Social Exclusion and Mental Health: A Preamble

Article

Social Exclusion and Mental Health: A Preamble

Psychology and Developing Societies 27(2) 1–12 © 2015 Department of Psychology, University of Allahabad SAGE Publications sagepub.in/home.nav DOI: 10.1177/0971333615600008 http://pds.sagepub.com

Komilla Thapa1 Rashmi Kumar1 The notion of social exclusion has generated a significant literature in the past few decades and has become the focus of action at global, regional, national and local levels. It has most policy salience in Western Europe where it was developed (Popay, Escorel, Hernandez, Johnston, Mathieson & Rispel, 2008). There are important nuances in the nature of social exclusion discourses around the world. In developing societies, the dominant discourse continues to be focused on poverty, marginalisation, vulnerability and sustainable development. In Southeast Asia, the discourse retains a focus on multiple dimensions of poverty and on concepts of capability and resource enhancement that resonate with previous discourse and practice in the region (Dreze & Sen, 1991; Saith, 2001). Race and caste as well as religion, age and gender have dominated the discourse in India (Ziyauddin, 2009). This would require a rethinking and reworking of the multiple notions that constitute social exclusion and recognising that alternative discourses would have greater relevance for policy and action. Social exclusion has emerged as a prominent concept in discussions about social disadvantage. Social disadvantage has been traditionally set in terms of poverty, hardship and destitution. The social exclusion paradigm has been seen as an extension of this approach, as it extends the scope to the examination of multiple deprivations and helps in the identification of those whose non-participation arises through discrimination, chronic illness or cultural identification. 1

Department of Psychology, University of Allahabad, Allahabad, Uttar Pradesh, India.

Corresponding author: R. Raguram, Department of Psychiatry, Kempegowda Institute of Medical Sciences & Research, Bangalore, India. E-mail: [email protected]

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Psychology and Developing Societies 27(2)

There is still a lack of clarity about the definition of social exclusion and the term is simultaneously evocative, ambiguous and multidimensional (Silver, 1994). There have been numerous attempts to define social exclusion, each one having different emphasis and each one underpinned by different philosophical perspectives. These definitions vary according to the context and they come with their ‘theoretical and ideological baggage’ (Silver, 1994). Most commentators locate the origins of the modern conception of social exclusion in the work of Lenoir (1974). Lenoir used the term les exclus to refer to those who fell through the social insurance system and are thus administratively excluded by the state such as the disabled or unemployed. In the political field, social exclusion has been seen as an alternative means of speaking of poverty and deprivation (Berghman, 1995). Sen (2000) argued that the inability to interact freely with others is an important deprivation and has the implication that some types of social exclusion must be seen as constitutive components of the idea of poverty. Similarly, sociologists view social exclusion as a failure of the society to provide certain individuals and groups with those resources and benefits that are usually available to members, such as employment, housing and health care. Thorat and Sadhan (2009) have placed emphasis on the denial of fair and equal opportunities to certain social groups in multiple spheres in society and their consequent inability to participate in the basic political, economic and social functioning of the society. Continuing this discourse, Silver (2007) presented a definitive statement when she conceptualised social exclusion as a ‘dynamic process of progressive multidimensional rupturing of the “social bondî at the individual and collective levels’. This ‘precludes full participation in the normatively prescribed activities of a given society and denies access to information, resources, sociability, recognition and identity eroding selfrespect and reducing capabilities to achieve personal goals’ (p.1). It is evident that there are several complexities and contradictions inherent in the concept of social exclusion. Thus, Levitas (1998) argued that there are at least three ways of thinking about social exclusion. These include the redistributive discourse where emphasis is placed upon the way in which poverty limits social participation and the exercise of citizenship rights, the moral underclass discourse with emphasis on the moral and cultural causes of poverty and the social integrationist discourse with its emphasis on the social integration of people through paid employment. These discourses have obvious relevance for any discussion on social exclusion and inclusion.

