This chapter begins with a review of the evidence for the social and structural determinants of mental health, with particular attention to the ways in which mental illness diagnoses have resulted in discriminatory practices and beliefs about people experiencing mental distress. The concept of intersectionality is then introduced as a way of understanding the complex interconnections between different forms of power and social positioning. Although the development of intersectional policy and practice is in its early stages, it is a promising paradigm for occupational therapy practice and in line with the aims and goals of occupational justice. Next, there is a review of recent mental health reforms, which indicates the complex environment in which occupational therapists practice. We concentrate on the historical move away from institutional care to community care and the adoption of recovery and wellbeing models. Neoliberal government agendas are analysed for how they reinforce individual models of wellness and self-sufficiency, which more easily play into the predominant biomedical paradigm in mental health.

We suggest that the adoption of an intersectional framework in occupational therapy can assist practitioners in better understanding and responding to the lives of the people with whom they work. The next section explores activism and how people with lived experience/service users critique psychiatry, through their involvement in the development of mental healthcare policy and in directing care towards their own needs and concerns. We show how intersectional frameworks can be used in the practice of reflexivity, to foster the awareness of occupational therapists working with a diverse clientele and to better respond to the power relations inherent in their work. Finally, an example is given, of a structural-level intervention that is being developed in Canada to address some of the larger issues faced by people with mental health issues with respect to employment – the social enterprise model. In this chapter, we use the term inequity to refer to ‘differences that are unfair or unjust as a result of structural arrangements that are potentially remedial’ (Pauly 2008, p. 5).

Occupational Therapy and Mental Health Practice

Questions about power and justice are often viewed skeptically as being too political. Yet not addressing power and justice is also political; [occupational therapy] can either remain silently compliant with client/consumer injustices and our professional lack of empowerment, or we can take a visible, active stance to advocate for change.

(Townsend 2003, p. 85)

Occupational therapists face constantly shifting social and economic contexts and increasingly complex and diverse practice situations. Recognizing this, it is essential that all practitioners realize the importance of, and work to acquire, the knowledge and competencies to engage with these practice realities, while upholding the profession’s core values and principles inclusive of equity, social inclusion, cultural awareness and human rights. This requires, rather demands, that occupational therapists’ competencies include engaging in, critically analysing, and contributing to the ‘larger political debates’ and dialogues (Richards 2008, p. 26) that shape the profession. Engaging with practice realities, while upholding values, can influence the resources and opportunities available to people striving to attain meaningful experiences in all life activities (Whalley Hammell 2009). The larger political and policy landscape is concerned with social inclusion, workforce modernization, extended roles and new ways of working, which require a greater breadth of knowledge beyond traditional psychiatry.

Political Contexts

Occupational therapy can be understood as a profession embedded in larger political, social and cultural contexts. These contexts include complex and often contradictory political environments. For example, there is increased reliance and focus on recovery and on community mental healthcare. Yet, there is limited commitment of governments to provide the resources necessary to maintain these supports. There is a legal environment internationally that upholds the rights of people with disabilities, whereas at the national level, mental health legislation often undermines these rights. Paradoxically, while research and practical experience show that the social environment is critical to mental wellbeing, responses continue to be biomedically focused. Indeed, the continued historical reliance on the biomedical model of psychiatry has restricted development of a mental health system that responds adequately to the stresses caused by the social determinants of mental health (McGibbon 2012). Occupational therapy itself is embedded in a set of complex relationships to a range of professions dominated by a biomedical paradigm, which influences the frameworks occupational therapists use in their practice. This paradigm also marginalizes occupational therapy as a profession, because of the increasing professional focus on social justice and the social causes of mental distress (Townsend 2003).

These contexts raise important and compelling questions for occupational therapists who are working towards addressing ‘unjust inequities that limit opportunities for participation in society’ (Braveman and Suarez-Balcazar 2009, p. 7):

■ How do the frameworks used by occupational therapists impact on existing social and structural inequities associated with mental health and the attainment of meaningful occupation?

■ What is the role of occupational therapists with respect to larger political debates about reforms in mental health?

■ What does it mean to be a reflexive practitioner and advocate for occupational justice?

While there is a long and rich tradition of occupational justice in occupational therapy, which has oriented practitioners towards a social justice framework and has meant that professional organizations have engaged in larger political debates (Townsend and Wilcock 2004; Kronenberg et al. 2005; Bass-Haugen 2009; Braveman and Suarez-Balcazar 2009; Wilcock and Townsend 2009), less attention has been paid to the day-to-day reality of occupational therapy, to ensure that practitioners are skilled and knowledgeable and supported in responding to the complexities of practice. For example, many people present with multiple health problems within their families, which can be complicated by who they are, where they live and who they live with. These complexities can be understood by considering the social and structural determinants of mental health.

