Building Bridges 2 – A Pathway to Cultural Safety, Relational Practice and Social Inclusion

Schedule B

Belonging: Social exclusion, social inclusion, personal safety and the experience of mental illness

By Barbara Everett, Ph. D. October 2009

This paper was prepared for the MDSC and the NMHAC for the Building Bridges 2 project by Barbara Everett, PhD. It includes a review of research literature on social exclusion, inclusion, personal safety and the experience of mental illness, as well as an overview of various government policies aimed at promoting the social inclusion of marginalized people. The Executive Summary of the resulting discussion paper – Belonging – appears below.

Belonging: Social exclusion, social inclusion, personal safety and the experience of mental illness

Everyone wants to belong but it is clear that many people are denied the opportunities that others have and relegated to the margins of society. People with mental illness call this stigma and discrimination. Others call it social exclusion. Whatever language is chosen, it harms.

Around the world, factors such as the globalization of labour, people fleeing war, disaffected second generation children of immigrants, a widening gap between the rich and poor and 24/7 media reports of riots, bombings and terrorism have awakened mainstream society to the threat that marginalization can pose. What we previously thought “could never happen here” is now understood as all too likely to happen here – and soon.

Social inclusion is the formal name given to a fairly recent set of government policies aimed at including marginalized people more meaningfully in society – not only for their sake – but for the sake of protecting social cohesion and lessening threats to economic progress. Examples of social inclusion policies from the European Union, the United Kingdom, Italy, New Zealand and the Australian Ministry of Social Inclusion indicate just how seriously governments are taking the marginalization of certain groups within their borders. These examples also serve to show that social inclusion policies have widened to include not only ethno-racial minorities and immigrants but also the poor and the disabled, including people with mental illness.

Social inclusion policies are not without their critics who most commonly fear that they fail to state strongly enough that they value diversity or at worst, that they are simply assimilation or colonization dressed up in new language.

If adopted as a new way of thinking, would policies of social inclusion benefit people with mental illness? Certainly, examples of social inclusion mental health policies – those from Scotland are a prime example – indicate that yes, they very well may.

The path to belonging (social inclusion) is rooted in recovery which begins with establishing personal physical, relational and emotional safety aided by finding safe places to belong such as peer support, the psychiatric survivor movement, or through mechanisms of cultural safety. From this platform of personal safety, people can venture out into the community to establish (or re-establish) meaningful social roles. However, mental health services are often criticized for being siloed and cut off from their own communities and thus, failing to promote their clients’ independence and integration into society. Policies of social inclusion, if carefully thought through, may provide openings for the second and necessary aspect of recovery – an opportunity for full participation and a chance to belong – in your community, your province or territory and your nation.

Social inclusion is a complicated set of ideas that requires careful consideration – from all angles. It is clear that in some parts of the world, mainstream society has heard the thunder of deep discontent. They are beginning to recognize the harm that marginalization does to people because the marginalized have struck back. Social inclusion policies, even those with teeth, can only do so much. Powerful historical and cultural forces divide the world while those that unit it are less visible and less commanding. The policies, as reviewed in the enclosed paper, do not speak strongly enough to the preservation of identity and the celebration of difference. Perhaps these ideas are implicit but comfort for many will come only from explicit statements and visible actions. Otherwise, social inclusion policies are open to igniting fears that they are really assimilation dressed up in new words. A possible way forward may be to establish the clear distinction between political integration (all groups have rights, protections and access to civic engagement) versus social integration (acceptance is the only passport to all that society has to offer). Is there something here for people with mental illness and their families? A cautious yes – if the goals of potential social inclusion policies are carefully thought through and clearly articulated.

“To feel at home is to feel that people understand not only what you say, but also what you mean.” Sir Isaiah Berlin 1

Belonging is perhaps best understood as feeling at home in your own skin and among family and friends. But it is also an idea that has wider social implications because to understand yourself as a “member of society” means that you feel that you belong in your community, your province or territory and your nation.

People with mental illness and their families are only one example of society’s excluded groups. Others include visible minorities, people with HIV/AIDS and other stigmatized health problems, some seniors groups, people in trouble with the law, lesbian, gay, bisexual or transgendered people, First Nations, Inuit and Métis, certain groups of youths, immigrants and refugees – the list cango on and on.

The purpose of using the term social exclusion is to counteract the tendency to blame marginalized groups for their own exclusion and concentrate only on interventions to “fix” them. While important, proper education, an emphasis on recovery for people with mental illness, rehabilitation for offenders, employment for visible minorities or settlement strategies for immigrants and refugees (as only a few examples) do not automatically lead to inclusion for marginalized groups.3 The point of the theories surrounding social exclusion is to highlight the role that mainstream society plays in the exclusionary process. People who are recovered, rehabilitated or now employed know only too well that, while personally these achievements have been gratifying, they do not – at all – constitute an unconditional invitation to join those who are included.

