition (2010) ix
Preface xi
Acknowledgements xiii

1 Introduction: Poor, Excluded, and 10 Exclusion from Material

Unequal 1 Resources 194
11 Exclusion from Socially Valued
Activities 227
Section 1 Social Exclusion,
12 Exclusion from Social Relations and
Poverty, and Inequality Neighbourhoods 249
2 Social Exclusion: Basic Concepts 21
13 Exclusion from Health and Health
3 Social Exclusion: Applying the Services 274
Paradigm to People with Mental
14 Exclusion from Civic
Health Conditions – Key
Participation 290
Aspects 35
15 Social Exclusion in Specific Social
4 Poverty and Deprivation: Getting
Groups and Individuals with Mental
Under the Skin 57
Health Conditions 299
5 Poverty, Deprivation, and Social
16 Social Exclusion and People with
Exclusion in the United
Mental Health Conditions:
Kingdom 87
Developing a Clearer Picture 321
6 Poverty, Inequality, and
Health 116
Section 3 Including People
7 Social Policy, the Welfare State, and
17 Enabling Social Inclusion for People
Social Exclusion 141
with Mental Health Conditions: The
8 Mental Health Services and Policy in Role of Mental Health Services 347
the United Kingdom 161
18 Theory into Practice 359
19 Broadening an Inclusive
Section 2 Participation of Approach 374
People with Mental Health
Conditions
9 Mental Health Inequalities and
Index 387
Exclusion 187

bli h d li b C b id i i
bli h d li b C b id i i
 Foreword to Second Edition
I have long argued that the health of a society provides insight into how well that society is
functioning. This is true of physical health and life expectancy, and perhaps even more so of
mental health conditions, to use the terminology adopted here. Social inclusion is one
measure of the good society and is vital to health. The evidence on mental health shows how
that plays out.
There are at least three important ways in which society is important for mental health
conditions. The first is the social determinants of mental health. Social structures, poverty,
and inequality, acting through the life course, are important determinants of health.
Psychosocial pathways are important for both physical and mental health, but particularly
for mental health. One example is adverse childhood experiences (ACEs). Children who
experience four or more ACEs have increased risk of mental health conditions and,
probably, physical ill-health. But the frequency of ACEs is strongly linked with level of
deprivation: the greater the deprivation, the more common are most kinds of ACEs. We
therefore have a potential causal chain from the structure of society and magnitude of
inequalities in all the components that go to make up deprivation, to ACEs, to adverse
outcomes.
A second way the nature of society is crucial for mental illness is in the development of
mental health services. When people with mental illness were treated as destitute and
consigned to the workhouse, or locked away in asylums, it told us a great deal about
society’s view of mental illness. Such inhumanity may now seem extreme, but vestiges of
it are still in operation. Much lip service is devoted to parity in provision of services between
mental and physical health, but this is yet to be realised. At a more nuanced but no less
important level, there are marked differences in the conception of what mental illness is and
how it should be treated. It is not difficult to link these back to societal attitudes.
Third is the experience of people with mental health conditions. In general, the social
determinants of health operate more to the detriment of people with mental health condi-
tions and those with disabilities of various kinds. Housing, income, job prospects, and social
inclusion are all more problematic for people with mental health conditions.
The present volume gives a rich and detailed account of how all this works. It has a grand
historical sweep, pays detailed attention to each of the concepts with which it deals, and
provides a comprehensive review of the evidence. There is so much that is good here, not
just on mental health conditions but also on social inclusion, poverty, social capital, welfare
policy, capability theory, human rights, and all the features of social processes relevant to
mental health conditions. It does feel like the definitive book on the subject.

Michael Marmot, UCL Institute of Health Equity

vii

h d i 0 0 9 8 9 62360 00 bli h d li b C b id i i
h d i 0 0 9 8 9 62360 00 bli h d li b C b id i i
 Foreword to First Edition (2010)
Being part of society, contributing to it and, in return, being recognised and acknowledged,
is a core need of human beings. The impact of social factors, whether they be isolation,
unemployment, poor housing, financial hardship or debt, in the aetiology of mental and
physical ill-health and their role in its management cannot be underestimated. Whether an
individual is egocentric or socio-centric, social inclusion is of great significance in ensuring
that an individual feels part of the larger community. Mentally ill individuals often seek
employment, housing and social contacts as their key priorities and it is essential that
clinicians do not forget these goals. There is little doubt that social inclusion is often seen as
a political or moral concept, but it is much more than that: it is a quintessential basic need
that every individual has, to be accepted and to have the self-esteem and the self-confidence
which will allow the individual to deal with stress. Social inclusion for individuals has many
meanings, depending upon gender, age, sexual orientation, educational attainment or
socio-economic status, among other things. The challenge for clinicians and policy makers
is to make social inclusion work and not simply to rely on rhetoric. This book is doubly
welcome for highlighting an important topic and for guiding practitioners and policy
makers to encourage social inclusion. The book originates from a report which was devel-
oped by Jed Boardman, and for the book he has managed to attract many eminent
contributors. I hope that it will be of interest not only to clinicians but also to stakeholders,
including politicians and policy makers.

