Aims: To investigate the systemic circumstances required for mental health professionals to engage in the core processes of evidence based practice. Background: Successful evidence based practice is the function of inter-related processes including knowledge acquisition, generation, and application, which occur in complex and dynamic circumstances. Dominant models and approaches to facilitating the use of knowledge in practice by health professionals remain based on linear, technical processes which aim to instigate behavioural changes at the individual level. Emergent conceptualisations argue the need for strategies that consider systemic factors which can impede or facilitate the processes underpinning the operation of evidence based practices in mental health. As yet no efforts have been made to actively apply systems thinking in efforts to improve evidence based practice in mental health. Method: A collective case-study research design was developed by adapting Soft Systems Methodology. Three cases were examined, each selected due to their ability to provide information about one of the core processes under investigation; knowledge acquisition, knowledge generation and knowledge application. Data was collected iteratively from thirteen participants through focus groups and semi-structured interviews. Analysis was undertaken through the inductive open coding of data into sub-categories, following which key categories were identified and considered against individual, group and organisational systems levels. Findings: This study identified twenty-four key categories across the cases and located these against the three systems levels. As anticipated, complex dynamic interactions between different elements at the different levels were identified including, the role of motivation, perception and skill at the individual level, the importance of team wisdom, support and decision making, and the need for organisations to provide adequate infrastructures, ensure access to specialist expertise and a number of elements contributing to a culture of space and support for evidence based practice.

This thesis contributes new knowledge to the field of arts therapies and their relevance in the treatment of depression in adults. The global burden of depression means that available treatments do not address all areas within the complexity of the condition and arts therapies may potentially present a relevant alternative by offering opportunities for non-verbal expression and exploration of creativity. Literature up to date does not offer comprehensive enough description of arts therapies practice and therefore establishing of credible evidence has not been possible. This thesis addresses the gap by exploring the nature of arts therapies practice and its value in the treatment of depression. The research consists of two phases: phase 1 provides a description of arts therapies practice with depression in the UK based on data collected from 395 survey respondents, while phase 2 evaluates group brief art therapy for adults experiencing mild to moderate depression. The project employs mixed methodologies within a creative research design incorporating surveys, interviews, arts-based inquiry and a pilot clinical study to examine multiple perspectives and offer findings meaningful to diverse audience. This project establishes that depression is a common condition among arts therapists’ clients while some of the practitioners consider work with depression their main area of professional interest. It further finds that the therapists address depression through the use of humanistic, psychodynamic and integrative approaches and discovers that certain areas of the therapy process have particular relevance in the treatment of depression (e.g. time, group work, motivation, reconnecting). The pilot clinical study concludes with decrease of depression levels and increase of subjectively perceived wellbeing in all participants immediately after nine sessions of art therapy and in the follow-up. Participants’ experiences, researcher’s observations and arts-based reflections on the therapy process highlight the potential value of arts therapies in areas relating to, among others: connection and sharing, awareness of others and self, sense of achievement, self-expression and regain of meaning. The findings are integrated in the final discussion, which proposes a set of concepts particularly relevant to the treatment of adult depression through arts therapies. This research provides the first comprehensive description of arts therapists’ work with depression in the UK and confirms the potential of this practice to be effective, which is relevant to health professionals and may lead to increased involvement of arts therapies in mainstream healthcare. The particular value of this project lies in shaping the basis for further explorations in the form of larger RCTs as well as demonstrating relevance and superiority of creative research designs in evaluating arts therapies.

