In contrast, the discourse on social inequalities has little credibility within the specific field of mental health, despite overwhelming evidence that this approach is both valid and urgently needed.
Pressure to acknowledge the significance of social inequalities has been coming for many years from people with experience of using mental health services (e.g. Barker and Peck, 1987;Chamberlin, 1990;Sassoon and Lindow, 1995). Their dissatisfaction and anger with service provision is of sufficient level to sustain many local action groups and an international social movement. The indifference and insensitivity of mental health services to problems originating in inequality is a central theme in the criticisms of service users (e.g. Sassoon and Lindow, 1995). Service users are making it clear that they do not want mental health services to replicate wider social injustice, they want to be offered sensitive and relevant help that acknowledges the implications of, for example, their gender, race and sexuality. Neither do they want to feel powerless when they use services; they want a more equitable relationship with service providers (Williams and Lindley, 1996) or to provide mental health services themselves (Chamberlin, 1990).
The importance that people who have used mental health services give to issues rooted in inequalities is now supported by an extensive academic literature exploring the effects of inequalities (e.g. of gender, 'race', class, sexuality and age) on mental health and on mental health provision. It is a literature that also identifies the ways that the effects of social inequalities can be mediated by poverty, sexual and physical abuse, discrimination and other profound experiences of powerlessness and loss (see Williams et al., 1993; Fernando, 1995). Although the advances made in this field in the last 20 years are considerable, this knowledge base also has limitations which are largely a function of its marginalized status within the field of mental health. These limitations are noted here not to diminish the efforts of contributors to this literature, but to give us guidance about how to strengthen this knowledge base.
Existing knowledge about social inequality and mental health is neither comprehensive nor coherent: its development has mainly been shaped by the emergence