Let’s begin with a formal definition of social exclusion so that we know exactly what we are talking about:

“Social exclusion is a multidimensional process of progressive social rupture, detaching groups and individuals from social relations and institutions and preventing them from full participation in the normal, normatively prescribed activities of the society in which they live.” (pg. 15) 4

This definition is chosen because it actively emphasizes society’s role in exclusion by using words like “detaching” and “preventing.”

A well-defined (and deeply dispiriting) example of systemic social exclusion is contained in a recent study of Ontario’s youth called the Roots of youth violence. 5 The dimensions of exclusion as described by the youths themselves in their testimony include:

Poverty – without hope, with hunger and with isolation. Poverty also in stark and obvious contrast to the bounty that surrounds them and which seems to be enjoyed by everyone –except people from their group.

Racism – systemic targeting and excluding non-white youth. While all groups suffer, the report particularly identified black youth as the persistent and primary targets of racism.

Community design – isolated enclaves of poverty, dangerous and unhealthy housing, poor and unsafe transportation, no place to gather for community exchange and communities designed to foster (instead of impede) crime.6

An unwelcoming education system – studies that mean little to non-mainstream youth, guidance counsellors who discourage ambition, harsh policies and disciplinary actions that suspend, expel or even criminalize students, and teachers from the dominant classes who do not disguise their low expectations of non-white youth.

Criminalisation and harsh treatment in the justice system – needless aggression and harassment on the part of the police, harsh treatment while in custody, belittling and degrading lectures in open court, an almost knee-jerk tendency to charge without regard for the life–altering consequences (a charge can follow youth into adulthood and further narrow their opportunities even when they are found not guilty).

Health consequences – particularly mental health where problems go unaddressed and, even if identified, access to services is limited.

Family problems – (speaking to the inter-generational impact of exclusion) single parent families, absent fathers, teenage parents, violence and substance abuse, poverty, youth in foster care or homeless altogether.

Lack of mainstream economic opportunity – youth who cannot get jobs but all too easily can make money in socially unacceptable ways (dealing drugs, crime, running guns or prostitution).

Denial of voice – youth, in general, but in particular, non-white youth have no opportunity to shape their own communities or education – and when they find the courage to protest their poor treatment, are actively ignored and silenced.

The results of such all-encompassing exclusion are, indeed, youth violence, but also a double–digit income gap among racialized groups (30% living below the poverty line), three times the level of unemployment, poverty twice as likely and contact with the criminal system increasing 200% for black males (from 1986 to 1995) as opposed to 23% for white males.7

Further consequences relate to poorer health overall, including more injuries due to accidents because of unsafe working conditions, increased levels of stress and mental illness, no benefits due to low paying jobs and limited access to health care overall.8

A recent examination of health inequities in Toronto found that three times as many people with low income reported poor health, that the incidence rates of diabetes are twice as high in low income neighbourhoods and that, although poor people go to their doctors for arthritis more than people with higher incomes, the rate of hip replacements for them is less than half that of their higher income counterparts.9

Social exclusion also has a circularity in that the problems experienced by the marginalized (mental illness, addiction, poor health, contact with the law, unemployment, isolation and violence) lead to even further exclusion.10

Belonging to an excluded group can mean that members mirror their social experience and adopt methods for awarding some of their group with insider status while rejecting others. 11These internal splits are one of the reasons it is difficult for excluded groups to come together as a united front to fight the forces that have denied them opportunity and full membership in society.

Finally, members of excluded groups can come to believe, on a personal level, that they deserve the treatment they are receiving. They can hold the same prevailing beliefs as mainstream society and, much like the dynamics of self-stigma, 12 they can participate in their own exclusion by withdrawing (or attacking in defense) when discriminatory actions are anticipated, or by wearing an ever-present chip on their shoulder to guard against further hurt.13 Understandably, once having been the object of exclusion, it is very hard to recognize instances where, in fact, the forces of exclusion are not at work.

Despite the fact that there are internal forces within excluded groups (internal splits and self-stigma/exclusion) that make it hard for them to come together to protest their lot, mainstream society can be afraid of them. Recent world events have only deepened this fear. The fact that there are now far-flung pockets of displaced people with the internet as a communication tool no longer means that they all have to agree on resistance strategies in order to act. Instead they can operate in isolation from one another or even as individuals to disrupt the fabric of mainstream society.

As a result, the developed world now contemplates seriously the spectre of social breakdown. Compounding fears are the recent threats to prosperity as evidenced by the global financial disaster of 2008 but also the widely broadcast incidents of civil unrest, labour uprisings, riots, and terrorism.

In its narrowest definition, social inclusion is a set of fairly recent strategies (most often government sanctioned) to counteract the extreme marginalization of certain groups so that society, as a whole, can function in relative safety and with assurance of continued wealth accumulation.