Background: Research exploring occupational therapists’ knowledge, beliefs and practice associated with alcohol misuse in physical health care settings is scarce, despite the recognition that professionals are likely to work with people who misuse alcohol irrespective of practice context. Furthermore, the relationship between pre-registration occupational therapy education and practice in the area of alcohol misuse is currently poorly understood. Aims: This critical appraisal aims to (a) frame the knowledge gaps and existing knowledge of occupational therapists related to alcohol misuse in physical health care settings, through the findings of five prima facie case papers and; (b) align this framed knowledge to wider professional literature in order to extend professional understanding of the relationship between education and practice, associated with alcohol misuse in physical health care settings. Methodology: A gap analysis approach was selected and modified to provide a way of critically introspecting and occupationally classifying the gaps in, and existing knowledge of, student occupational therapists, practitioners and educators linked to physical health care settings and alcohol misuse, as reported in the five papers. The introspective data linked to gaps and existing knowledge was unified and general inductive qualitative analysis undertaken. One practitioner working in physical assessment for older people in an acute hospital, and one occupational therapy educator provided stakeholder feedback of the tentative themes generated, further refining the analysis of data. Findings: Two themes emerged from the analysis of data; delimiters of professional education and conceptual contradictions. These indicate there is a need to educate ‘educators’ concerning the value of teaching alcohol-related policy as part of educational programmes, and in raising the visibility of alcohol as a topic. Therapists valued the Person Environment Occupation Model (PEO Model), however the essence of ‘transaction’ fundamental to this model, lacks fidelity in practice. Practitioners appear to separate out the entities of person and environment, placing greater emphasis on the observable aspects of the environment rather than the person, to support timely discharge. Thus, current practice in physical health care supports a process of occupational evaporation connected to alcohol misuse. Conclusion: These findings help to inform the future direction of educational and practice developments connected to patients’ alcohol misuse in physical health care settings, and in so doing, advance and re-emphasise the importance of the centrality of occupation to service delivery.

Purpose – The overall aim of the research is to develop a culturally sensitive arts therapies programme for children with Attention Deficit Hyperactivity Disorder (ADHD) in primary schools in the Kingdom of Saudi Arabia (KSA). This research adapted the UK arts therapies practice to fit these cultural requirements. Design/methodology – The study is a mixed methods design, carried out in two stages. The first stage was to identify the current provision and cultural issues in conducting arts therapies intervention for children with ADHD in KSA. Data was collected using interviews from twelve arts therapists from the UK and nine informants from KSA. The information obtained assisted in the development of culturally sensitive guidelines for the delivery of an arts therapies programme, which was conducted in stage two of the study. The second stage involved a pilot randomised control trial design that took place in an identified school in KSA. This stage involved 12 children aged 6-12, randomly allocated to either the intervention or the control group, with six participants in each group. The programme was carried out three times a week over a period of eight weeks. Data was collected using pre and post-tests (SDQ and ADHD scales) and from interviews of the parents and teachers of the children from both the experimental and control groups. Findings – The findings demonstrate that art therapists in KSA focus on behaviour modification while arts therapists in the UK focus on improving emotional wellbeing. Art therapists in KSA used more structured approaches which are less effective for children with ADHD. There may be cultural problems in using arts therapies in KSA, particularly music and dance. Safety, routine activities and ground rules were adopted from the current practices in the UK and adapted to be appropriate for the cultural context in KSA. A culturally sensitive arts therapies programme may be an appropriate and valuable intervention for children with ADHD. Qualitative and quantitative findings indicate that the intervention of this study achieved specific benefits such as; decreasing hyperactivity/ impulsiveness and inattention. Moreover, this intervention improves relationship/social skills and emotional wellbeing. Practical implications – This programme is found to be beneficial and it may have a significant impact on the treatment of ADHD in KSA. Understanding cultural issues by the therapist increases the value of arts therapies interventions. Value – This study has many benefits as a contribution to knowledge and for the development of services in KSA for this client population. Since children with ADHD currently have minimal access to therapy of any sort, and very limited access to arts therapies, this research has a key role in developing culturally sensitive arts therapies programme for children with ADHD.

