Research shows that UK Caribbean patients with psychosis have more aversive pathways in psychiatric care compared with the white British population. This may indicate "cultural mistrust" of services which is attributed by Caribbean patients to racism, explaining their poorer adherence and engagement with services. Mistrust may reflect a mismatch in the attribution of illness between patient and psychiatrist: whereby the patient perceives both his predicament and services as racist and oppressive, whilst the psychiatrist over-estimates the "dangerousness" of the patient. No study to-date has examined the association between the perception that society and services are racist and adherence with psychiatric treatment in Caribbean patients with psychosis. This is a London-based prospective cohort study of 100 Caribbean patients with psychosis. It uses the Perceived Racism Scale (PRS - a multi-dimensional measure of self-reported racism), the Drug Attitudes Inventory (DAI) and the Kemp seven-point scale (a commonly used self-report and multi-sourced measure of adherence, respectively). Perceived racism was measured at baseline using the PRS, with adherence and hospital admission data determined after 12 months, using the DAI and Kemp Scale. The study found small but independent and significant associations between measures of total perceived racism for the previous year, over a lifetime, and everyday racism for the previous year, with medication adherence one year later. It also found that feeling ashamed and powerless about any racism that was personally experienced within the health system were associated with increased adherence and fewer hospital bed-days in the subsequent year. Finally, the strongest positive association was between perceived racism within the system and both the number of subsequent hospital bed-days and length of hospital admission over the next year. This implies that in this group of UK Caribbean patients with psychosis, perceived racism is a determinant of adherence with psychotropic medication over a twelve-month period.

BACKGROUND: The relationship between psychotic disorders and substance use is well established but complex. High rates of psychosis and greater risk of negative outcomes have been found in Black Caribbean and Black African groups. In addition research within the general population has shown important ethnic differences in patterns of substance use disorders (SUD). An under researched issue is the impact of SUDs on treatment and outcomes for people suffering from psychosis and whether this impact differs by ethnic group. METHOD: This PhD study aimed to investigate the prevalence, correlates and experiences of comorbid SUDs in patients with an 8-12 year history of psychosis with special attention to Black African and Black Caribbean groups. The study comprised two phases. The first phase utilised data from the AESOP-10 follow-up study of 325 epidemiologically based White British, Black Caribbean and Black African individuals who originally presented to psychiatric services in London and Nottingham between 1997 and 2000 with a psychotic disorder. The second phase was a qualitative study that purposefully selected a sub-sample of patients from the AESOP London cohort. AIMS AND HYPOTHESES: It was hypothesised that there would be higher rates of SUDs in Black Caribbean and lower rates in Black African ethnic groups compared to White groups and that irrespective of ethnicity comorbidity will be associated various negative factors. The second phase aimed to describe the experiences of mental illness, SUDs and treatment experiences in all ethnic groups. RESULTS: The quantitative study found that Black African patients had a significantly lower prevalence of SUDs than White patients (Comorbid DUD: OR 0.090, CI 0.025-0.327, p=0.000; Comorbid AUD: OR 0.066, CI 0.013-0.322, p=0.001). Black Caribbean patients with drug use disorders and White British patients with alcohol use disorders were more likely to have negative outcomes however many these findings failed to reach statistical significance. Findings from the qualitative study highlighted the use of numerous devices and mechanism in account giving. Several thematic constructions were uncovered including lay models of illness aetiology, perceptions of a causal relationship between illness experiences and substance use, perceptions of a relationship between cannabis and paranoia, perceptions of cannabis use as non-problematic and the importance of the role health services (particularly talking based therapies), family and mastery play in the treatment and recovery process. CONCLUSIONS: Mixed method design involving large longitudinal epidemiological and qualitative studies are an appropriate way of investigating the relationship between psychosis and substance use disorders. Patients with comorbid SUDs may be more likely to have subsequent relapses and hospital admissions over the course of their illness, however the likelihood of this may differ for different ethnic groups and type of substances used. Talking based treatments which focus on lay models of aetiology, mastery of symptoms and cannabis use and involve the patients larger social networks are likely to be of benefit to this population. Further epidemiological and qualitative research into the changing patterns of substance use over a time are necessary.

