Social inclusion and recovery approaches have formed a major framework for mental health service provision in the United Kingdom (UK) over the past 10 years, including extensive policies that set out to tackle the complex relationship between mental health, social exclusion and recovery (National Institute for Mental Health in England 2004, Office of the Deputy Prime Minister 2004, Welsh Assembly Government 2005, Scottish Executive 2006, Bamford 2007). Occupational therapists have instinctively supported this work with an understanding of how occupation can deliver and facilitate inclusion and recovery (College of Occupational Therapists 2006a). However, as the National Social Inclusion Programme (2009) ended and was replaced by No Health without Mental Health (HM Government 2011) and Big Society (Conservative Party 2010), and with a global recession having an impact upon National Health Service (NHS) resource allocation (NHS Confederation 2009), evaluations of progress and considerations of future directions are required.
Social inclusion has been identified as fair access to opportunity in order to enable mental health service users to live side by side with the rest of society (Bates 2002, Repper and Perkins 2003). Recovery emphasises the importance of having a hopeful, self-determining and meaningful life, with or without the experience of mental health symptoms (Repper and Perkins 2003). Evaluation of the implementation of these values is challenging because of multifaceted contributing factors, such as poverty, stigma, unemployment, lack of social networks and low expectations (Sayce 2001). While some evaluation needs to consider quantitative aspects, such as how many people are in employment, qualitative understanding is also needed in order to examine whether individuals actually feel included and a part of their local communities (Berman and Phillips 2000).
Research considering various aspects of social inclusion was identified by searching the databases Allied and Complementary Medicine, British Nursing Index, Cinahl, Medline and PsycInfo for research published between 2000 and 2007, using the search terms 'mental health', 'social inclusion/exclusion' and 'occupation'. Fifteen studies were found, with seven quantitative, seven qualitative and one mixed methodology. They considered the extent to which mental health service users are socially included, and the possible factors that influenced levels of social inclusion.
Shimitras et al (2003), Minato and Zemke (2004a) and Dorer et al (2009) conducted studies in the UK and Japan, collecting data on a total of 517 service users categorising time use over 24 hours or 7 days. These time use studies used quantitative methodologies to measure occupational engagement and levels of participation in community occupations. The studies demonstrated that service users spend extensive time alone at home, sleeping or engaged in passive leisure, with little engagement in community occupations. However, the validity of time use studies needs consideration: accurate recording of time use may be compromised because of the reliance on retrospective recall. In contrast, Bejerholm and Eklund (2006) used a mixed methodology to triangulate findings: they collected data from 20 service users in Sweden using 24-hour diaries, as well as conducting qualitative interviews about time use. This revealed more variation in levels of community participation than the previous studies suggested, and highlighted the benefits of using mixed methodologies with the same sample to add depth to the research findings.
Symptoms of mental distress can impede participants' ability to engage in community occupations. Qualitative interview studies from Canada and the UK revealed how mental health symptoms restricted participants' involvement in employment and leisure (Pieris and Craik 2004, Woodside et al 2006). In …