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Three recurring features of social exclusion that emerge from this brief review of its definitions have been elucidated by Atkinson (1998). These include relativity (social exclusion and inclusion can be judged in the context of the situation as a whole; it refers to a particular place and time); agency (exclusion is seen as the outcome of the system with components of society intentionally or unintentionally acting as the excluding agents) and dynamics (exclusion is a dynamic process that operates across time and potentially across generations). In an attempt to further refine this discussion, it is clear that exclusion consists of dynamic, multidimensional processes driven by unequal power relationships interacting across the four major domains—economic, political, social and cultural—and at different levels, including individual, household, group, community and country. It results in a continuum of inclusion/exclusion, characterised by unequal access to resources, capabilities and rights, which can lead to negative physical and mental health consequences. In spite of this diversity, certain commonalities are evident and these can be stated using the following aphorisms: social exclusion is multidimensional, it is a dynamic process, it can be experienced at the individual as well as the group/collective level, it may be unique or specific to different cultures and societies and it is relational in nature. Various studies have suggested that there is a relationship between social exclusion and mental health problems, but this is complex, both in terms of how poor mental health is measured and how we might assess the direction of causality: does social exclusion cause poor mental health or does poor mental health lead to poverty and social exclusion (Payne, 2006). A conceptual and methodological review of social exclusion and its relation to mental health was conducted by Morgan, Burns, Fitzpatrick, Pinfold & Priebe (2007). Burchardt (2000) has argued that a lack of participation in mainstream social, cultural, economic and political activities is the primary element of most definitions and most share an emphasis on multiple dimensions of exclusion, on the dynamic nature of exclusion and the multilevel causes of exclusion. A number of questions remain. Despite general agreement that social exclusion is multidimensional, there is no consensus on which dimensions are relevant, which, if any, are the most important and whether multiple or cumulative disadvantage is necessary. It also remains unclear just what is to be excluded. Is it an objective state or a subjectively felt experience? A more critical approach is required to conceptualise social exclusion, particularly in terms of its relevance to understand the social experiences

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of people with mental health problems. Sayce (2001) argued that for mental illness, social exclusion has more explanatory power than poverty, as it focuses attention on the non-material advantages that result from the discriminatory behaviour of others and institutions. Sayce (2000) linked this with the social model of disability, arguing that many of the apparent social impairments experienced by those with mental health problems are a function of societal responses. Social exclusion clearly overlaps with other concepts such as deprivation. Silver & Miller (2003) have argued that social exclusion offers a broader, more holistic understanding of deprivation. This is particularly relevant to mental illness. The loss of roles, meaningful relationships and discrimination that both precede and accompany mental illness do not always stem from lack of material resources. Negative societal attitudes and responses towards individuals with a mental illness powerfully affect their social experiences and often underpin social rejection and isolation. The stigmatisation of mental illness is considered to be one of the important issues facing the mental health field (Crisp, 2000). Individuals with mental illness suffer from a wide range of negative impairments related to the disorder itself; these outcomes are exacerbated by societal stigmatisation of their illness. In fact, harsh stigmatisation of mental illness occurs across nations and cultures around the world, creating significant barriers to personal development and treatment (Tsang, Tam, Chan & Cheung, 2003). Stigma towards mental illness has been rampant throughout history, suggesting universal or even naturally selected ‘exclusion modules’ towards persons with mental disorders and the mental illness label itself (Kurzban & Leary, 2001; Link & Phelan, 2001). On the basis of the diverse strands of theorising and research on social exclusion and mental health, specific issues can be identified. These are as follows: 1. If social exclusion is multidimensional, is it possible for an individual/group to be socially excluded on one dimension and not on others? Since there are several types of socially excluded groups, categorised as such by different researchers, such as poor, mentally ill, physically disabled/challenged, homeless, aged, street children, unemployed youth, minorities—religious, linguistic, caste and sexual, the processes of social exclusion may be quite varied. While some groups such as the poor may be deprived on all dimensions, some others may be excluded on a single dimension or less intensely excluded.