Dinesh Bhugra President, The Royal College of Psychiatrists

ix

h d i 0 0 9 8 9 62360 002 bli h d li b C b id i i

h d i 0 0 9 8 9 62360 002 bli h d li b C b id i i
 Preface
The first edition of this book, published in 2010, was based on an unpublished report written
by the Social Inclusion Scoping Group of the Royal College of Psychiatrists. The Scoping
Group was set up to examine the nature and extent of social exclusion seen in people with
mental health problems and those with learning disabilities and the implications for the
future organisation, structure and culture of mental health and learning disability services,
and for the practice and training of psychiatrists. The report was published in a shortened
form as a position statement which summarised the findings and views of the Scoping
Group (Royal College of Psychiatrists, 2009). The evidence amassed by the Scoping Group
and their deliberations were considered too good to waste and were adapted to produce the
first edition, aimed primarily at psychiatrists but also of relevance to other mental health
professionals and others working in mental health services. It was also hoped that it would
be of value to those who had an interest in mental health policy and anyone who cared about
the plight of those more vulnerable members of our society.
Included in the Scoping Group review was the full range of people with different
diagnoses represented by the specialties within the Royal College of Psychiatrists at the
time, including learning disability, drug and alcohol problems, children and adolescents,
older adults, and mentally disordered offenders. In addition, people who have co-morbid
diagnoses, such as psychotic or non-psychotic mental health conditions, alcohol and/or
drug dependence, learning disability, personality disorder, and adult neurodevelopmental
disorders (autism spectrum disorder, attention-deficit hyperactivity disorder), were
included. The review also covered the full range of age groups and social identities:
women; people from Black and minority ethnic groups; lesbian, gay, and bisexual people;
and faith groups. At the time, most of these groups were represented by the various
Faculties, Sections and Special Interest Groups of the College, and they parallel many
groups covered in the Equalities Review (2007). Furthermore, specific groups, including
prisoners, the homeless, refugees, and asylum seekers with mental health conditions, were
highlighted by the Scoping Group as they are, by the nature of their circumstances, excluded
by society.
The original Scoping Group report took a broad view of the socially inclusive perspective –
anti-discrimination laws, equality and human rights, social justice, and citizenship – in
addition to a clinical perspective. The belief was that it is only from this standpoint that the
importance of social inclusion for people with mental health problems and learning difficul-
ties, and the role that our social and political institutions have in creating exclusion, can be
truly appreciated. The unpublished report’s title, ‘From Exclusion to Inclusion: The
Transformation of Psychiatry in the 21st Century’, implied that change is needed if we are
to move from ‘exclusion’ to ‘inclusion’.
The aspiration for the Scoping Group was borrowed from the Equalities Review: that we
wish ‘to live in a society . . . which provides for each individual to realise his or her potential to
the fullest’ (Equalities Review, 2007, p. 1). The original Scoping Group confirmed what was
already well established: that people with mental health problems and learning difficulties are
socially excluded and discriminated against, and that this remains a blight on the status of
a considerable number of citizens in our society. This first edition of the book reported and

xi

h d i 0 0 9 8 9 62360 003 bli h d li b C b id i i

 xii Preface

expanded the findings of the Scoping Group, examining the ways in which this blight is
manifest and how mental health professionals and services might respond to the challenges
posed by the social exclusion of people with mental health problems and learning difficulties.
This revised edition contains some of the material from that first edition, but this has been
thoroughly updated and rewritten by the three authors. It contains many new chapters,
notably those in Section 1 of the book. Our purpose in updating this book has been to provide
a more coherent account of the position of those with mental ill-health in contemporary
society as well as the importance of the social and economic environment in creating and
maintaining the mental health and well-being of the population. Whilst our primary focus in
this new edition is on people with mental health conditions and working-age adults, we do not
exclude those with substance misuse, intellectual disability or developmental disorders, nor do
we exclude older adults or children and young people. Our focus is on the United Kingdom,
but we also extend our scope to place this in both an international and historical context.