THE SOCIAL AND STRUCTURAL DETERMINANTS OF MENTAL HEALTH

The evidence concerning the interconnections between social and structural inequities and mental health and mental illness is clear. Occupational therapy as a profession has been on the forefront internationally in recognizing inequities in the context of mental health and work (e.g. Townsend 2003; Townsend and Wilcock 2004; Kronenberg et al. 2005; Bass-Haugen 2009; Braveman and Suarez-Balcazar 2009). Regardless of their origins, experiences of mental illness and distress take place in social, cultural and historical contexts (Hacking 2002; Shorter 2008). These contexts include practices and policies, which ameliorate, reinforce or worsen existing forms of discrimination based on psychiatric diagnoses and social positioning, such as gender, race, ethnicity, class, religion, ability and sexuality (Ussher 1991, 2011; Caplan and Cosgrove 2004; Chan et al. 2005; U’Ren 2011).

Discrimination is structured through legal, medical and psychological practices and policies. These practices and policies play out in distinct ways for different groups within society. Before proceeding with the research evidence, it is necessary to clarify the use of the terms ‘social and structural inequities’. Within the health literature, social inequities are defined by Whitehead and Dahlgren (2006, p. 2) and by Pauly (2008, p. 5) as the result of structural arrangements, which are systematic, socially produced and unfair. Pauly (2008) understands inequities as leading to differences in health status among and between different social groups and recognizes that these inequities are the result of social processes, which can be acted on to produce equity.

In the mental health field, there are similar definitions (Aneshensel 2009; Benbow 2009; Depauw and Glass 2009). Graham (2004, p. 101) argues that:

the social factors promoting and undermining the health of individuals and populations should not be confused with the social processes underlying their unequal distribution. This distinction is important because, despite better health and improvement in health determinants, social disparities persist.

It has been noted that, although these definitions emphasize unfair systemic social processes, they are lacking in their ability to describe overlapping and intersecting forms of inequity (Ingram et al. 2013). For example, there is an absence of analysis of the many complex ways in which power operates within the mental healthcare system itself, and the ways in which psychiatric diagnoses can become a form of oppression.

In this chapter, the term social inequities is used to put the emphasis on the ‘social’ first, rather than on ‘health’. Social inequities and mental health are defined by Ingram et al. (2013) as being caused by structural social arrangements, which result in inequitable distribution of resources and active discrimination against individuals because of their membership in one or more disenfranchised group.

Relevant Literature

The literature on social inequities and mental health comes from diverse paradigms and perspectives. The literature can be classified in the following (albeit overlapping) categories:

■ Literature that utilizes a social determinants framework (e.g. Alegría et al. 2003; Candy et al. 2007; Li et al. 2009)

■ Literature that addresses equity in the context of access to services (e.g. Marmot et al. 2008)

■ Literature that focuses on examining several specific social locations/processes (e.g. gender and ethnicity) to establish relationships between mental health and social context (e.g. Harris 1997; U’Ren 2011)

■ Critical and feminist literature that challenges psychiatry and the concept of mental illness (e.g. Caplan 1995; Caplan and Cosgrove 2004; Metzl 2009).

Further literature, from the work and scholarship of occupational therapy, uses a social model of disability and a social justice lens (Townsend 2003; Townsend and Wilcock 2004). Collectively, this body of literature constitutes rich evidence that documents the ways in which social inequities intersect with mental health, both in terms of exacerbating existing mental health problems and contributing to poor mental health. These frameworks for understanding inequities highlight different things, as the following examples illustrate.

A Social Determinants Paradigm

Literature that uses a social determinants paradigm for understanding social inequities has been at the forefront of documenting that social supports, housing, meaningful activity and adequate income are key factors in mental wellbeing and in recovery from mental distress (Mental Health Commission of Canada 2012). Where one is positioned in society also impacts mental health, that is, the social gradient of health extends to mental health (Marmot et al. 2008; U’Ren 2011). In this example, poverty can both lead to mental health problems and exacerbate them (e.g. Harris 1997) and how a person perceives their social status compared to others is also a mental health stressor. Many scholars have also investigated the links between racial discrimination, experiences of migration and mental health (e.g. Morrow et al. 2008). Researchers have documented the effects of social inequities such as homelessness, racism, colonialism and poverty on mental health, both with respect to exacerbating existing distress and/or creating distress (Boyer et al. 1997; Kirmayer et al. 2001; Mental Health Commission of Canada 2009). The links between trauma, experiences of violence, substance use and mental health are well documented and practitioners have begun to establish programmes to support people (Harris 1997; Poole and Greaves 2012). What these types of scholarship share in common is an interest in understanding the relationship between socially unequal contexts and treatment and mental health.