This does not mean that strategies of social inclusion are without merit for excluded individuals and groups – or, perhaps, are evidence of a kinder, gentler evolution of society (it’s good for everybody) – but it is helpful when examining the various manifestations of social inclusion to keep in mind that there can be a variety of motives behind the policies that guide their deployment.1

Obviously, people and groups have been marginalized and excluded from mainstream society since the beginning of time. So, why, now have certain governments decided that it is wise to do something about it?

The rise of government sanctioned social inclusion policies is attributed most often to events in France in the 1970s 1 which involved workers imported from North Africa and their subsequent marginalization and ghettoization (an experience that occurred in other countries as well). See Appendix 1 for a brief summary of the French experience.

Other forces driving policies of social inclusion may well be related to a whole series of troubling developments:

Globalization of commerce and manufacturing – meaning the easier movement of capital and labour across national borders. In Canada and the US, the news is often full of reports about “moving jobs to the Third World.” But there is a corollary and that is labour, itself, is on the move with large numbers of legal and illegal economic migrants seeking work in developed countries. As in France, many countries experience enclaves of unskilled and underpaid workers who are commonly ethnic and visible minorities, often viewed with deep suspicion by local citizens, and, if sufficiently angered, likely to engage in civil unrest or rioting in response to exclusion and injustice.

War torn countries experiencing protracted violence – The destabilization of populations living in perpetual conflict has many results including loss of livelihood, deteriorating health, unstable economies and currency, and the breakdown of law and order.1 The common consequence is the out-migration of people seeking security and work. These groups are taken into developed countries under refugee status and combine with immigrant or migrant labour in ways that can ghettoize them, deny them the work they crave and the social inclusion necessary to start a new life. They also bring with them the after effects of severe trauma which can gravely affect their health.

The disaffected second generation – Enough time has passed that there are substantial numbers of second generation youth and young adults of immigrant parents – many of whom are doing well. Some, however, figure disproportionately among the under-educated and unemployed. Caught between not belonging to their parents’ country of origin and feeling that they don’t belong in the country where they were born, they are vulnerable to recruitment to gangs1 and even terrorist organizations.1 In addition, the recent global recession has disproportionately disadvantaged youth in the labour market, particularly visible minority youth.1

An increased gap between the rich and the poor in developed countries – In Canada, as in other countries, the rich are getting richer and the poor, poorer. According to 2005 census data, the richest fifth of Canadians increased their income by 16.5% in a 25-year period. Conversely, the poorest fifth saw their income fall by 20.6% in the same timeframe. Middle income earnings have been flat-lined and, as a group, they are shrinking. There are now more low income children in Canada than low income seniors. Fourteen and one half percent of children under five live in low income families (13% for children aged 6 – 14 and 11.4% for 15 – 17).1

Globalization of news and the deep penetration of all forms of media – We have become, indeed, a global village and incidents of rioting, bombing, looting and terrorism are broadcast in all their frightening detail worldwide. Citizens of the developed world who previously felt “this could never happen here” are very worried that it could, very well, happen here. And it has evidenced by the bombings in Madrid, in the London subways and in Bali, by shootings in Mumbai and, most saliently, 9/11

Another important measure of the rise to prominence of social inclusion as a government strategy is the growing concern that traditional measures of Gross Domestic Product (GDP) – a compilation of all goods and services produced by a nation in a one-year period – have become inadequate. The criticism is that there is a growing gap between GDP reports and how citizens actually experience their lives.

France’s Commission for the Management of Economic and Social Progress, at the request of President Nicolas Sarkozy, asked renowned economists Joseph Stiglitz, Amartya Sen and Jean–Paul Fitoussi to develop a report (delivered in September 209)1 that analyzes why traditional measures of GDP have become inadequate. These authors conclude that the fault with GDP is that it does not measure social well-being. They argue that it is as important to know what is going on with the lower income earners as it is to know what’s happening at the top. The measurements they suggest be added to GDP are those directly related to social inclusion; material well-being, health, education, personal activities including work, political voice and governance, social connection, environmental degradation and the economic or physical security of the population. They also suggest that these measures be taken overtime to produce an index of the sustainability of social cohesion and prosperity of a nation.1

Not only do nations feel under threat from increased marginalization of certain groups within their borders, they are beginning to believe that lack of social cohesion is a direct threat to economic progress – powerful factors that have been known to move governments to action with haste.

Broader definitions of social inclusion seek to expand its horizons so that it is not merely focused on the pressures of immigration and the mobility of the world’s labour force, or threats of civil unrest and terrorism.