Background - One of the most significant changes within healthcare practice and research is a shift from ‘treating’ disability at the level of body function to an ecological approach that addresses the children’s involvement in everyday life, conceptualised as participation. Participation encompasses children’s involvement across home, school and community settings. A complex interaction of personal characteristics, performance skills and environmental factors influence children’s participation. Therefore, assessments that comprehensively and ecologically capture children’s participation and contributory factors are important. Gathering information from parents and teachers may enhance the accuracy of information. Of the currently available assessments, few include multiple informants and provide an overarching portrait of the child’s participation across all settings. The ACHIEVE Assessment is one that does and forms the focus of this work. Methods - Services from across Scotland agreed to participate in the research by implementing the ACHIEVE Assessment and inviting parents to consent to use of their child’s information. Rasch modelling was used to analyse the ACHIEVE Assessment. Parent and teacher questionnaires were also compared. Results – The study includes a large clinical sample ranging in age from 4-17 years old, with an average age of 8 years. The results from the study demonstrate that the ACHIEVE Assessment provides unidimensional measurement of children’s participation and contributory factors. The environment items measure a separate latent trait and are too easy for respondents to endorse. Parent and teacher questionnaires fit on the same dimension. However, self-care and social skills items differ in function between respondents. In addition, there is a low correlation between parent and teacher questionnaires. Overall, items relating to children’s participation in activities are easier than items about contributory factors. Process skills items are the hardest to endorse, despite the sample predominantly including children referred for reasons related to motor difficulties. Items about children’s school activities are relatively harder than items about community activities. Finally, item function differs for children in the youngest age group. Conclusion – Using Rasch analysis allowed exploration of the complexity of factors that interact to influence children’s participation as captured by the ACHIEVE Assessment. The study demonstrates the measurement qualities of the participation items on the ACHIEVE Assessment, however the environment items require further development as a separate measure. The item hierarchy emphasises the importance of further investigating the association between children’s process skills and their participation, in addition to research in the area of school participation. As there are only weak associations between parent and teacher reports, one is not substitutable for the other and multi-informant assessment will be an important strategy for gathering comprehensive information about children’s participation.

The chronic pain associated with rheumatoid arthritis (RA) is identified by patients as a priority for treatment and is said to shape their illness experience. However, review of the literature reveals that little is known about patients' perspectives on pain in RA, with even less being known about how rheumatologists, the clinical experts in patient care, perceive this phenomenon. Increasing knowledge and understanding of patients' and rheumatologists' perspectives on pain can be used to try to influence their action/inactions as well as helping to identify patients' specific concerns and unmet needs. The aims of this study were: To describe patients' and rheumatologists' perspectives on the meaning of pain in RA; To explore how these pain meanings are constructed; and To consider the implications of these constructions for pain management. This interpretive, qualitative study used semi-structured interviews to generate accounts related to respondents' perspectives on pain in RA. Purposive sampling was used to select a heterogeneous group of patients with RA (n=29) and rheumatologists (n=16). Thematic analysis was used inductively to generate findings using a cumulative, constant comparative technique (Strauss and Corbin, 1998). Both patients and rheumatologists presented multiple pain meanings but generally viewed pain as an expected symptom of the disease, both being resigned to the belief that most patients would have some degree of daily pain. Additionally, both groups considered the pain experience to have a pervasive, negative impact on life, potentially threatening the patient's concept of 'self'. In contrast, patients' and rheumatologists' pain meanings regarding clinical topics were not similar. Patients' views of medical responsibility were narrowly difined, rooted in western biomedical conceptions of pain and were influenced by experiences of clinical interactions. Accordingly, patients viewed the rheumatologist to be responsible only for 'legitimate' pain i.e. pain associated with the body and disease processes. Rheumatologists, on the other hand, presented a more comprehensive understanding of pain by incorporating psychological and social theories along with an associated 'ideal' model of care (reflecting a biopsychosocial approach). Consequently, they identified eclectic roles/responsibilities for themselves in patient management. However, rheumatologists viewed this 'ideal' as difficult to attain in the context of their experiences of clinical work where multiple constraints were perceived to exist, such as difficulties in deciphering pain, the perception of limited resources (e.g. time) and organisational barriers. In light of this, their role was often reduced to focusing simply on disease management, thus displacing the 'ideals' of patient-centred care and perpetuating the dominant biomedical discourse of pain in the clinical context. This thesis adds to the body of knowledge about patients' perspectives on pain when they live with a chronically painful condition and patient barriers to reporting pain. New findings are presented regarding the medical experts' conceptions of pain; in particular, those related to complex clinical work. The findings also identify areas of unmet need regarding patients' knowledge of pain, pain management and of the roles and responsibilities of healthcare professionals. Suggestions are made for further work in the areas of investigating patient barriers to reporting pain; exploring patient perspectives on self-management and using alternative research methods to complement and develop the findings from this study.