Stigma and Access to Services

Practitioners and scholars have also widely noted that many populations are under-served within the mental healthcare system (Marmot et al. 2008). The intense stigma experienced by many individuals in their communities is one reason why services are not accessed. Other reasons include the lack of culturally appropriate services and supports. For example, despite the variety of mental health services and supports available, many women, particularly those who are economically disadvantaged, are unable to access appropriate treatment, to meet their complex and diverse needs (O’Mahoney and Donnelly 2007). In addition, there are barriers to mental health treatment for immigrant women due to limited financial resources, language skills, education and mobility (Chui et al. 2005). Self- and social stigma have also been found to play an important role in women’s access to social support and their decisions to seek mental health treatment (Chui et al. 2005). This problem extends especially to communities that have been further marginalized or historically pathologized by psychiatry, for example gays, lesbians, bisexuals and transgendered people. More medically oriented literature has made the argument that certain groups in society are more vulnerable to mental health problems and are thus at risk of not receiving services and supports (Patterson et al. 2008; Standing Senate Committee on Social Affairs, Science and Technology 2009).

Critical and Feminist Analyses

Critical and feminist analyses challenge psychiatry and the concept of mental illness. Typically using social constructionist paradigms, these scholars investigate the ways in which social and structural inequities are built directly into psychiatric diagnostic practices, resulting in discriminatory labels being applied to disenfranchised groups. So, for example, there are now substantive bodies of literature which illustrate the ways in which the practices of psychiatry have served historically to pathologize some groups of people (e.g. women, racialized peoples, people living in poverty) over others (Caplan 1995; Baker and Bell 1999; Caplan and Cosgrove 2004; Appignanesi 2008; Metzl 2009). This has resulted in psychiatric diagnoses being disproportionately applied to certain groups (e.g. schizophrenia to black men) and the ‘psychiatrization’ of women’s normal life experiences such as the post partum period and menopause (Ussher 1991, 2011; Metzl 2009). Furthering this critique, is the argument that diagnoses and labels of mental illness in and of themselves constitute a form of inequity (Morrow and Weisser 2012). This is referred to as ‘sanism’ (Perlin 2000, 2003; Birnbaum 2010; Fabris 2011; Ingram 2011) or in LeFrancois’s (2013) terms, ‘psychiatrization’, which she sees as the practice, or result, of sanism. Sanism and psychiatrization are thus used to understand the discrimination against people diagnosed with mental illness, but also go further in their aim to unsettle assumptions about rationality, normality and madness.

Other scholars have investigated the ways in which the understanding of what constitutes mental health problems differs dramatically across cultures (e.g. Summerfield 2001; Watters 2010). Some seek to reinforce the dominance of Western psychiatry as a framework for understanding distress, while others point to the ways in which the categorization of experience is beyond psychiatry and deeply culturally and historically rooted. Still others posit alternative world views based on long-standing indigenous traditions that point to very different modalities of support and care for people (Kirmayer and Valaskakis 2009). Occupational therapists have adopted and utilized a variety of these frameworks in their work.

Power and Explanatory Paradigms

The varied literature on the connection between social inequities and mental health indicates tensions around which explanatory paradigms are used to understand those connections. Some scholars working in this area adhere to a biomedical understanding of mental health and understand the social environment as relevant only in the context of treatment and recovery, while others suggest that it is the social environment itself that can make people ill and finally, some question the whole validity of the ‘psy’ sciences (psychiatry, psychology and criminology) (Chan et al. 2005) and are pushing the boundaries of how we conceptualize differing states of mind/consciousness. Taken together, however, these varied ways in which scholars and activists have understood social inequities in mental health tell us something about the ways in which power is distributed in society and how this extends to the mental healthcare system itself. Chief among these forms of power is biomedicalism, which, when coupled with neoliberalism and the erosion of the welfare state, has led to a system that rations resources based on diagnosis and severity of symptoms, and responds primarily through medication and medication management over and above social supports and responses. In order to build on the existing literature and expand our understanding of the ways in which social and structural inequities operate in mental health, we propose the use of an intersectional lens for the practice of occupational therapy.