Amartya Sen (the Nobel winning economist mentioned above) has, for many years, asked society to re-think its ways of defining disadvantage and, by inference, social inclusion. He argues that inclusion is not just about what people possess, but what they can do to shape their own lives.1

Thus, the various definitions of social inclusion that have emerged (regardless of country) are focusing on common themes such as reducing poverty, ensuring citizen engagement, providing access to health care and education, and acknowledging difference (ethno-racial groups, but also disability, including mental illness.1

For example, in Canada, the Laidlaw Foundation refocused its child and youth strategy using the lens of social inclusion in 2000. In doing so, it developed a definition:

“…social inclusion extends beyond bringing the ‘outsiders’ in, or notions of the periphery versus the centre. It is about closing physical, social and economic distances separating people, rather than only about eliminating boundaries or barriers between us and them.” 1

Its tenets include:

  • Valued recognition – acknowledging difference and common worth
  • Human development – nurturing talents and abilities
  • Involvement and engagement – in decisions that affect one’s self
  • Proximity – opportunities for interaction, sharing space, support for diverse neighbourhoods
  • Material wellbeing – food, money and housing

A second, earlier version of a Canadian definition is:

“Social cohesion is the ongoing process of developing a community of shared values, shared challenges and equal opportunity within Canada, based on a sense of trust, hope and reciprocity among all Canadians.” 1

These definitions signal the types of broad interpretations of social inclusion that underpin a number of formal government policies that have arisen. As another example, Australia defines social inclusion as:

“People have the resources (skills and assets, including good health), opportunities and capabilities they need to:

  • Learn – participate in education and training,
  • Work – participate in employment, unpaid or voluntary work including family and carer responsibilities,
  • Engage – connect with people, use local services and participate in local, cultural and recreational activities, and
  • Have a voice – influence decisions that affect them. 1

Many countries have formally adopted social inclusion policies, and sometimes legislation, which are intended to have a prominent influence in all that government does.

The following examples are not exhaustive but intended to provide evidence of the strength of commitment to social inclusion that is emerging in many jurisdictions and the efforts being deployed to measure first, the extent of the problem and second, the actual outcomes of the strategies to reduce disadvantage. A notable exception is that social inclusion has an extremely limited profile in the United States. Canada has a few pockets of activity but no federal policy.

European Union (EU)

The European Union Social Protection and Social Inclusion Process was established in 2000. The policy calls for the eradication of poverty and greater social cohesion by 2010. Strategies involve making labour markets more inclusive, ensuring decent housing for all, overcoming discrimination and increasing the integration of people with disabilities, ethnic minorities and immigrants, providing access to financial services and benefits for all (i.e. loans and mortgages) and tackling over-indebtedness. The main initiatives, in the near term, are child poverty, pensions for the elderly and access to long term care services and health equity for all.1

United Kingdom

In England, the government established the Prime Minister’s Strategy Unit responsible for an action plan on social inclusion. The plan, published in 2006, has five guiding principles:

Better identification of populations at risk and the development of early intervention strategies, Systematically identifying which social inclusion strategies work and which do not, Promoting government support and health agencies working together, Personalizing rights and responsibilities which means holding professionals and agencies accountable for positive outcomes based on “strong, persistent relationships” with those at risk, and supporting achievement in these agencies and managing under-performance.1

To accomplish these ends, the National Social Inclusion Program1 offers ten good practice messages for United Kingdom government agencies and services in relation to mental health:

Social inclusion is:

  1. about getting people back to work but also fostering wider social participation,
  2. not just about access to services but broad community participation and engagement,
  3. agencies working across traditional boundaries, among each other and with non–governmental organizations,
  4. creating partnerships among and beyond government agencies and services,
  5. for people with mild and serious mental health problems, and is also about mental illness prevention and mental health promotion,
  6. public sector agencies actively (not passively) promoting equality and opportunity and acting against discrimination,
  7. full involvement of people with mental health problems in a co-production approach,
  8. ensuring that people with a mental illness understand themselves as whole people – not just a diagnosis,
  9. the desegregation of mental health services and integration of concepts of mental health and illness into all services,
  10. workplaces and learning venues that support good mental health with an accommodating environment and enabling attitudes

Italy

Italy has a legal definition of “esclusione sociale” – poverty combined with social alienation. It also established the Commissione di indagine sull “esclusione sociale” as early as 1984.1 The role of the Commission is to report to government yearly on measures of poverty and disadvantage.

Australia

In 2008, the Australian government developed a Social Inclusion Board and appointed its Deputy Prime Minister as the Minister of Social Inclusion.1 It is focusing on at-risk children, jobless families, homelessness, Indigenous people, employment for people with disabilities (including mental illness) and at-risk and disadvantaged communities. Australia has also developed a toolkit for all its government agencies that holds them accountable, while at the same time, guiding the development of local social inclusion policies and service delivery. The implementation steps included:

  1. Identify groups at risk of exclusion,
  2. Analyze the nature and cause of disadvantage and exclusion,
  3. Strengthen protective factors and reduce risk factors,
  4. Work with other agencies to coordinate efforts across government and other sectors,
  5. Redesign delivery systems and promote changes in culture, and
  6. Establish a clear implementation plan and monitor delivery.1

Based on work in the EU, the Australia Social Inclusion Board has also developed a series of indicators it will use to performance measure and evaluate social inclusion activities in the country.1