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2. Are inclusion and exclusion two sides of the same coin? Are they bipolar concepts? While some thinkers are of the opinion that mitigating social exclusion of individual and groups will make them more included in society, others feel that the two processes are entirely different. Social exclusion has often been associated with the phenomenon of ‘othering’, that is, constructing the other group as different from own group and believing own group to be better than the ‘other’. Will reducing othering of the out-group ensure harmonious relations with the out-group and acceptance of the other? 3. Is it possible for the excluded group to be simultaneously included in some other group? Does social exclusion by the majority groups or society at large facilitate the process of increasing own group ties in case of excluded groups? Or do they become included in similarly excluded other groups? All these processes have repercussions for social cohesion and social harmony. 4. What is the relationship between social exclusion at an individual level and at a group level? Is it possible for the members of a socially excluded group to feel included at an individual level? What are the consequences in this case? 5. Is social exclusion a cause of mental illness or a consequence of mental illness? It is believed that the relationship between social exclusion and mental health is a complex one. While the process of social exclusion of individuals and groups may have different types of mental illness as consequences, it is also conceptualised that due to stigma associated with mental illness, such people often become targets of social exclusion. Are these phenomena the same or are they different? 6. Are the mental health consequences of social exclusion of different types of excluded groups the same or are they different? People with mental illness become visible in society by virtue of their symptoms and they are excluded due to prejudices associated with people with different types of mental illness. On the contrary, social exclusion of the poor or elderly is not associated with manifest or visible signs, symptoms or characteristics. The discourse on Social Exclusion and Mental Health would be incomplete without the mention of two significant concepts and initiatives: social capital and social inclusion. A brief discussion is, thus, merited. This would enable us to end this Introduction on a somewhat more promising and hopeful note.

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Social relationships and networks are a key requirement for a fully participative and inclusive life. Social relationships are an integral part of social capital, which itself is a complex and contested concept. At the heart of all conceptualisations of social capital is the idea that networks of social relationships are a valuable resource that people can draw on and, thus, constitute a form of capital. The connections among individuals and social networks and associated trust and reciprocity that form social capital are the ‘glue’ that holds societies together. De Silva, McKenzie, Harpham & Huttly (2005) have examined the association between social capital and mental illness. Their theory of social capital includes a behavioural/activity component and a cognitive/perceptual component, referred to as structural and cognitive social capital respectively. In a review of studies, they found an inverse relationship between cognitive social capital and common mental disorders with high levels of social capital associated with lower risk of mental illness. They also found a significant inverse association between structural social capital and common mental disorders. Policy interventions could include political inclusion, economic inclusion and inclusion in social services access (DESA, 2008). As Ghosh remarked, ‘unfriendly ghosts can live peaceably in the minds of individuals if they have a widely shared psychological universe’ (E.S.K. Ghosh, personal communication, 2015, Review of S. Sonpar’s Paper).

About the Special Issue The issues and concerns raised in the preceding section resonate in many of the articles included in this issue. These articles cover issues ranging from conceptual and definitional issues, the processes underlying social exclusion, to empirical studies on social exclusion in different groups based on diverse criteria of exclusion. Six of the seven articles in the special issue focus on the Indian context, with the exception of the article by Castaneda and colleagues that deals with immigrant groups in Finland. Most of the articles have grappled with conceptual issues seeking to establish definitional boundaries and to delineate the dimensions of social exclusion. Krishnan’s article deals with issues related to disadvantage, social exclusion and felt injustice of different groups, primarily in India, such as of mentally ill or of low caste or of Dalits (Krishnan, this issue), while Pal’s article focuses on the mental health problems of low caste/ Dalits as a consequence of the discrimination and pervasive violence