INTERSECTIONALITY AND MENTAL HEALTH

Intersectionality is a paradigm, which seeks to reveal the complex interactions among multiple social categories, such as gender, race, class, culture, age, ability and sexuality, and systems and processes of domination and oppression, such as sexism, racism, classism, colonialism, ageism, ableism and homophobia, which simultaneously produce experiences of discrimination and privilege (Morris and Bunjun 2007; Hankivsky and Cormier 2009; Hankivsky 2012). Thus, intersectionality involves a relational analysis that seeks to disrupt homogeneous health analyses (e.g. those based on only one or two factors, e.g. gender or race) in favour of understanding the relationships between and among social categories and experiences, to enhance population health and wellness in the pursuit of social justice through the amelioration of health inequities.

These experiences of discrimination and privilege are also the concern of occupational justice (see Chs 3, 29). Understanding of the social and structural barriers which interact to maintain inequity and injustice can be enhanced and clarified by using an intersectional framework. The framework has the potential to reveal the ways in which power works within occupational therapy and mental health, by showing how processes and systems of power operate to either reinforce or ameliorate discrimination. The promise of intersectionality comes in its ability to work both as an analytic lens through which to understand inequities but also as a powerful policy and practice tool for working with individuals and influencing social policy. There is growing attention being paid to the value of intersectional frameworks for practitioners, policy actors and researchers to examine increasingly complex practice realities (see Burman and Chantler 2003; Burman 2004; Morris and Bunjun 2007; Hankivsky 2011, 2012; Rossiter and Morrow 2011). Responses to inequities at an individual and collective level in mental health can be informed and shaped by understanding the social and structural determinants and how they intersect or connect.

Origins of Intersectionality

Intersectionality has its roots in Black American feminist writing and thinking, emerging primarily during the second wave (i.e. 1970s and 1980s) of the feminist movement in North America (e.g. Combahee River Collective 1977; Cherríe and Anzaldúa 1981; Hill Collins 1990; Crenshaw 1991) and the critique of forms of feminism that focused on gender as the sole or most important form of oppression. Indigenous, Black, Latina and South-Asian feminists argued that gender and race could not be understood separately and that indeed, all forms of oppression/privilege are interconnected and inseparable. More specifically, they pointed to the ways in which forms of oppression/privilege like patriarchy, white supremacy, class domination, etc., are interconnected, and prop each other up through professional practice and the use of legislation, policy and ideology. Essentially, they called into question that women could find solidarity in their shared oppression as women and thus began intense debates about diversity and difference and the multiple ways in which oppression affects women. Although the term intersectionality was not coined until the 1990s (Crenshaw 1991), its historic elements are visible throughout these early works.

Traditionally, the knowledge of professionals (i.e. expert knowledge) has been seen as superior to knowledge that comes from personal experience. In intersectional frameworks, personal experience is understood as epistemologically significant, that is, it is recognized that personal experience is deeply shaped by oppression and privilege and thus, a significant form of knowledge and evidence (e.g. Combahee River Collective 1977; Hooks 1984; Hill Collins 1986, 2000). Knowledge that arises from the margins of society can deeply inform our understanding of the social world and the practices we engage in as professionals (see also Ch. 29). Intersectionality must always be coupled with a social justice framework, which understands social and health inequities to be about differential access to power and resources (e.g. Hill Collins 1990; Burgess-Proctor 2006; Hankivsky and Cormier 2009).

It is implicit in intersectional frameworks that resources and power are distributed in inequitable ways in society and that these inequities should be challenged and addressed. As Lynn Friedli (2009, p. 111) indicates,

‘Levels of mental distress among communities need to be understood less in terms of individual pathology and more as a response to relative deprivation and social injustice, which erode the emotional, spiritual and intellectual resources essential to psychological wellbeing’.

Although intersectionality has a long history, especially as an activist paradigm and a body of theory, it has only more recently been used in the field of health and mental health as a methodology, research, policy and practice paradigm.