This study involves a qualitative investigation into the experiences of 10 White/Caucasian fathers who have a diagnosis of psychosis (schizophrenia, schizoaffective or other psychotic-type disorder). Fathers with psychosis have often been ignored by the research community. This project was designed to explore some of the potential issues concerning this group, such as: What is it like to be a father with psychosis How do they evaluate themselves in terms of fulfilling their idea of the parenting role Do they have fears of passing on the illness to their children Do they have fears of losing custody of their children The collected data was analysed by means of Interpretative Phenomenological Analysis and evaluated with regard to previous research. This study found that psychosis may directly and indirectly undermine the father-child relationship and the work of parenting. The fear of one's children inheriting psychotic illness is a widespread concern amongst this group. In the process of fulfilling the role of fatherhood, men with psychosis benefit from a sense of pride in the father role, a sense of purpose to one's life, a feeling of pleasure in the creation and development of life, and motivation to change for the better. The results are used to identify possible innovations and improvements in the services received by fathers with psychosis and their families. The results were also used to suggest further avenues of research with this group.

Stigma is a widely researched concept, with public stigma, courtesy stigma and self-stigma (or internalised stigma) frequently cited as issues for those experiencing mental health issues. Individuals with experiences of psychosis are some of the most stigmatised in society, and yet the consequences of stigma on outcomes in psychosis are unclear. The four studies presented in this doctoral thesis used mixed methods to examine the impacts of stigma on recovery from psychosis, and the psychological mechanisms through which these effects might occur. It addresses two areas lacking in sufficient research within the stigma literature: clarity in the relationship between experiences of stigma and internalised stigma; and the effects of stigma on outcomes in psychosis. In particular it examines the relationship between stigma and internalised stigma with two diagnoses on the psychosis spectrum: schizophrenia and bipolar disorder. The study reported in Chapters 3 and 4, was a qualitative investigation based on interviews with 19 individuals who had received a diagnosis of either schizophrenia or bipolar disorder. The objective of the investigation was to explore how individuals processed receiving a diagnosis of schizophrenia or bipolar disorder, and how perceived, experienced and internalised stigma influenced the participants’ self-perception, interactions and recovery feelings. Three overarching themes were identified which were negatively affected by stigma: reactions and responses; relationships; and recovery. The study reinforced the notion that stigma is a significant concern for service-users with diagnoses of bipolar disorder and schizophrenia, and was pervasive in all spheres of life; ultimately impacting on hopes for the future. An unexpected aspect of the qualitative interviews was the participants’ focus on the role of mental health services and experiences of treatment, particularly antipsychotic medication. As this is clearly an important aspect of the participants’ experiences of living with psychosis, this was written up separately, forming Chapter 4. Five overarching themes were identified: living with medication; reinforcing stigma; involvement in care; unmet needs; and positive aspects of care. The findings from this study indicated that whilst service-users made positive reports of aspects of both medication and clinical services; they had extensive concerns about the use of medication, and felt limited in their choice of alternatives. Moreover, service-users felt they lacked autonomy, were not involved in care decisions, and thought their contact with services lacked the ‘human touch’ and could be both invalidating and frustrating. The study presented in Chapter 5, used an epidemiological, longitudinal dataset (n=80) that formed part of independent research commissioned by the National Institute for Health Research (NIHR) under its Programme Grants for Applied Research scheme (RP-PG-0606-1086). This study aimed to examine how stigma impacts on symptomatic and subjective recovery from psychosis, both concurrently and longitudinally. We also aimed to investigate whether self-esteem and hopelessness mediated the observed associations between stigma and outcomes. In cross sectional regression and multiple mediation analyses of the baseline data, we found that stigma predicted both symptomatic and subjective recovery, and the effects of stigma on these outcomes were mediated by hopelessness and self-esteem. When the follow-up data were examined, stigma at baseline continued to predict recovery judgements and symptoms. However, self-esteem only mediated the effect of stigma on passive social withdrawal. The study reported in Chapter 6 utilised a clinical sample of 59 service-users with a diagnosis of either schizophrenia or bipolar disorder. The objectives of the study were to assess the impact of stigma on subjective recovery from psychosis, and whether self-esteem and internalised stigma mediates the observed associations between stigmatizing experiences and outcome, thus clarifying the relationship between stigma, self-stigma and recovery. Diagnosis was a persistently significant factor in all analyses, suggesting a negative effect of the term ‘schizophrenia’ on subjective recovery perceptions. In a multiple serial mediation analysis, experiences of stigma predicated subjective recovery and this effect was mediated through internalised stigma, which consequently impaired self-esteem. Findings from these studies suggest that stigma reduces individual’s perceived ability to recover, impairs individual’s perceptions of their progress in recovery, and negatively impacts on psychosis symptoms. These effects occur predominantly through the internalisation of stigma, causing devaluation of self-image and consequently reducing self-esteem. The findings further suggest that whilst the experiences of individuals diagnosed with bipolar disorder and schizophrenia are predominantly similar, ‘schizophrenia’ is an inherently negative term which affects subjective recovery perceptions even when controlling for symptoms. Finally, it is evident that help-seeking is not always helpful, and there are numerous issues with medication and mental health services that can create feelings of hopelessness and reinforce stigmatising stereotypes of severe mental illness. Overall, the findings have significant clinical implications. Internalised stigma is an important psychological mechanism in recovery, and directly links to experiences of stigma. There is a need for clinical services to work in a stigma-informed way in an effort to reduce the impact of stigma post-diagnosis, as well as the development of interventions aimed at preventing stigma from being internalised. Interventions aimed at improving self-esteem and reducing hopelessness for psychosis-spectrum service-users are needed to further reduce the effects of stigma on recovery. Moreover, there is a need for clinical services to reduce behaviours that reinforce stigma, and work collaboratively and transparently with service-users; ensuring that goals for treatment correspond between clinicians and consumers to provide a more patient-centred approach to care.