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against them (Pal, this issue). Mishra raises issues related to acculturation and marginalisation experiences of adivasi (tribal) communities and the mental health consequences that follow them (Mishra, this issue). Vahali deals with the inferior quality of treatment given to the extremely poor, marginalised and homeless people (Vahali, this issue) and another article focuses on the psychological and social well-being of immigrant groups in Finland (Castenada et al. this issue). Sonpar focuses on the dynamics responsible for dehumanization and annihilation of minority groups (Sonpar, this issue) and Raguram on the experiences of social exclusion, discrimination and stigma of the mentally ill (Raguram, this issue). Focusing on the less explored aspects of social exclusion, Lilavati Krishnan attempts to explicate the complex relationship between social exclusion, disadvantage, deprivation and injustice. She focuses on the bilateral relationship between mental health/ill-health and social exclusion processes using concepts such as stigmatisation and ‘othering’. In India, she asserts, the social exclusion discourse frequently centres on exclusion based on caste, class or religion. Extending the domain of social exclusion, Krishnan adds another group: people with mental health problems and disabilities. The social exclusion of this group is experientially different, as it occurs in the form of stigma, so that this group is shunned and actively ostracised. Stigma, she asserts, is a social process that is connected to dominance and exclusion, and competition for power at the macro level. Shobna Sonpar, in her article Including, Excluding … Annihilating, attempts to explicate the malignant process that leads to a breakdown of intergroup relations, resulting in hate and violence. Citing different models and theories relating to the self and the other, group differentiation and identity, she provides instances of the inclusion–exclusion dynamic in the social and mental health field. She maintains that the concept of othering can be used to differentiate self from the other and is essentially a protective or defensive strategy. In the realm of the moral community, the inclusion–exclusion interplay is again evident so that moral exclusion may become institutionalised. Moral exclusion is characterised by lack of concern, responsibility or duty towards those outside the ‘moral community’. This moral exclusion of people with mental illness as well as some ethnic groups becomes the basis for their dehumanisation and they become targets of violence. Here, race, caste, class, religion, gender and ethnicity maybe the markers. The fault lines that have the potential of disturbing this balance include change, threat of change to the pattern of resource distribution, perceived threat to the group’s existence and

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identity, hurt to collective esteem, inter-group power and status hierarchies. Citing her own work on former militants in Jammu and Kashmir, she explains how a threat to in-group existence, identity and self-esteem can damage the individual and the social fabric. Humiliation and victimisation can lead to an accentuation of one’s own identity, a need to undo experiences of torture and impotence by using violence and an increased polarisation of Us and Them. This can lead to the stereotyped and polarised thinking characteristic of othering and a loss of empathy and altruism. This is accompanied by an assertion of in-group virtue, a need to maintain the purity of the in-group so that annihilating the out-group becomes a moral imperative. The article by G. C. Pal focuses on caste-based social exclusion. The working definition espoused by Pal includes physical, spatial and social segregation and denial of equal rights and opportunities mediated through social interactions. He attempts to identify the social psychological processes underlying social exclusion. These include social categorisation (in-group versus out-group), group identity processes (strengthening of own group identity and downward comparison of other groups) and specific processes of everyday social interaction that reinforce the social hierarchy. Upward mobility, positive identity and assertion by lower caste groups may invite collective retaliation. In the face of caste-based discriminatory and exclusionary practices, discouragement from full participation and devaluation of dignity and self-respect, low-caste groups can face adverse psychological, social and moral consequences, the effects of which may be pervasive and, thus, would impact negatively on their mental health status. In particular, in schools, exclusion of low-caste students is perpetuated by the indifferent and caste-based attitudes of teachers as well as visible discrimination in the delivery of nutritional and other services. This leads to low self-esteem and passivity and has been linked to the unfortunate rise in the incidence of suicide in lower caste students in institutes of higher learning. Social inclusion may be achieved through trust-building measures such as inter-community communication. R.C. Mishra chose to focus on yet another socially excluded group in Indian society His article is based on a series of studies on adivasi (tribal) communities of UP, Bihar and Jharkhand regions of India that have generally remained excluded from the mainstream of society. Traditionally, these communities had confined themselves to remote areas of hills and forests, living on hunting and agriculture. They are not part of the vertical social structure prevalent in India. The life of these communities is now changing, owing to government initiatives and by coming into contact with other groups of society. The studies have focused on different