A Critical Tool for Theory and Practice

Thus, in the context of mental health, intersectionality can be seen as a critical tool for both theory and practice (Rossiter and Morrow 2011). It can help us understand how macro-structures of power such as mental health services operate and enable us to appreciate the impact on the lives of individuals. Intersectionality as a framework in mental health has an emerging focus on gender, race, ethnicity and class, to the exclusion of other social categories and processes (e.g. homophobia, transphobia, ableism and ageism). The framework has been applied primarily to certain populations (African Americans, South-Asians) and mental health problems (depression) (Rossiter and Morrow 2011). This focus on certain social categories and processes and on certain ethno-cultural groups and mental health problems has resulted in a dearth of knowledge about a broad range of social categories and mental health issues (Rossiter and Morrow 2011). Some, for example, argue that one of the key forms of oppression that must be attended to in mental health is sanism (Fabris 2011; Ingram 2011). In the use of the term ‘sanism’, there is an attempt to understand how the diagnoses and labels of mental illness can result in active forms of discrimination against people, for example barring them from making their own medical decisions or from participating in civil society (Perlin 2000; Birnbaum 2010). Naming sanism is also meant to challenge our assumptions about what constitutes normal behaviour (Fabris 2011; Ingram 2011).

Challenging Simple Categories

Thus, despite a growing interest in intersectional approaches in mental health (e.g. Mental Health Commission of Canada 2012), there is still a lot of work to be done to move beyond analyses of social categories to analyses of social processes of discrimination and oppression – that is, systems of power and how they operate in mental health. Attention to structural processes is critical for overcoming the limitations inherent in the treatment of social categories as static and unchanging variables, an approach that artificially simplifies complex phenomena by categorizing individuals according to broad group membership (Warner 2008). Intersectional scholarship, exploring multiple interlocking forms of oppression, challenges the assumptions that result from simplistic categorization of individuals, thereby helping researchers, policy-makers and practitioners to better understand the complexity of lived experiences, and determine the implications of these intersections for service delivery (Burman 2004). This is especially challenging in environments where rapid psychological assessments are encouraged and where community-based mental health organizations, which arguably can come to know their clientele well, are under-resourced and over-stretched.

Although intersectional scholarship and practice is complex, it is well-suited to understanding the diverse experiences of people who come into contact with the mental healthcare systems and/or who experience mental distress. Intersectionality has the potential to reduce psychiatric stigma and discrimination, and increase opportunities for recovery, inclusion and citizenship (Rossiter and Morrow 2011). Thus, its utility in the field of occupational therapy is such that it is consistent with the goals of occupational justice – namely, to strive to create space in society for the integration of people with mental health problems to engage as full citizens and members of their communities.

MENTAL HEALTH REFORMS AND THE COMPLEX PRACTICE ENVIRONMENT

This section begins by laying out, in general terms, the broader context in which occupational therapists do their work. There is particular emphasis on the historical importance of mental health reforms, which have resulted in a shift from institutionalized to community care, a move towards recovery-oriented practice and promoting mental health and wellbeing, and an emphasis on the involvement of people with lived experience in policy and programme development (see also Ch. 2). The focus here is on an inclusive understanding of occupational therapy, as pertaining to a wide range of meaningful life activities, which may or may not include paid employment. In this context the changing nature of work is particularly relevant. Tensions have arisen from shifting government agendas and neoliberal reforms, which favour reduced social welfare benefits and put the emphasis on individual self-sufficiency (Oliver and Barnes 2012). Context is important because occupational therapists are required to adapt to a constantly changing work environment and the degree to which progressive shifts towards a social justice orientation are supported are, in part, contingent on this environment.

From the Institution to the Community and the Changing Nature of Occupation

Although deinstitutionalization has been unfolding for almost five decades in Europe and in North America, in some places the closure of large psychiatric hospitals is still ongoing or is relatively new (e.g. the Canadian provinces of British Columbia and Manitoba). With this, has come a shift to community-based care, which in practice, has meant that most places now maintain a wider range of care options from acute psychiatric inpatient care, to a range of outpatient programmes and housing options (Pilgrim 2005; Hill 2006). Although institutions, themselves, have not disappeared, what has changed is a commitment to ensuring that people, regardless of their level of disability, be supported to live as independently as possible. With this has come a changed and expanded role for occupational therapists. Specifically, occupational therapists have been challenged to work in a variety of institutional and community settings and have themselves in many instances shifted from older rehabilitation models to approaches which foster recovery and wellbeing (see also Ch. 23). With this development, a space has opened up for increased attention to inequities that limit opportunities for participation in society and about the social causes of mental distress and thus, for a dialogue in occupational therapy about social justice and health inequities (e.g. Townsend and Wilcock 2004; Kronenberg et al. 2005; Braveman and Suarez-Balcazar 2009; Wilcock and Townsend 2009).