Common mental disorders (CMD) is used to describe depressive and anxiety disorders. Community prevalence rates worldwide are estimated between 15%-30%. Mental health services however are mainly geared towards those with the more severe forms of mental disorder. Although the prevalence of CMD is high, little is known about help-seeking behaviour for people with CMD in community settings, particularly in developing countries. The main aim of this research is to investigate the patterns of help-seeking behaviour for CMD in an urban Malaysian community and identifying the determinants of helpseeking behaviour. A two-stage cross-sectional survey was conducted in a Malaysian urban community. Participants aged between 18-45 years, were randomly selected from an electoral register. A total of 614 participants were interviewed and assessed. In addition to background information and self-reported help-seeking behaviour, all participants were presented with a vignette depicting a person with depression and were questioned to assess level of recognition, causal beliefs of depression, recommended help-seeking behaviour and stigmatizing attitude towards sufferers. All were screened with the General Health Questionnaire (GHQ-12) and probable cases of CMD were further interviewed with the diagnostic Mini International Neuropsychiatric Interview (MINI). Stage 2 was conducted to carry out a descriptive study of pathways to care of participants with diagnosed CMD. Prevalence of CMD was 8.8%, and the risk factors associated with CMD were age, marital status, ethnicity, unemployment, and status as student. Following adjustment, only age remained significantly associated with CMD. About one third (33.1%) of the study sample had engaged in general help-seeking behaviour in the past 4 weeks. The types of help sought were namely biomedical and complimentary or alternative medicine (CAM). Those who sought help were more likely to be female, older and diagnosed with CMD (p<O.05). Similar factors were found to be significantly associated with seeking biomedical care (p<O.05). In relation to the study's main interest of the associations between help-seeking and CMD, the results indicated that people with CMD were more than 2 times more likely to utilize biomedical care (p = 0.016), where help-seeking may not have specifically addressed CMD in particular. Explanatory Models for CMD were investigated across domains of recognition levels, causal attributions and stigmatising attitudes. Almost all the participants recognized CMD as a problem (96.9"10) although only half (5 1.8%) belived CMD amounted to an illness. Six different causal attributions to CMD were generated namely psychological, physical, employment, relationship, financial and supernatural. For help-seeking specifically for CMD, the results were analysed for a hypothetical case via responses to vignette, as well as actual cases based on diagnosis. The major factors predicting biomedical help seeking for the vignette were recognition of depression as a problem, as an illness and fmancial causal attribution. Of the confinned CMD cases, only 42.6% have sought any kind of help for their problems and almost none sought specialised mental health care. Based on the findings, it is evident that a substantial number of people in the community have CMD and they generally utilize biomedical sources at the primary care level more than those not diagnosed with CMD. Although socio-demoraphic factors were predictive of help-seeking behaviour in general, they were not predictive of help-seeking for CMD. Results indicated Explanatory Models were predictive of help-seeking behaviour specifically for CMD. Help-seeking behaviour generated for CMD were mostly in line with the biomedical approach, followed by self-help and lastly CAM. Implementing policies to integrate care for CMD into primary care, promoting awareness, recognizing roles of other sectors, supporting self-help and ensuring accessibility to care would ensure people receive the appropriate care they need.