New Zealand

The New Zealand government thinks of social inclusion in terms of fairness. Its policy statement is as follows:

“An inclusive New Zealand where all people enjoy opportunity to fulfill their potential, prosper and participate in the social, economic, political and cultural life of their communities and nation.” 1

The New Zealand government defines social inclusion as both the results it wants to see from its social policies and the means by which these results are achieved – through inclusion rather than exclusion and through the promotion of engagement and participation in all facets of society.1

New Zealand policymakers link the concept of social inclusion, as well as social capital, and social cohesion, to the development and maintenance of a strong national identity. They state that the key aspects of social inclusion are:

  • Belonging – common experiences, aspirations, values and norms but also relations which are safe, secure and trusting,
  • Inclusion – access to employment, services, institutions and social networks,
  • Participation – the ability to contribute locally and nationally and to affect decisions,
  • Recognition – acknowledgement and affirmation of difference while valuing the contributions diverse groups make to society, and
  • Legitimacy – the protection of civil liberty and rights for all and equal access to trusted social institutions.

New Zealand’s guide for implementing social inclusion policies in its government agencies is similar to Australia’s with the steps including: Define desired outcomes and indicators, analyze and define the problem, set objectives, identify, analyze and design options, present recommendations to decision-makers, plan for implementation and service delivery and finally, monitor and evaluate.1

While social inclusion seems like it would be good for everyone, there are possible negatives. For example, one author describes social inclusion policies as thinly disguised racism. Because immigrants and refugees are most often from racialized groups and because poverty and disadvantage are prevalent within racialized communities, these are policies that divide the world along racial lines.1 Perhaps their real utility is to have governments appear to be genuinely inclusive while the status quo is maintained.

A second critique speaks to whether or not marginalized groups want to be included in the mainstream. First Nations, Inuit and Métis, as only one example, have strong identities and a culture that they want to maintain. Are policies of social inclusion an echo of government sanctioned colonization and assimilation – hugely damaging strategies from the mainstream that led to reservations and residential schools.

A third criticism arises from the Jewish experience but could apply to any outsider group. Marmur (2002)1 argues that a conscious pariah is someone who maintains his or her dignity outside of the mainstream. Conscious pariahs accept their status as outsiders and refuse to imitate insiders and, instead, struggle for equality within their own identity. On the other hand, parvenus (an old-fashioned term for upstarts who are trying to ingratiate themselves with their betters) long for insider status but are never really admitted to the inner circle. They are patronized by the mainstream – possibly tolerated but usually looked down upon in subtle (and not so subtle) ways. “Morality means that it was worth remaining a poor Jew even when one ceased to be a poor Jew.” 1 This author makes the distinction between political integration (access to equal opportunities and human rights protection) and social integration (acceptance).

There is a fourth potential criticism, not well articulated in the literature but one which comes readily to mind given this review. While social inclusion may imply a welcoming of diversity, policies rarely state this value explicitly. To neglect an open statement of value for diverse identities leaves social inclusion policies open to the criticism that what they really mean is that the door to full participation in society requires you to morph from your marginalized identity into a mainstream one – to learn how to “pass,” as it used to be called. Practically speaking, passing meant, for white people anyway, disguising one’s original ethnicity by anglicizing your last name, by denying your religious roots or changing your diet to hot dogs and hamburgers. Certainly, many immigrants who came to the shores of Canada and the United States in past decades chose this path as a way to make life easier for their decedents. Today, our visible minority, multi-cultural immigration patterns do not present the choice of passing, whether or not it may be preferred, because people of different racial backgrounds simply cannot pass. Thus, social inclusion, if it is to be truly inclusive must offer real opportunities for people of diverse identities to participate in society and share equally in its opportunities and wealth.

With these ideas in mind, it can only be argued that the road to inclusion for people with mental illness has been long. In the 1980s, we began with the concept of empowerment – people being included fully in the treatment decisions made about them and having their opinions valued. In the 1990s we moved to participation– people with mental illness invited to become involved in Boards of Directors, task forces, and service planning and delivery. In the new millennium, recovery came to prominence – meaning that service providers, community members and others must recognize that people can live full and meaningful lives despite mental illness and that services must be delivered with recovery as a goal.

While the above definitions are brief and miss complicated nuances, they nonetheless imply some sort of progression for people with mental illness but no one can deny that stigma and discrimination remain common experiences. So what would adopting policies of social inclusion do for people with mental illness that empowerment, participation and recovery have not yet accomplished?

In answer to that question, it is useful to look at examples of where policies of social inclusion, specifically aimed at people with mental illness, have been enacted and applied. The following examples have been chosen because they are robust – involving legislation, policy, assignment of responsibility and monitoring – in other words, they have teeth.

Scotland

The Mental Health (Care and Treatment) (Scotland) Act 2003 defined a “statutory duty on local authorities to promote well-being and social development for those who have, or have had, a mental disorder.” 1 “Mental disorder” includes people with mental illness, learning disabilities and personality disorders. A toolkit of best practices has been developed that directs local authorities on the process by which they must change in order to comply with this statute.