Occupational Apartheid

The concept of occupational apartheid has been used to describe the inequities that people with disabilities face in gaining access to paid employment (see Chs 2, 21). Nilsson and Townsend (2010) remind us that occupational apartheid is an outcome of forms of governance and social policies which structure access and participation in meaningful work and activities. They point to the division of labour and the classification of occupations as two key structural factors that contribute to occupational injustice (Nilsson and Townsend 2010). Put slightly differently, Stadnyk et al. (2010) talk about forms of exclusion from the workforce, which include, occupational alienation, occupational deprivation; occupational marginalization and occupational imbalance (see Chs 3, 29 for elaborations of these concepts). The contemporary political and economic context is important for understanding how social policies, in particular, influence these forms of injustice. The social model of disability is useful for understanding the current context and is discussed next, followed by neoliberalism, another perspective on this context.

Social Model of Disability

The social model of disability takes issue with biomedicalism, or medical ideas which view the body as objectively mechanistic and as something that medicine should strive to fix, to conform to ideals about what is normal. By contrast, the social model of disability points to the fact that disability is experienced within specific social contexts that often engender discrimination and exclusion from society. That is, while people have many physical variations, these in and of themselves do not lead to disability but rather it is society’s response to these people that is disabling (Oliver 1990). Shakespeare (2004) reminds us that the concept of social disability arose in Britain in a political context influenced by Marxism and the labour movement and was tied closely to the disability rights movements of the 1980s and 1990s. What this suggests is that the understanding of disability shifts and changes in part due to theoretical developments in the field but also in response to the political context. Indeed, the social model of disability has often been used to explain why people with disabilities have been excluded from the labour market and/or used as under-employed forms of reserve labour (Grover and Piggott 2005) (see also Ch. 11). From a social model perspective, disability can be reduced or overcome by a social response rather than individual efforts to change. This directly challenges neoliberal emphasis on individual autonomy.

Neoliberalism

Neoliberal ideologies currently prevail and are having a substantive impact on how we understand the body, health and disability (Rose 1989; Grover and Piggott 2005). Neoliberalism is an unfailing belief in market forces, economic liberalization, privatization and free markets. In recent years, the term neoliberalism has come to be used to describe a whole system of governance that critics feel is severely eroding the social welfare state. When translated into policy, neoliberalism promotes individualistic understandings of complex social problems, the increased use of market mechanisms in health and mental healthcare delivery (‘managerialism’) and favours self-reliance and volunteerism. Consequently, neoliberalism has a way of propping up biomedicalism, since both are focused at the individual rather than social level. One of the cornerstones of neoliberalism is its promotion of autonomy of individuals from the state and therefore its adherence to individualistic understandings of complex social problems. Thus, in a neoliberal climate, individuals are increasingly asked to assume the roles and risks of the state, and governments can then avoid addressing systemic problems, resulting in, for example, unemployment and poverty.

Changes to Health and Welfare Programmes

Although the form that neoliberalism takes differs in different contexts, several recent examples in Canada and the UK help to illustrate our points. In the Canadian context, the shift towards neoliberalism can be traced back to significant social policy changes in the mid-1990s, which were accompanied by massive cuts to health and social welfare programmes. Through the 1990s and into the present day, some provincial governments (notably British Columbia, Ontario and Alberta) have responded by either introducing work for welfare programmes; tightening access to disability and employment insurance programmes; failing to raise social assistance rates to meet rising costs of living and/or stressing self-reliance and volunteerism. These changes have had specific implications for people with mental health problems with respect to income security and employment opportunities (Morrow et al. 2009).

In the UK, the shift towards neoliberalism is usually credited to the policies of Margaret Thatcher, supported by her famous statement, ‘there is no such thing as society’. This shift has been supported by successive governments, and, as in the Canadian example, resulted in new forms of governance and, in particular, in more regulation and scrutiny being placed on people with disabilities and those living in poverty. For example, in the UK, the introduction in 2011 of the work capability assessment, which was applied to people receiving incapacity benefits, resulted in the re-assessment of people receiving benefits to get them back to work. Leading up to this policy shift people speculated on the devastating implications:

We’ve found that the prospect of IB reassessment is causing huge amounts of distress, and tragically there have already been cases where people have taken their own life following problems with changes to their benefits. We are hugely worried that the benefits system is heading in a direction which will put people with mental health problems under even more pressure and scrutiny, at a time when they are already being hit in other areas such as cuts to services’.

(Farmer et al. 2011)

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