References
Equalities Review (2007) Fairness and Freedom: Social Inclusion: Making Psychiatry and
The Final Report of the Equalities Review. The Mental Health Services Fit for the 21st
Equalities Review. www.equalrightstrust.org Century. Position Statement (PS01/2009).
/content/fairness-and-freedom-final-report- Royal College of Psychiatrists. www
equalities-review. .rcpsych.ac.uk/docs/default-source/mental-
Royal College of Psychiatrists’ Social Inclusion health/work-and-mental-health-library/pos
Scoping Group (2009) Mental Health and ition-statement-2009.pdf?sfvrsn=97bca29e_2.

h d i 0 0 9 8 9 62360 003 bli h d li b C b id i i

 Acknowledgements
Many people generously shared their time and knowledge to help us write the first edition of
this book. Their contribution has not been forgotten and our thanks still go to this group.
The original Scoping Group members all participated in the intense discussions that took
place in the group’s meetings, provided written material, made comments on drafts of the
original report and subsequent position statement and helped write the report. The Scoping
Group was chaired by Jed Boardman, and Sarah Davenport was Deputy Chair. The
members of the group were: Maurice Arbuthnott, Kam Bhui, Sophie Corlett, Angela
Greatley, Bob Grove, Naomi Hankinson, Rupert Lown, Alison Mohammed, David
Morris, Nick Niven-Jenkins, Michael Parsonage, Rachel Perkins, Chris Phillipson, Miles
Rinaldi, Liz Sayce, Tom Scharf, and Geoff Shepherd. Several others provided written
material and substantial advice, including: Roger Banks, Susan Benbow, Tania Burchardt,
Tom Carnwath, Tom Craig, Alan Currie, Ches Denman, Shaun Gravestock, Louise
Howard, George Ikkos, Paul Maklin, Kwame McKenzie, Robert Lindsay, and Jo Stubley.
Susan Brook, David Chang, Mike Osborne, and Rosemary Wilson also contributed chapters
which are not included in this edition. Without the initial kind help of these individuals
the second edition would not have been possible.

xiii

bli h d li b C b id i i
bli h d li b C b id i i
 Chapter
Introduction: Poor, Excluded,

1 and Unequal

Introduction
The terms ‘social inclusion’ and ‘social exclusion’ are relative newcomers to the social
policy lexicon. Whilst they have been used in European policy since the 1970s, it was not
until June 1997 when Tony Blair, then the prime minister of the United Kingdom, used the
term ‘social exclusion’ in a speech he gave at a South London housing estate that it became
employed in UK policy. Later that year the New Labour government’s Social Exclusion
Unit (SEU) was born. It was the introduction of this term into policy and the SEU’s report
on Social Exclusion and Mental Health (Office of the Deputy Prime Minister, 2004) that
prompted the creation of the Royal College of Psychiatrists’ Scoping Group on Social
Inclusion and, subsequently, the first edition of this book. Since the publication of the first
edition the term ‘social exclusion’ has disappeared from UK policy to be replaced by
a series of euphemisms, including the ‘big society’ and ‘levelling up’. Nevertheless, the term
still has currency and can shed an illuminating light on the position of people with
disabilities and a range of health conditions in contemporary society.
Underlying this book is the recognition that, in our society, people with mental health
conditions are marginalised and disadvantaged in multiple ways. Social inequalities can
precipitate and exacerbate mental health conditions, and the presence of mental ill-health
can act as a factor that precludes people from playing a part in society, not only because of
the resulting incapacities but also because of the many barriers, including prejudice and
discrimination, that stand in their way. Thus, the concepts related to social inclusion and
exclusion offer us a means of examining the many social factors that play a role in
hampering the participation of people with mental health conditions in society. Whilst
the idea of social exclusion may be seen as ‘old wine in new bottles’ by some, it is seen by
others as offering a means of broadening our understanding of material deprivation and
extending its focus to include not only the outcomes of but also the processes that lead to
deprivation (Bradshaw, 2004; Room, 1995). Social exclusion is fundamentally relational,
concerned with the connections between ourselves and others in the social world. In
Chapter 2 we will discuss this in detail and settle on a definition, the core of which is
participation in key activities of society. Exclusion can be seen in terms of ‘inadequate social
participation, lack of social integration and lack of power’ (Room, 1995, p. 5), all of which
can be readily related to people with mental health conditions. The relational nature of
social exclusion means that we can move beyond a purely descriptive approach to exclusion
and mental health to consider a range of themes, including hope, agency, opportunity,
recognition and respect, power and empowerment, intersectionality, social justice, human
rights, citizenship, and democracy.

h d i 0 0 9 8 9 62360 004 bli h d li b C b id i i

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