There seems no doubt that people with mental health problems are at risk of exclusion from many aspects of society, but it is also recognised that certain social identity groups are similarly at risk. In this chapter we examine the ways in which people with mental health problems who belong to these identity groups may be disadvantaged. In fact, they may be considered to be doubly disadvantaged, excluded by the nature of their ethnicity, culture or skin colour, their gender or sexual identity, or their faith and perhaps also by their mental health problems, or by the interaction of these characteristics. The idea of double disadvantage may be an oversimplification of the status of these groups – the disadvantage is unlikely to be straightforwardly additive – but it serves to illustrate the many ways in which disadvantage may operate. In addition, there are certain groups in society that are defined by their exclusion – prisoners, refugees and asylum seekers, the homeless – and the occurrence of mental health problems in these groups is higher than in the general population. They are excluded by their lack of liberty, lack of citizen status and lack of essential material needs.

Women with mental health problems

Women with mental health problems are especially vulnerable to exclusion in the areas of family activity and access to physical healthcare. Mental health problems are associated with the experience of domestic violence, which has an impact on social activity, income, leisure activities, and mental and physical health. Female mentally disordered offenders have particular problems.

Family activity

Women with mental health problems have as many children as those in the general population with the exception of women with schizophrenia and those with anorexia. The fertility rate for women with a diagnosis of schizophrenia is lower than that for other women (Howard et al, 2002). This is not fully explained by prescribed medication, especially as fertility is likely to increase with increasing use of atypical antipsychotics (Howard et al, 2002). Two-thirds of women with long-term psychoses have children (McGrath et al, 1999; Howard et al, 2001) and the majority describe motherhood as rewarding and central to their lives (Diaz-Caneja & Johnson, 2004).

The exclusion of many women with mental health problems is influenced by their increased risk of problems during the perinatal period and beyond.

In Chapters 14 and 15 we set out some of the components for the future of socially inclusive psychiatric practice and service delivery. In this chapter we examine some of the implications of this for the training of psychiatrists. It is important that the principles of social inclusion and recovery are embedded in the training of future psychiatrists, whether they be medical students or psychiatric trainees, and in the continuing professional development of consultant psychiatrists and non-consultant grades. This shift in training also applies to other mental health professionals and a consensus across these groups needs to be developed as to what is required in training and practice to deliver the shift from conventional to socially inclusive practice.

The training and policy context

Policy drivers

There have been a number of policy drivers to promote social inclusion and to reduce stigma and discrimination in mental health service users, including the recovery approach, the expert patient initiative and New Ways of Working, which we have outlined in Chapter 4. In addition, two further policies that relate to socially inclusive practice are: the Race Equality Action Plan and the Disability Discrimination Act 1995 (with 2001 and 2005 amendments) (Sayce & Boardman, 2003, 2008).

Revision of postgraduate medical training

The changes to the curriculum for trainee psychiatrists of the Royal College of Psychiatrists (2009) seen since 2000 and the move towards the acquisition of specific competences during training (knowledge, skills and behaviour) provide an opportunity to ensure that social inclusion is incorporated as a unifying theme of mental health service provision. Social inclusion in mental healthcare can be seen as part of a cultural shift towards patient/ user choice, empowerment and partnerships between patients and carers, as opposed to the traditionally didactic and disempowered status of mental health users, particularly in relation to their consultant psychiatrists.

There has been a radical overhaul of postgraduate medical training, resulting in the development of specialty-specific training posts, a new curriculum and the development of competence-based assessments. The main psychiatric specialties, represented by the Faculties of the Royal College of Psychiatrists, have been involved in developing their own competence-based curricula and workplace-based assessments for trainees. Social inclusion competences need to be incorporated into these frameworks.

The origins of this book lie in the unpublished report written by the Social Inclusion Scoping Group of the Royal College of Psychiatrists. The Scoping Group was set up to examine the nature and extent of social exclusion in people with mental health problems and those with learning disabilities, the implications for the future organisation, structure and culture of mental health and learning disability services and for the practice and training of psychiatrists. The report was published in a shortened form as a position statement which summarised the findings and views of the Scoping Group (Royal College of Psychiatrists, 2009). The evidence amassed by the Group and their deliberations were considered too good to waste and have been adapted to produce this book, aimed primarily at psychiatrists but also of relevance to other mental health professionals and others working in mental health services. It should also be of value to those who have an interest in mental health policy and anyone who cares about the plight of those more vulnerable members of our society.

Included in the Scoping Group review was the full range of people with different diagnoses represented by the specialties within the Royal College of Psychiatrists, including learning disability, drug and alcohol problems, children and adolescents, older adults and mentally disordered offenders. In addition, people who have comorbid diagnoses such as psychotic or non-psychotic mental illness, alcohol and/or drug dependence, learning disability, personality disorder and adult neurodevelopmental disorders (Asperger's syndrome, autism, attention-deficit hyperactivity disorder) are included. The review also covered the full range of age groups and social identities – women, people from Black and minority ethnic groups, lesbian, gay and bisexual people, and faith groups. Most of these groups are represented by the various Faculties, Sections and Special Interest Groups of the College and they parallel many groups covered in the Equalities Review (2007). In addition, specific groups, including the homeless, refugees and asylum seekers with mental health problems, were highlighted by the Scoping Group as they are, by the nature of their circumstances, excluded by society.

The original Scoping Group report took a broad view of the socially inclusive perspective – anti-discrimination laws, equality and human rights, social justice and citizenship – in addition to a clinical perspective.

The preceding chapters confirm what psychiatrists already know from their daily practice – that the people they see experience exclusion and lack access to a wealth of opportunities including employment, housing and education and that this exacerbates their mental health problems.

Psychiatric training, with its long and repeated exposure to direct clinical contact and involvement in the lives of patients equips practitioners to see the importance of social disadvantage. Psychiatrists are well able to see that social disadvantages are both a cause and a consequence of mental illness (Horwitz & Scheid, 1999), that these disadvantages do not necessarily stem simply from a lack of material resources (Morgan et al, 2007), and that those with mental health problems are often excluded in multiple ways (e.g. low income, poor housing). Psychiatry has a long tradition of highlighting the disadvantages that service users face and of working to increase their control and empowerment.

To address the social exclusion experienced by users of mental health services practitioners need skills, knowledge and values that recognise not only the damaging effects of exclusion, but also the benefits of inclusion. Improving the breadth and quality of opportunities afforded not only benefits a person's mental health, it allows people to make positive contributions to their communities and to society and restores the hope for them and their families that they can adapt to the constraints that may be enforced by illness or disability.

These themes overlap significantly with the idea of recovery as applied to psychiatry (Chapter 3). Central to this is the hope that individuals can be helped and supported to define and find new roles and learn to live well even in the face of significant illness or impairment. Empowering individuals to describe their own new roles, to support them in finding or rediscovering opportunities and, where possible, equipping and allowing them to direct and manage their own care, are all important if socially inclusive practice is to become the norm (Case study 14.1). Acquiring the skills for both recovery-oriented practice and to support self-care is a necessary stepping stone for practitioners who aspire to genuine socially inclusive practice.