Atul Gawande, a surgeon and professor of public health, delivered a TED talk in April 2017 called ‘Want to get great at something? Get a coach’ (Gawande 2017). He begins his talk by describing an innovation in coaching by training nurses to observe other nurses acting as birth attendants in rural India. The way the local birth attendants were handling infected material was leading to significant mortality. The coaching intervention completely reversed this trend and the approach of the coaches was found to be just right in facilitating change rather than imposing change from outside. This was transformative in delivering better care.

What has this got to do with the professional development of psychiatrists? The connection is, of course, coaching (or mentoring), but it also symbolizes the way psychiatrists often naturally seek to influence beneficial change in indirect ways.

In the UK in 2003, Dean wrote a brief editorial for Advances in Psychiatric Treatment about the importance of having a mentor for newly appointed consultants (Dean 2003). This will be the main context of thinking about coaching and mentoring for many psychiatrists.

This chapter covers the development of social policies and the modern Welfare State. Welfare states represent recognition that the key welfare needs of the country will be met by the state through the provision of income transfers and key public services. Their development has been closely associated with the expansion of citizenship and human rights. In the UK the Poor Law was a long-lasting historical core on which the nation’s welfare state was built, and was associated with the important infrastructure of local authorities, health systems, and education along with the provision of payments in times of need. A well-functioning welfare state is important for the wellbeing of the population and has valuable redistributive roles. They provide social investment in children’s early lives and guard against social risks such as unemployment and poverty. They have the potential to assist economic growth and to provide the infrastructure and support for human capital, such as through the creation of a ‘healthy workforce’. Generally, the more egalitarian states perform better on a range of well-being measures. They remain a central pillar of the maintenance and improvement of the quality of life of people with disabilities associated with mental health conditions.

The term ‘social exclusion’ appears to have originated in France in the 1970s and had a significant influence on European social policy before being taken up by the UK’s New Labour Government in the 1990s. This chapter outlines the concepts of social exclusion and some of the competing discourses associated with the term. Several notable definitions of the term are discussed before we settle on the CASE definition of ‘An individual is socially excluded if he or she does not participate in key activities of the society in which he or she lives’. The concepts of social exclusion may provide added value to discussing the more traditional concepts of poverty and deprivation. It is a relational concept and thus is of importance for developing a social psychiatric perspective. The relationship between Social Exclusion and Social Inclusion is complex and they are not necessarily polar opposites; rather, they may be viewed as a continuum, but a continuum of several dimensions which may differ over time and place. The chapter sets out a framework for examining the social exclusion of people with mental health conditions.

Medicine is a rapidly developing field. Much of what many of us learned in medical school is now obsolete, and an expanding knowledge base has led to increasingly specialized services. If you add to this the fact that many doctors – by choice or as the result of service changes – change their areas of clinical practice, the need to continue learning and developing after completion of formal training is undeniable.

We learn on a day-to-day basis in our clinical practice. As well as taking the relatively obvious forms of reading a literature review or asking the advice of a colleague, learning will also be through continuous feedback, for example from patients about a particular approach we take or a good clinical outcome. Being open to everyday feedback and thoughtfully working in teams is therefore an important part of remaining a safe and effective practitioner.

Medical conferences such as those held by the American Psychiatric Association, the Royal College of Psychiatrists, the College of Psychiatrists of Ireland and many other international medical academic bodies include workshops in their programmes. They are also included in the academic teaching programmes aimed at undergraduates, postgraduates and continued professional development. Teaching methods such as workshops, which actively require the learner to participate, are widely accepted to achieve a deeper level of learning. Educational research recognizes student engagement as valuable and as having a significant impact on their learning (Mandernach 2015). However, it is only when workshops are correctly planned and appropriately used that these interactive learning environments foster sound pedagogic principles and result in effective learning. Guidelines for conducting workshops are available and guidelines specific to psychiatry can also be found (Tiberius and Silver 2001), but for workshops to be effective it is important to understand the concepts of adult learning, the learning targets and the principles and process of delivering a workshop.

Groups who are socially excluded often lack a voice, something that holds for people with mental health conditions, especially if these are serious and enduring or if they are part of a socio-economically deprived group or a group that is marginalised because of their social identity. This chapter examines the involvement of people with mental health conditions in political and civic activities and the extent to which their human and civil rights are violated. Whilst there is a lack of studies examining the involvement of people with mental health conditions in these areas, there is nevertheless good reason to believe that they are excluded in this domain. Taking a global view of people with mental health conditions there are clear examples of violations of human and civil rights across the world’s continents. These violations take many forms and cover the following domains of exclusion: poverty, education, employment, personal, family and social relations, violence and persecution, health and access to essential services. Worldwide, people with mental and psychosocial disabilities face injustice and are not free from cruel, inhuman, degrading treatment, and punishment; they also lack the right to participate in the economic, cultural, and social life of their communities.