Empowerment has been identified as important in recovery from severe psychological distress by policy makers, mental health services and by service users. However, while there has been a huge amount of research into the role of empowerment in recovery for people with severe psychological distress, constructions of mental health and illness differ regarding the factors involved in recovery and what encourages empowerment. In addition, much of the research in this area has been conducted by professionals; the process of empowerment has yet to be explored and delineated from the perspective of the service user. This research aims to explore the role of empowerment, and conversely disempowerment, in recovery from the severe psychological distress which involves the experience of hearing voices or having unusual beliefs which have led to overwhelm. A social constructionist grounded theory methodology was adopted using two methods of data collection: semi structured interviews with 8 service users and 12 narrative accounts written by authors in recovery. Findings indicated that participants were disempowered by invalidating and events and relationships. This led participants to attempt to cope with distress and voice hearing by disconnecting from themselves, from other people and from their feelings. Compensatory fantasies regarding power were often developed as a way of coping with disempowerment. These strategies tended to be unsuccessful and participants became increasingly overwhelmed, losing a coherent sense of self and eventually became socialised into becoming a ‘mental patient’ and surrendering control to professionals. Conversely, participants became empowered through feeling validated in their relationships with others, with their voices and with themselves. Participants made connections socially through forming more understanding relationships, reintegrating parts of themselves and understanding voices through relating them to past experiences. Through this people gained an increased sense of autonomy and purpose found it easier to accept themselves and their voices. Recommendations for practice are made and areas for further research suggested.

Ideas about shared decision making (SDM) began to emerge in the 1970s as a challenge to the tradition of paternalism in healthcare. Theoretical models have focused on delineating this process and identifying discrete stages including exploration of service-user preferences, deliberation in relation to possible interventions and an emphasis on interactional, two-way communication processes that prioritise collaboration. There are particular challenges in terms of enacting the principles of shared decision-making with those with more complex mental health needs including experience of psychosis. Types of experience (unusual beliefs, intrusions, suspiciousness, changes to cognitive processes) along with issues of capacity, consent and the legal framework of the Mental Health Act (MHA; 1983) make it more challenging to implement these principles, even though they are laid out in best practice guidelines, and consistently correlate with positive outcomes for service-users. This study focused on the construction of SDM in routine clinical practice by video-recording consultations involving decisions between service-users with experience of psychosis and mental health staff in a community setting. This was with a view to moving beyond exploration of the experience of SDM to look at the enactment of these ideas in practice. Three separate clinical meetings were recorded, which captured seven decisions related to different aspects of care and treatment. The final sample comprised 3 service-users, 1 carer and 5 professionals. Participants then watched the recording with the researcher, and reflective interviews were conducted to facilitate exploration of their experience in the meeting. The study proceeded from a social constructionist perspective, drawing from the principles of Discourse Analysis, more specifically Discursive Psychology. Analysis focused on constructions of psychosis, key features of participant talk and discursive and rhetorical features in order to examine impact on SDM. The findings highlighted different ways of sharing opinions, directing or redirecting the dialogue, expressing agreement or disagreement and the challenge for staff in terms of promoting choice whilst also fulfilling legal and clinical responsibility. The findings also pointed to some important differences between physical and mental health SDM, and supported previous findings indicating that dominant discourses of psychosis impact collaboration at the micro-level of interactions between speakers in individual meetings. Based on these findings, I offer some reflections on implications for clinical practice, including consideration of idiosyncratic and decision-specific approaches to SDM with this population that account for the nuanced experience of psychosis. I also make some suggestions for directions for future research, including repeating the study in acute inpatient settings.

