This chapter covers the basics of large- and small-group teaching, including methods of delivery, evaluation, practical tips and assessment methods. It includes evidence from teaching in psychiatry and from medical, and higher, education. The chapter comprises the following sections.

This introductory chapter outlines the structure of the book and some of the themes that appear throughout the book. The themes include intersectionality, the role of social factors in causing and maintaining mental ill-health, the need for a public mental health approach, and the role of mental health professionals and services in facilitating social inclusion. We discuss why social exclusion violates social justice and social solidarity, and put forward ten reasons why mental health professionals should be concerned with social exclusion.

‘E-learning’ can be defined broadly as the use of internet technologies to deliver teaching and to enhance knowledge and performance. It is also referred to as web-based, online, distributed or internet-based learning (Ruiz et al. 2006). Many sites use ‘blended learning’, where e-learning is combined with in-person or virtual face-to-face instructor-led training.

The increase in portability, power and connectivity of devices means that most smartphones can easily access information in real time (Marzano et al. 2017) and, of internet users worldwide, 93% access the internet via mobile devices (Johnson 2021). This means that access to the internet to gather information about mental health is immediate, but the vast number of information sites can easily become overwhelming for both patients and clinicians. A simple search for a single mental health topic generates a huge number and range of results. These vary from reviews of the evidence and primary research articles, to news articles and advertisements for treatment centres. The internet user is swamped with an array of sites of variable (and often unknown) quality, which are neither necessarily relevant to the original question nor ranked in order of reliability.

Psychiatrists must seek to make the most of the opportunity offered by the increase in Foundation Programme training posts in psychiatry (see Chapter 15), while continuing to enhance the teaching of medical undergraduate students. We need to create good doctors who are highly professional, good communicators and sympathetic to psychosocial needs of all patients. We also need to improve recruitment to our own specialty.

Medical students prefer to learn general skills rather than specialised ones – this is a ‘strategic’ outlook that cuts their workload. For a busy foundation year doctor, this problem is further magnified by the added pressure and responsibility of working and the steep learning curve that comes with it. Students’ and trainees’ views must be balanced with the necessity to teach fundamental principles of psychiatry, otherwise the care of the mentally ill will be compromised through lack of knowledge (Davies 2000; Oakley 2008).

The traditional lecture has proven to be a remarkable survivor in the fickle world of medical teaching and learning. The traditional, 50-minute, didactic lecture is continually under attack, with critics arguing that its format is inflexible, audiences lose interest and there is insufficient interaction, if any, in most lectures. But while the lecture certainly violates many of the sacred tenets of contemporary education, it has nonetheless survived and even thrived in a world of incessant educational innovation and countless online teaching initiatives. Why?

Why is the traditional lecture still so popular? How has it survived? And how can we use the enduring appeal of the lecture format to best advantage in modern medical education and postgraduate training?

In addition to adopting greater person-centred and recovery-oriented approach to build more productive partnerships between mental health staff and service users, mental health organisations that wish to become more socially inclusive need to develop partnerships with other agencies, particularly those that provide supported accommodation, supported education, and supported employment, so that these become more of a focus for care planning alongside traditional mental health interventions. Working in partnership to build bridges with local community resources and build capacity for the inclusion of people with mental health conditions acts to break down the stigma and discrimination that they experience. Services also need to ensure that people have access to personal budgets so that they are empowered to direct their own care and support. These approaches bring obvious benefits for carers too since creating a network of services and resources in the community for people will increase the social supports available and potentially reduce carer burden. Clinicians may also experience greater shared responsibility with other providers as they expand their community resource networks and are further rewarded by witnessing people building successful and participatory lives in the community.

In this chapter we look at the social inequalities of physical health in relation to the poorer physical health experienced by people with mental health conditions and their access to health services. People with mental health conditions often experience a ‘triple jeopardy’: they experience an excess of physical health problems relative to their peers in the general population, are more likely to get serious forms of physical illness, and, once diagnosed, are more likely to die within five years. They face greater difficulties accessing good-quality healthcare than people without mental health conditions. These distinct findings also give us an illustration of the complex pathways involved in the exclusionary processes, this time linking mental and physical health conditions and outcomes through a synchrony of broader structural factors, social inequalities, early life experiences, life course adversities, risky health behaviours, the nature of the mental health condition, the medications prescribed, and the discriminatory attitudes prevalent in public services and in broader society. They also point to the need to clearly appreciate the disabilities associated with mental health conditions and to develop broad public health approaches to address these inequalities in health outcomes.

Here we look at poverty from a quantitative viewpoint to examine trends over time as well as highlighting the social and demographic groups who are most disadvantaged. This reveals a section of society that faces the hardship of life on reduced resources and that lack the necessities for daily living. It also shows the central role that poverty plays in the notion of social exclusion, particularly in exclusion from social activities. Since the 1970s there has been an increase in poverty in the UK, alongside an increase in the cost of key necessities such as energy and housing costs. unstable and under-employment, problem debt. and financial instability, alongside stringent reforms of the social security system, all of which have disproportionately affected those on low incomes. Associated with these has been an increase in material deprivation and the dramatic rise in foodbanks, and we see increasingly precarious and risky lives lived by significant sections of the population. This changing social and economic environment has implications both for the quality of life of people living with mental health conditions as well as the health and well-being of significant numbers of the general population.