Psychiatrists are often called on to do presentations, of which PowerPoint slides are usually an expected component. Even more frequent is the experience of ‘death by PowerPoint’: sitting in someone else’s presentation and simultaneously experiencing both intense boredom and cognitive overload. This phenomenon has been cited for more than 20 years: ‘poor documents are so common that deciphering bad writing and bad visual design have become part of the coping skills needed to navigate in the so-called information age’ (Schriver 1997, p. xxiii). Mayer’s (2009) text is seminal in describing how this arises: there are dual channels for processing (the visual and the auditory), which both have limited capacity. The death by PowerPoint experience happens when one channel is overloaded and one channel is ignored: typically, a presenter reading text from a screen (cognitive overload – the audience cannot read and listen simultaneously) and boredom (there is no visual stimulation).

The Foundation Programme (Box 15.1) was instituted in 2005 and brought together the preregistration house officer grade and the first year of the senior house officer grade (UK Foundation Programme Office 2015). This created an integrated two-year programme, governed by a single curriculum produced by the Academy of Medical Royal Colleges (2016). The majority of students completing undergraduate medical training in the UK will enter the Foundation Programme directly after leaving medical school.

This chapter outlines concepts related to social exclusion that are relevant to people with mental health conditions. These concepts highlight the political and civil nature of exclusion (citizenship, equality and human rights, choice); the importance of material (poverty and deprivation), social (social capital, stigma, and discrimination) and individual factors (participation, choice, and agency); and a means of identifying and describing causal factors for social exclusion (agency and process, dynamic dimensions, multifactorial causes, life course, and longitudinal perspectives). It also covers personal recovery, which provides a bridge between the literature on social exclusion and that on mental health conditions.

This chapter examines the importance of family, social networks, social capital, and personal safety to people with mental health conditions and how these are often missing from their lives and replaced by social isolation and loneliness. For people with mental health conditions, social contacts and levels of support play a role in the genesis of their conditions as well as their recovery. People with mental ill-health often lack access to some forms of social capital but may benefit from the buffering effects of other forms. Social interaction may be curtailed by the subjective experiences of the mental health conditions, but also from the stigma and discrimination experienced by people with mental health conditions as personal experience of or fear of crime, aggression, and persecution. These are experiences that can set up a vicious cycle of loneliness and depression and exclusion for social contacts and important sources of support. These mental health and social conditions are unevenly distributed and exacerbated by the nature of the physical and social conditions of neighbourhoods. Whilst communities can be supportive, they may also present unacceptable risks to vulnerable groups in the form of crimes and victimisation.

Here we examine governmental policies that affect how people with mental health conditions are treated in society. The development of UK mental health services has been closely associated with the evolution of social policies, the increasing role of the state in the provisions for the population’s well-being, and the ‘Welfare State’. The provision of poor relief, dating from the Elizabethan Poor Law to its Victorian revision, has dominated the care of people with mental health conditions, both within and outside of institutions. Until the nineteenth century, the British state played a minimal role in the care of mental ill-health, and the 1800s witnessed a substantial growth in publicly funded asylums. These County Asylums were Poor Law institutions and remained so into the twentieth century. The UK’s modern mental health services arose from the Beveridge welfare state reforms but carried with them much of the baggage of the Victorian Poor Laws. The close relationship between the welfare state and mental health services illustrates the importance of social policy provision relating to income, employment, housing, education, health, and personal social services, to the broader provision of services for people with mental health conditions and the running of effective mental health services.

The final section of the book examines how the social exclusion of people with mental health conditions can be tackled. Health services can play a part in improving health, but these services have traditionally been focussed on treatment and have a limited effect on the broader social determinants. The health of a nation is highly dependent on social, economic, and political forces and broader government policies. The occurrence, course, and outcome of physical and mental health conditions are socially determined and are inequitably distributed in the population. Therefore, broader social, economic, and fiscal policies are needed to address these health inequalities and, in turn, the social exclusion of people with mental health conditions. A public mental health approach is also required. Mental health services play a crucial role in enabling social inclusion for the people they work with. There are continuing challenges for services in preventing the marginalisation of those with the most severe and complex needs. There is a growing evidence base for the effectiveness of specific social interventions that operate at the service or individual level on social inclusion outcomes. For successful implementation, authentic, multi-level stakeholder support and adequate investment is required.