This dissertation provides an interpretation of the accounts of six mothers who have a diagnosis of mental illness and also have children who are being treated for emotional or behavioural difficulties. The participants took part in an interview where questions were asked about their experiences of being a mother, having a child with difficulties and the impact of their children's difficulties on them. The data produced were analysed using Interpretative Phenomenological Analysis (IPA). Attention was given to the role of the researcher as a clinician who works closely with this client group and its influence on the interpretation of the material. From the analysis, one main superordinate theme emerged, the idea of a split identity between three elements: mental illness, motherhood and being a person in their own right. These three aspects of identity often entered into conflict with one another. Motherhood was the most valued aspect of their identity. However, mental illness influenced the way in which they performed as mothers. A desire to be seen as good mothers influenced their narratives of how mental illness affected their children and promoted a neglectful attention to their own needs as individuals. A number of sub themes describe particular aspects ofthis tripartite identity. The relationship between the findings in this study and existing literature, as well as implications for clinical practice are discussed.

The aim of the study was to explore the link between perceived parenting and later psychological wellbeing by considering the potential mediators of mindfulness and self-compassion. Trait mindfulness and self-compassion have both been shown to be linked to wellbeing and perceived parenting, as such, it is timely to explore these as the potential mediators. It was proposed that the quality of parenting received, in particular parental care and parental overprotection as measured by the Parental Bonding Instrument (parker et al., 1979), is associated with psychological wellbeing later in life, that of depression and anxiety symptoms and quality of life, through the influence that parenting has on the child's developing mindfulness skills and their ability to be self-compassionate. The different facets identified within mindfulness were explored as potential mediators, these being 'observing', 'describing', 'acting with awareness', 'accepting without judgement' and believability in negative thoughts and the related construct of self-compassion. Participants were 409 undergraduate students, who completed measures of perceived parenting, mindfulness and self-compassion, depression and anxiety symptoms and quality of life. Mediation analysis demonstrated that 'acting with awareness', believability in negative thoughts and self-compassion were significant and unique mediators for the relationship between both parental care and parental overprotection, on the one hand, and depression and anxiety symptoms and quality of life on the other. Additionally, the mindfulness skill of 'describing' was a significant unique mediator of the relationship between parental care and overprotection and quality of life. The mindfulness facets of 'observing' and 'accepting without judgement' were not found to be unique significant mediators. These novel findings have implications in developing the focus of clinical interventions on the specific facets of mindfulness that were found to be unique significant mediators when working with those who are experiencing poor psychological wellbeing and who also report a poor bond with their parents

Myalgic Encephalomyelitis (ME) remains a controversial disease, shrouded in medical and social uncertainty. This thesis examines connections between language, space and representations of becoming diagnosed and living with the often severe effects of this chronic illness. Dominant medical and political institutions, often successful in funding, hold the power to drive the medical debates surrounding aetiology and treatment. As these institutions govern and wrangle over the ‘making’ of a definable truth, people are living with the ‘reality’ of illness. In order to address the issues of living with this chronic illness, this thesis examines 9 life stories and 8 subsequent Photo-Elicited Diaries of 2 males and 7 females diagnosed with ME (also known as Chronic Fatigue Syndrome). This thesis adopts a transdisciplinary approach and employs critical discourse and narrative analyses to both the bio-political and socio-cultural contexts. A kaleidoscopic view was applied to examine the discursive, material and relational aspects of living with a particular chronic illness. This method identified issues of ‘doing’ illness whilst ‘being’ chronically ill. Taking such an approach exposed the power relations, social practices and subjective experiences of becoming and mastering illness, often within the enclosed spaces of homes/hospitals and house/bedbound. The findings reflected on the severe effects as a causal agent for displacing personal and social truths, for continually plugging in and out of social worlds and the conditions of possibilities for resisting and surviving chronic illness. By combining narrative and visual accounts the rich complexities of living with a severe chronic illness could be better explored. This study advocates the benefits of combining spoken and visual experiences of illness for future studies and has the potential to impact approaches employed within the therapeutic setting. As the house/bedbound tend to remain the missing voices within medical and social research, this study joins an urgent call for research to focus not merely on disability issues, but impairments and the associated effects - relapsing, recovering and surviving chronic illness.