This chapter covers three main areas of activity: the labour market, education, and leisure. These three areas all overlap and interact within the scope of the human life course and have important implications for health and socio-economic outcomes. They are also interdependent with the material factors and the social networks examined in other chapters. All are inequitably distributed and are important for the health and well-being of the general population. People with mental health conditions are disadvantaged in all three of these areas, especially those with severe and enduring conditions, and work, leisure, and education can all play a role in causing and perpetuating mental ill-health. Factors that are integral to the mental health condition may contribute to excluding people from these important activities, but there are additional extrinsic factors that also play a part in this exclusion. The existence of such external factors supports the application of a social model of disability for people with mental health conditions and questions the assumptions of an approach that views exclusion solely in terms of a person’s ‘illness’. This has implications for the rehabilitation and the personal and social recovery of people with enduring mental health conditions.

A useful aim for all psychiatrists is to write at least one competent, not necessarily first-rate, article or chapter on a subject on which they have become an expert. ‘I am never going to be an expert’, we hear some of you say, but this is simply not true. Everyone can become an expert in one area, even it is very tiny indeed. So, for example, if you come across someone in your practice who has the feeling of ants crawling over their skin, commonly called formication (please get the spelling right), and this is severe and troubling, you might want to write a review of ‘formication in psychiatry’. You will find about 50 published references on the subject but not very many from psychiatry.

The traditional medical education system has produced scientifically grounded and clinically skilled physicians who have served medicine and society. Sweeping changes launched around the turn of the millennium have revolutionized undergraduate and postgraduate medical education across the world (Gutierrez et al. 2016; Shelton et al. 2017; Samarasekera et al. 2018). Training has moved from being time-based to become more outcome-based, with a move away from the apprenticeship model to a more structured and systematic approach, emphasizing learning and development of skills.

Broadly speaking, virtual learning refers to the delivery of education via the use of digital technology. It encompasses a broad range of learning techniques, communication methods and electronic media to provide a learning experience that is flexible, engaging and learner centred (Ellaway and Masters 2008).

Virtual learning has been possible since the invention of the Internet in the late twentieth century. In 1969, the Open University pioneered the use of emerging digital technologies to increase the accessibility of higher education. Since its inception, the Open University has provided remote learning opportunities for over two million students (The Open University 2021). Over the past few decades, virtual teaching and learning have become increasingly popular within medical education, but their use has been particularly accelerated by the COVID-19 pandemic (He et al. 2020). Since the onset of coronavirus, medical educators have used virtual learning to safeguard the delivery of medical curricula, whilst also abiding by social distancing precautions and protecting staff and students from disease transmission. This has been akin to the global upsurgence in the use of telehealth and remote delivery of physical and mental healthcare (Monaghesh and Hajzadeh 2020)

In this chapter we examine the historical background to poverty research, the definition and concepts of poverty, and how is it experienced by individuals, families, and communities. The focus is mainly on the UK and on qualitative studies. Poverty is a cause of human suffering and the experiences of people living in poverty are mediated by social divisions such as gender, ethnicity, and disability. It can be understood in terms of the need of material resources, but also in terms of its psychosocial effects. It has clear effects on mental and physical health. Many aspects of the lives of people in poverty parallel the position of people with mental health conditions: lack of agency, opportunity, and voice; living compromised lives with stigma and discrimination; and struggling with day-to-day functioning, employment, and housing. Poverty impacts negatively on self-esteem and produces feelings of shame and guilt in response to inadequate material and social situations. It is possible that some of the mechanisms for understanding mental ill-health may also be shared with those related to poverty.

Medical education has changed considerably from models based mainly on knowledge acquisition and duration of training towards the achievement of predefined learning outcomes (Krackov and Pohl 2011). In such a competency-based approach to education effective feedback has become an integral and important constituent of teaching and learning.

In the learning process, feedback is a process of sharing observations, concerns and suggestions with another person. Feedback helps to maximize learning and development by raising an individual’s awareness of their areas of strength and relative weakness or need as well as outlining the actions required to improve performance.

Detailed and prompt feedback coupled with clear opportunities to improve enables individuals to achieve previously agreed milestones such as curriculum outcomes (Krackov and Pohl 2011) or continuing professional development (CPD) objectives.

This chapter outlines the levels of poverty, debt, and financial hardship in people with mental health conditions, the social security system, and living conditions, including neighbourhood deprivation, housing, and transport. People with mental health conditions are more likely to be excluded from material resources than others in society. They are over-represented in low-income group, those living in poor housing, and deprived environments. They are likely to be in debt or have other financial difficulties and to be receiving inadequate amounts of state benefits. The severity of the condition and its longevity exacerbates the degree of exclusion. There appears to be a two-way relationship between mental ill-health and material deprivation: social and environmental aspects of material exclusion play a role in the cause of mental ill-health and mental ill-health leads to material exclusion. Poverty mediates the relationship between mental health conditions and the many other social problems that people face, as well as impeding their ability to cope with their mental health difficulties. People’s responses to poor conditions are universal and, for those with mental health conditions, may be more appropriately seen as a consequence of their impoverished circumstances rather than due to their mental health conditions.