Some salient aspects of the toolkit are:

  • Mental health assistance is for everyone – not just those with the most severe disorders.
  • All government services must become integrated and inclusive of people with mental illness – not just specialized mental health services.
  • The entire community must be involved in the support of people with mental illness by offering employment, housing and social networks.

In order to comply with the Act, local authorities and the services they fund are to get out into their communities and form relationships with employers, arts and sports groups, financial institutions, city councils, schools and charities. Through these relationships, they are to promote the full involvement of people with mental illness in their communities with a particular emphasis on employment.

A senior employee of each local authority is to be assigned responsibility for managing the necessary change and for achieving results. No new funding was to be allocated but compliance is expected nonetheless.

The local authorities must report publicly on their progress and could be subject to legal challenge if they are not in compliance. Monitoring tools and inspections are under consideration.

Groups of service users – people with a mental illness, learning disability or personality disorder – have been formed to provide an audit function. This means that they will visit a service, community centre or education centre (places where people with mental disorders usually go) to access how they are treated and report on the results. In some cases, they will provide advance notice of their visit. In others, they will simply show up and see what happens (a “mystery shopper” approach). As well as visiting, they will interview other service users on their experiences of the chosen location. It is suggested that they provide written reports on what they have discovered to the local authority which funds these services and which is likely very interested in whether or not they are in compliance with the well-being and social development statue of the Mental Health Act.

Ireland

The National Economic and Social Forum in Ireland commissioned a report on social inclusion and mental illness in 2007.1 The report called for a focus on work as the cornerstone to recovery. It also sought to broaden the responsibility for mental health to whole communities so that they are better able to provide social support and decrease stigma – along with opportunities for integrated social and health services and a particular emphasis on peer support and self-help.

Australia

In 2008, Australia conducted consultations1 on experiences of social exclusion for people with mental illness and other disabilities finding that interventions to increase social inclusion must involve human contact (social support) first and foremost along with work, help for disadvantaged communities, alterations in government funding formulas to eliminate short term, one time and inconsistent funding for supports and services and an emphasis on measuring actual outcomes (as opposed to units of service).

For people with mental illness and their families, policies of social inclusion have some aspects that are promising in the fight against stigma and discrimination. The policies feature work as a central goal. All too often, formal mental health services have neglected this aspect of a person’s recovery. They have mechanisms for transparency and accountability that call for measurement of actual effectiveness – as opposed to quantifying activity. They challenge communities to step up the plate with employment, support and housing and call for social and mental health services to, themselves, better integrate into their community. Finally, the policies speak to the whole person, not just to a diagnosis.

However, the critiques of social inclusion need to be kept in mind. Can policies like these really make a difference in changing individual beliefs and attitudes towards people with mental illness? Don’t people with mental illness want to be valued because of their experiences as opposed to in spite of them? And, finally, are social inclusion policies more about maintaining peace and prosperity for mainstream society than they are about sharing that peace and prosperity with all?

As a last note, is there just the faintest whiff of condescension to be detected? If governments are now going to entreat services, employers, educators and communities to treat you better, is the (perhaps unintended) message that you are to be pitied?

The themes that have arisen from this brief review of social inclusion policies are:

  1. A focus on poverty relief and at-risk groups
  2. Access to education, work and health care
  3. Civic engagement and participation in decision-making

An additional theme was raised in the New Zealand policy – but was not mentioned specifically among the various other policies sited in this paper. This is the idea of belonging defined as social relations which are safe, secure and trusting.

People who have been stigmatized and excluded have been harmed in fundamental ways. They need experiences of safety in order to be able to learn, work, engage and participate. In other words, social inclusion is a two-way street. Society must offer openings for excluded groups to become fully engaged citizens (rights), but members of excluded groups must find ways of healing so they can take advantage of these new openings in healthful ways (responsibilities).

If social inclusion is the societal version of safety and security, meaning that those who are included feel at home in their communities, provinces, territories and nation, then personal safety and security is its expression at the individual level.

The foundation for all human development is safety. Eric Erikson, a famous developmental psychologist, defined the beginning stages of child development as the creation of security for infants. In the toddler stage, parents become a safe refuge when children begin to explore the world.1 Without these solid experiences, children do not develop (or develop inconsistently) the feelings of trust that are so necessary for their entry into the wider social world. Further child development theories relate to attachment, meaning that a secure relationship with at least one adult is required in order for children to develop socially and emotionally.1

Many people with mental illness have had traumatic experiences in childhood and can, in adulthood, live in unsafe neighbourhoods and with unsafe relationships. Others have found that hospitalization and a diagnosis of mental illness are traumatizing life events in themselves. Add to these experiences the fact that they are objects of stigma and discrimination and it becomes plain that there is a lot to recover from in the healing journey.1 Creating personal safety and security is an essential first step in the process of recovery.1

People with mental illness can have a hard time believing that they deserve to be safe. The mental health system is itself unsafe with the spectre of involuntary treatment and hospitalization ever present for many. In fact, safety, as it is often talked about in mental health settings, can be code for one sided risk assessments1 with mechanisms like no cutting contracts or the harsher implicit or even explicit demand, “don’t go killing yourself on my watch” message. What is meant is all too clear – it’s not so much about your safety as the safety of the professional’s reputation, of the service and of society as a whole.