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Adivasi groups such as the Birhor, Asur, Oraon, Agaria and Kharwar. Using Berry’s acculturation model, he points out that ‘co-existence’ is an important acculturation strategy employed by these groups, together with integration. Marginalisation that resulted from conditions of cultural disconnection led to greater mental health and physical problems. These problems are attributed to physical and economic constraints, and social inclusion and integration may be ameliorative. Honey Oberoi Vahali takes a refreshingly different and provocative approach, wherein she presents a case of how social exclusion has been practiced and perpetuated by mental health practitioners who tend to negate the distress and experiential realities of the traditional outsiders, those who live on the margins of society. She highlights the lesser known aspects of Psychoanalysis that were inspired by socialist-democratic values and predicated on the ethics of social responsibility. Over the years, however, Psychoanalysis has become more elitist and exclusive and has insulated itself from the everyday struggles of the marginalised groups such as the mentally ill, the poor and the homeless. While empirical research has established a close relationship between poverty and mental illness and the intergenerational transmission of trauma, mental health professionals continue to diagnose such patients as having a severe illness that requires medication and give them direct advice that is unrelated to their life situation. Thus, social class determines the quality of treatment. Upper class patients are accorded dignity, respect and time, while lower caste and poor patients are treated with indifference, apathy and impatience. Moreover, the poor person has been historically and culturally denied the right to his/her own emotional state, and thus lacks the vocabulary to express his/her emotional content. The somatic expression and cultural representations of distress are seen as being alien and are often disregarded. Mental health professionals themselves need to distance and dissociate themselves from social injustice by drawing boundaries between ‘us and them’. In working with the poor, she advocates an authentic contact, a non-reactive stance, an attitude of care as well as an opening of the self and most importantly, self-work. In an empirical study, Castaneda and others investigated the association between experienced discrimination and psychological and social well-being in Russian, Somali and Kurdish immigrants in Finland. In general, previous studies have shown that migrant groups have more mental health problems and lowered psychological and social well-being, as they face discrimination and violence. This study also focuses on the trust towards various institutions, which is a key element of social capital and societal well-being. Using data from the Finnish Migrant Health and

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Wee-being Study, the authors found that experienced discrimination was associated with feelings of unsafety and low trust towards different institutions in society in all three groups. In Russian and Kurdish immigrants, discrimination was linked with mental health symptoms and poor quality of life. They highlighted the point that the relationship between discrimination and mental health may be different for different groups, depending upon their local circumstances and broader cultural context. The article by R. Raguram, entitled ‘The ache of exile: Travails of Stigma and social exclusion among the mentally ill in India’, explores the consequences of social exclusion of people with mental illness. The author highlights how the mentally ill have been traditionally excluded from the mainstream and their alienation has been further compounded by the stigmatising attitudes. Although the author refers to the high prevalence of mental health problems in India with the increasing rate of depression, anxiety and suicide, the stigmatisation of people with mental illness and illness itself has been less studied. Raguram reports the findings of some of his studies where people with depression and schizophrenia had experienced stigma. The most common consequences of stigma were related to marriage and interpersonal interactions. He asserts that while depression is often expressed in the form of somatic symptoms, such symptoms are culturally and socially sanctioned, and thus less stigmatising than the depressive affect. Raguram also raises the issue of the complex and circular relationship between mental illness, stigma, social exclusion and poverty. Individuals with mental illness are systematically excluded from participation in the occupational and social life of their community and face stigma, isolation and denial of basic rights. This is seen as a form of structural violence in which the dynamics of disparity are structured by unequal social and economic processes. It is clear that the concept of social exclusion provides a unique framework for understanding the social determinants of mental health and for developing more appropriate and effective action to address them. Diversity in the meanings attached to the concept should not be allowed to mask the commonality of exclusionary processes around the world and their fundamental expression in terms of inequalities in human dignity, human rights and human health. Acknowledgement The Editors of this Special Issue would like to express their gratitude to Professor R. C. Tripathi for his mentoring and able guidance from the inception of the National Seminar on Social Exclusion and Mental Health (21–22 September 2015) to the production of this issue.

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