Social inclusion and exclusion are successful buzzwords in today’s political discourse. At their core, these concepts were created to explain and help to transform the complex reality of our times. Famously, according to the citizenship theory by Marshall (1964), one of the more significant master trends in modern social change is movement toward increasing social inclusion (Colomy & Brown, 1996). The notion of social inclusion has been associated with various dimensions related to the basic needs of humans: occupation, protection, recognition, education, bonds, and participation (Canal, 2010, p. 15). Social exclusion, in contrast, has been defined as “refusing people and/or social groups’ access to the resources which, in a specific place and at a specific historical time, are considered socially valuable and necessary for a dignified and autonomous life” (Canal, 2010, p. 10). While there are many causes of social exclusion, one of the factors repeatedly shown to lead to social exclusion is mental illness, which may hinder people in developing themselves in accordance with their wishes and abilities (e.g., Knapp, 2003; Morgan, Burns, Fitzpatrick, Pinfold, & Priebe, 2007; Payne, 2006). Even today, people with mental illnesses are in one of the most marginalized positions in society (WHO, 2013).
Participation is a key dimension of social inclusion—and one that we particularly seek to increase understanding of in this volume. Participation is an element of democratic citizenship that enables citizens to actively shape their social and economic circumstances (Pateman, 1970). In this volume, however, we focus on participation taking place in face-to-face social encounters, with reference to what Erving Goffman (1983) called the “interaction order.” In other words, we seek to get to the root of the preconditions and consequences of participation by unraveling the interactional processes that underlie what makes it possible. We presuppose that participation in any social or societal sphere presupposes social interaction, which in turn requires the capacity to coordinate with and make sense of others’ actions. Thus, drawing on joint decision-making as a specific arena of social interaction, where the participants’ collaborative management of the turn-by-turn sequential unfolding of interaction can have tangible consequences for the participants’ social and economic circumstances, we seek to increase understanding of the specific vulnerabilities that individuals with mental illness have in this context.
Social Inclusion and Participation in Mental Health Care
Both social inclusion and participation are central notions in the contemporary discussion on social and health care services. Current international mental health policy recommendations emphasize the importance of client involvement, which means actions that support clients’ willingness and ability to make independent decisions about their own lives and to take action to enhance their own well-being (Royal College of Psychiatrists Social Inclusion Scoping Group, 2009; WHO, 2013). In social and health care, social inclusion refers to the individual’s sense of belonging within the community, and that he or she can influence issues affecting himself or herself and the surrounding environment (Sihvo et al., 2018). Social inclusion includes the right to be informed about issues relating to oneself, the opportunity to express one’s opinion and contribute to the decisions concerning one’s health and well-being (Sihvo et al., 2018). Social inclusion requires a feeling of meaningfulness, belonging to a whole, and the ability to form meaningful social relationships. The elements of social inclusion include both the right to participate in one’s own care and opportunities to influence the planning and development of services (Sihvo et al., 2018).
From Professional Authority to Client Involvement
Even though mental health clients’ opportunities for social inclusion remain weak in many respects (e.g., WHO, 2013), over the past few decades there have been significant changes in this regard. At the beginning of the 1900s, mental hospitals were the mainstream structures for the treatment of people with mental illnesses (Grob, 2014). Treatment decisions about hospital admission and discharge were made by professionals, often against the patient’s own will. Since the 1940s the human rights movement gained more international influence, focusing attention on violations of basic human rights of patients in mental hospitals (Hänninen, 2012). The process of de-hospitalization that began in the 1950s led to the downsizing and closure of hospitals, reducing the number of hospital patients and leading to the development of different types of inpatient facilities (Grob, 2014). This trend was strongly influenced by the social psychiatry movement, which demanded respect for the agency of those suffering from mental illnesses and thereby shifted the focus from the ill individuals to the societal structures (Alanko & Hellman, 2017). At the same time, movements such as the antipsychiatry movement and the survivor and service user movements campaigned strongly for the patients’ rights to self-determination (Alanko & Hellman, 2017). However, decision-making within mainstream psychiatry remained focused on the professionals’ authority. Psychiatric professionals made decisions on the basis of medical knowledge, relying on what was deemed best for the patient without much of their involvement in the decision-making process (Charles, Gafni, & Whelan, 1997). The role of the patient was mainly restricted to expressing his or her consent to the professional’s decision—consent that most often was not needed to implement the treatment decisions in practice. On the other hand, the expansion of psychiatric care to include, not only those seriously ill but also anyone suffering from mental health problems had resulted in a new group of individuals voluntary seeking access to treatment (Alanko & Hellman, 2017). Thus, mental health professionals had increasingly to respond to individuals’ own perceptions of having a mental health problem, which necessitated treatment. This resulted in the service users starting to be seen as active agents, autonomously seeking help, rather than as passive, stigmatized patients, subjected to professionals’ authoritative power (Alanko & Hellman, 2017).
In the 1980s, psychiatry was strongly influenced by the so-called “consumerist” movement with its members enforcing their role as consumers of mental health services (Rissmiller & Rissmiller, 2006). This movement did not seek to abolish the traditional mental health system, as was the aim in the antipsychiatry movements, but it did seek to increase the opportunities for patients to decide what services and treatments were most suitable for themselves (Rissmiller & Rissmiller, 2006). From a decision-making perspective, it became vital for professionals to provide patients with all the information needed for them to be able to decide on the most effective solution (Charles et al., 1997). The role of a professional became limited to providing the kind of medical information that a patient would not have access to without the professional’s specialized expertise. At its most extreme, a professional should not give any recommendations for specific treatments, as they might reveal the professional’s own views, which, in turn, could constrain the patient’s ability to make his or her own...