While many members of marginalized groups may not have had the safe beginnings that children require for optimum human development, creating places of safety in adulthood –while never easy – is possible.

Establishing personal safety and security

Physical safety – For an organizing framework it is useful to reference Maslow’s well-known hierarchy of needs which specifies that the basics of life (food, shelter and clothing) must be present in order to launch the journey of human development. Similarly, the recovery process requires first, that people are housed in safe and affordable settings, have a stable income and live in non-violent communities – physical safety in other words.

Relational safety – Second, people need to examine their relationships as they may find that they have become used to being surrounded by people that are, themselves, unsafe (violent, sexually or financial exploitative, judgmental or cruel). Finding the courage to extricate yourself from damaging relationships is extremely difficult. There is a strong fear of abandonment (will anyone want to be my friend/partner now?) and the challenge of developing new social skills, new ways of judging whether or not a potential relationship can be healthy, all the while, suppressing fears of rejection.

Emotional safety – Closely aligned with relational safety is the need to learn to manage your own emotions in the recovery process while protecting yourself against others who are emotionally damaging. Here too, there can be mixed messages from mental health settings if medication is the only tool offered to manage thoughts and feelings. While many people find medication helpful, it is not a substitute for learning the skills of calming yourself, acknowledging your sadness or managing anger.

Healing and recovery takes place among people. Finding mental health services, treatments and medication regimes that are helpful – and safe – can be a long search. However, formal services are only one aspect of recovery.

Peer support

Self help and other opportunities to be among people who have “been there” (peer support) are valued for many reasons but the main one is safety.

“Peers are not professional caregivers but fellow travellers who have suffered (mental illness) and struggled with recovery – just like you. In rare instances, peers can be paid by mental health organizations to visits clients and provide support or run peer programs. Most often, they are unpaid volunteers wanting to give back – or prevent others from experiencing some of the suffering they have gone through.” 1

With peers, you can feel at home because you “feel that people understand not only what you say, but also what you mean.” 1 You belong. In self-help groups you give and receive help, learn new skills and coping mechanisms, and test out new ways of thinking and behaving among people who are just like you and in safety.1

Psychiatric survivor movement

In the 1970s and 80s people who had bad experiences in the mental health system came together to protest their treatment. As in the initial stages of most protest movements, their positions were anti: anti-psychiatry, anti-hospitalization, anti-involuntary treatment, anti-medication and anti-electroconvulsive treatment (ECT). People who were drawn to the psychiatric survivor movement felt they were finally among others who understood them.

The movement was not without its internal struggles most often dividing along lines such as those who felt medication might be helpful versus those who thought that taking medication was akin to sleeping with the enemy. Other fault lines were naming your identity. Were you a survivor or were you a consumer? Those who identified as a survivors were capable of labelling consumers as the lapdogs of the powerful.1

Today, the movement remains alive and well although perhaps more subdued than in earlier times. Many founding members have moved from protest and advocacy to jobs within the mental health system that relate to arts programs, employment, peer support or formal system and government advisory councils – as the system itself has altered so that they feel more welcome and more able to express their criticisms.

The movement has had many victories, only one of which was its ability to provide a safe and secure outlet for expressing anger at the treatment its members have endured at the hands of psychiatric and mental health systems. While fissures arose, in the main, members viewed the movement as home – with the conflicted feelings that “home” holds for most people.

Cultural safety

First Nations, Inuit and Métis people have experienced harm due to experiences of colonization and the institutionalized discrimination that exists today. This harm affects them in many areas of their lives, not the least of which is physical and mental health. Western medicine perpetuates structural inequities that make the health encounter between practitioner and the First Nations, Inuit or Métis patient profoundly unsafe.1

Cultural safety was a method of health practice developed by Indigenous Maori nurses in New Zealand.1 In order for health and mental health practices to be safe, clinicians are asked to recognize the unequal relations that stem from a colonial past and which remain in the post–colonial present.

Cultural safety is distinct from cultural awareness, cultural sensitivity and cultural competence.

  • Cultural awareness – a beginning step in understand there is a difference among people.
  • Cultural sensitivity – the experience of all people includes aspects of similarity and difference to the clinician’s background. All difference is important and must be respected.
  • Cultural competence – the skills, knowledge and attitudes to safely and satisfactorily deliver health and mental health care.1

These definitions tend to ascribe “culture” to the patient but not to the practitioner. Cultural safety, on the other hand, asks clinicians to be aware of their privilege and membership in the dominant class – and that their membership carries with it a whole culture (often invisible to the mainstream) which can interact unfavourably, if the power imbalance is not addressed, with the culture of the First Nations, Inuit or Métis patient.