The thesis contextualises creative dance as art in a community setting. The participants were teenage members of a community-run creative dance company. The aim was to explore any links young people make between their creative dance experience in a community class and their feelings of social well-being. The literature gives a brief historical overview of dance as a performing art and of the nature of aesthetics and creativity. It considers the art of dance as a form of communication, and the conditions for creativity to flourish. It looks at Bourdieu‘s (2005) theory of ‗habitus‘ and ‗field‘ in understanding the social experience which the dancers derived through creative dance. Consideration is given to theories and accounts of adolescent development and how community interaction can affect the dancers‘ feelings of social wellbeing. The methodological approach is hermeneutic phenomenology, with influences from ethnomethodology and social constructionism. The ontological principle is that personal meaning is socially constructed. Epistemologically the study is informed by the belief that knowledge is generated through the creative dance experience. The main data collection method was semi-structured interviews with the dancers (n=10), supported by observation of dance classes (n=7; filmed: n=4), group discussions (n=3) and graffiti walls (n=8, completed by the dancers). The data were organised and analysed thematically using a method of presentation inspired by Bourdieu‘s concept of a ‗social trajectory‘ - a lifetime journey of social encounters – offering headings under which the data were loosely organised. Selected observations are presented on DVD. The responses suggested a dance ‗journey‘ from preparation to performance, which allowed further organisation of data. The emergent themes included the dancers‘ motivation for dancing, their feelings about the creative process, experiences of social interaction and of taking control of one‘s own identity, through all the stages of experimenting with movement, refining the dances and performing. The main findings are: the dancers attached importance to company membership because it offered a means to clarifying self-identity through physical and artistic endeavour; the creative dance context gave them freedom to explore their movement capabilities and to interact socially, and thus gave them a means of negotiating their ‗habitus‘, i.e. adopting and adjusting social norms and values on their own terms. Performing was a celebration of achievement and confirmation of identity as a dancer. The study contributes to the understanding of how adolescents make sense of their identity in their social context through their creative dance experience and how that influences their feelings of social wellbeing.

M.A. (Clinical Psychology) / Please refer to full text to view abstract

This research explores the overlap between community-based art therapy and school-based art therapy through the surveyed experiences of art therapists working in school settings, and informed by community-based art therapy components and characteristics identified in A Model for Art Therapists in Community Practice by Dylan Ottemiller and Yasmine Awais. A literature review focused on five components and characteristics identified within the community-based art therapy literature, and informed the review of school-based art therapy literature based on the community-based art therapy themes. A qualitative survey approach was utilized through the distribution and data analysis of an electronic survey and findings were enriched by the researcher’s participation in the development and implementation of a brief community-based art therapy program providing an art therapy experience to families receiving services at a domestic violence intervention center. Analysis of the data revealed three major themes and specific areas where school-based practice is facilitating community-based art therapy (CBAT) components and characteristics. The findings discuss which CBAT components and characteristics are and are not being facilitated within school-based practice, and in conclusion the research offers ways school-based art therapy programs may offer opportunities for community-based practice.

Meno terapija – tai savęs pažinimo procesas bet kokia menine išraiška, kuri kyla iš emocinių gelmių. Meno terapija padeda mintis ir emocijas išreikšti vaizdais, muzikos garsais, šokio judesiais, o ne žodžiais. Svarbiausia – procesas ir žmogus. Menas naudojamas kaip priemonė komunikuoti, kaip būdas išsakyti nesuprastus jausmus. / Art therapy - this self-discovery process in any artistic expression that stems from the emotional depths. Art therapy helps to express the thoughts and emotions of images, sounds, music, dance moves, and not the words. The most important thing - the process and the person. Art is used as a means of communication, as a way to express feelings misunderstood.