“Cultural safety is both a process and an outcome – it is a relational concept. It includes those actions which recognize, respect, and nurture the unique cultural identity of those we engage with to safely meet their needs, expectations and rights. Although it is important to recognize both the shared and unique beliefs, values and attitudes of people in our relationships, including ourselves, culturally safe practice also involves recognizing and addressing power dynamics between people and structural inequities such as stigma and discrimination that influence health care, health and well-being.” 1

Thus, cultural safety is a methodology whereby First Nations, Inuit and Métis people can experience their encounters with the health and mental health systems as occurring in safety –and in a safe place.

In its strongest iteration, cultural safety is equated and measured along with clinical safety, and safety is defined not by those who deliver the service but by those who receive it.1

The above are but a few examples of safe places. In fact, a safe place can be a completely individual choice. Some may find that a return to organized religion is a safe place while others would not. Some may choose the gay community as a safe place. Others define a safe place as a geographic location – such as moving to your own apartment or to the country. The choices are endlessly creative.

These examples serve to illustrate the critical role personal safety and security plays in healing and recovery, and in the eventual goal of taking up one’s place in society – be it as a member of the mainstream or as a “loud and proud” member of a group that isn’t – and doesn’t want to be – mainstream.

A crucial aspect in the recovery journey is access to life opportunities and finding a way to belong in your community. While formal mental health services may provide some of the help you need, too often they can form a sort of ghetto in themselves. Getting into services in the first place can be such an uphill battle that arrival in the “community” of supportive mental health services can be prized as a permanent home.

As the examples of social inclusion mental health policies from other jurisdictions show, mental health services have been criticized for their insularity – siloed as it is called in health planning circles. Canadian services are not immune from this criticism. There are many consequences of siloing such as community agencies that don’t know about other important services for their clients, the inability for clients to easily make their way through a complicated de-linked system and the oft– repeated complaint of having to tell your story over and over again to many service providers.

However, there is another consequence. Mental health services are failing to move clients towards membership in their wider communities. This is where policies of social inclusion specific to mental health may have their utility. As the example of – particularly – Scotland shows, agencies must actively reach out to their communities so that they have relationships with employers, landlords, recreation centres, religious groups, sports and arts venues – the very places where their clients must “graduate” to in order to belong as full citizens.

This is not to say that the only way to achieve positive membership in your community is with policies of social inclusion and the help of community mental health agencies. Many people find this path on their own. However, it emphasizes that a critical part of the journey of recovery is becoming part of your community – from two angles: First, through you establishing your own personal safety and security so that you can heal and recover and second, through wider society providing you with real opportunities to participate as a full citizen in your community, province or territory or nation (social inclusion).

Social inclusion is a complicated set of ideas that requires careful consideration – from all angles. It is clear that in some parts of the world, mainstream society has heard the thunder of deep discontent. They are beginning to recognize the harm that marginalization does to people because the marginalized have struck back. Social inclusion policies, even those with teeth, can only do so much. Powerful historical and cultural forces divide the world while those that unit it are less visible and less commanding. The policies, as reviewed in this paper, do not speak strongly enough to the preservation of identity and the celebration of difference. Perhaps these ideas are implicit but comfort for many will come only from explicit statements and visible actions. Otherwise, social inclusion policies are open to igniting fears that they are really assimilation dressed up in new words. A possible way forward may be to establish the clear distinction between political integration (all groups have rights, protections and access to civic engagement) versus social integration(acceptance is the only passport to all that society has to offer). Is there something here for people with mental illness and their families? A cautious yes – if the goals of potential social inclusion policies are carefully thought through and clearly articulated.

Appendices

The French Experience

France built a large number of public housing projects in the 1950s to overcome a shortage of affordable housing for its citizens. The projects were gladly occupied by people with low to middle income and functioned well. In the 1960s, foreign nationals (many from North Africa and other racialized groups) were hired in large numbers as unskilled labour for France’s burgeoning manufacturing sector. These foreign nationals were not allowed access to the projects and began to occupy poorer neighbourhoods that were seen to deteriorate into slums. In the 1970s, the policy regarding entrance to the projects changed to include foreign nationals and was accompanied by two things; the government ordered the bulldozing of the slums where the foreign nationals lived while it built a second wave of public housing where people could buy their homes with low interest mortgages. The traditional French occupants of the projects took up the offer of affordable new housing while at the same time, fleeing the projects as they felt that the decision to admit foreign nationals was ruining their peaceful existence.

Also in the 1970s, France experienced a significant downturn in its manufacturing sector and the foreign nationals were the first to be let go. The projects became occupied – almost exclusively – by foreign nationals of visible minority status who were unemployed, at loose ends and angry.1