This qualitative research set out to explore how far understanding is shared between systemic psychotherapists who write expert reports for family courts and the judges who receive them, with particular reference to various concepts involved in the process such as truth, objectivity and expertise itself. Data obtained from semi-structured interviews with systemic “experts” and family judges was analysed using Grounded Theory. In response to ideas emerging from initial interviews, the focus broadened to consider how, despite the potential advantages of a relational approach to this working context, the possibility of these benefits being delivered by the involvement of systemic psychotherapists remained “invisible” to judges. Different beliefs were identified around the idea of being able to assess openness to change without actually introducing change. The complexity of cases and the responsibility of making hugely significant decisions about children and families were seen to require family judges to be more “interventive” than judges in other areas of law, and systemic experts to be more “certain” than in other contexts. The values, beliefs and sources of knowledge which inform the ways in which experts and judges reconcile those challenges and tensions within the context of a rapidly changing family justice system were compared. Some ideas were generated both about ways of supporting and enhancing these professional roles, and about implications for practice.

Continuity of care in mental health care is considered both an important objective of NHS policy and vital to clinical practice. However, it remains poorly defined and there is little research into its association with outcomes. Mental health services are unique in their ability to legally compel patients to adhere to treatment in the community and there has been no research into how this may affect continuity. My thesis aims to critically appraise the definition of continuity of care and systematically review the literature on its association with outcomes. It also measures its association with readmission by conducting a longitudinal study, and measures the association between community compulsion and continuity of care. The literature review confirmed that continuity of care is best understood as the process of care of an individual patient over time. This is perceived by both the patient and providers of care as comprehensive, consistent, and connected. The systematic review found little evidence for an association between continuity of care and outcomes but that this may be due to persisting variation in both measures and outcomes. Results from the longitudinal study suggested that better continuity was associated with both better and worse hospital outcomes. Community compulsion had no association with continuity of care. My findings suggest that patient follow-up has improved considerably in the last three decades and, because of this, some traditional measures of continuity may be redundant. Measures of frequency of contact do not accurately measure the flexible, assertive practice that is a feature of current services. Continuity of care is useful as an indicator of the process of care but for it to be an effective research tool there needs to be a radical change in the way it is measured. Current mental health services are characterised by separation and specialisation into different components of care. Therefore, the most useful measures of continuity of care may be ones which successfully measure how it can be maintained between these services.

For the period 2012-2016, the Thai 11th National Health Development Plan focuses on the accessibility and equity of mental health care by using community collaborations in order to ‘strengthen and empower the sub-district health system’. In reality, demands and supply should be balanced, based on available resources. Therefore, including the patients’, caregivers’ and health care providers’ perspectives for schizophrenia care improvement is considered helpful to gain an in-depth understanding of the community mental health nursing care situation; this endeavour is aimed at improving mental health nursing practices, based on available resources. There has been no previous research exploring stakeholders’ perspectives of care at the primary level in the rural Thai community. This qualitative study aims to provide an in-depth understanding of both service users’ and service providers’ views. Semi-structured interviews were carried out with 40 participants within three groups, which involved patients with schizophrenia, their caregivers, the primary care staff in the community, and the supervisory teams in the community and psychiatric hospitals. Interviews were transcribed verbatim, translated into English and analysed using thematic analysis. Each group of participants was analysed individually to provide specific and integrated themes. Three key areas relating to all three groups are 1) the lived experience, 2) the importance of medication and 3) the service and support needs. The results illustrate the complexity of the Thai situation, due to poverty within a rural environment and conflicting views regarding the need to move away from a biomedical model of care. The results will be used to inform community mental health nursing practice and education in Thailand.

There is a wide and impressive historiography about British lunatic asylums in the nineteenth century, the vast majority of which is concerned with their nature and significance. This study does not ignore such subjects but is primarily concerned with the patients, and specifically those of the Bristol Asylum. It asks who they were, what their stories were, how they fared in the asylum, and how the patients’ experience of the asylum changed during the period 1861-1900. It uses a distinctive and multi-faceted methodology, including a comprehensive database - compiled from the asylum records - of all the patients admitted in the nineteenth century. Using pivot tables to analyse the data, the range and nature of the patients admitted according to social class, occupation, age, sex and diagnosis have been accurately assessed. This data dispels suggestions that the patients as a group represented an ‘underclass’. It has also been possible to determine in what ways the asylum changed and how successive medical superintendents altered its nature and ethos. One of these results showed how these various doctors relied on significantly different diagnostic criteria. This affected the lives of the patients and illustrates the somewhat erratic nature of Victorian psychiatric diagnostics. The database was also the starting point for the research here into the patients as individuals. Many aspects of life in the asylum can best be understood by looking at individual cases. The database and other records demonstrate the extent of epilepsy at the asylum, for example, but only individual case studies will show the extent of the suffering and life changing effects consequent upon that illness. Contributing to the telling of these stories is a substantial collection of photographs of the patients. Although their value as evidence is a matter of judgement, it is demonstrated here that they significantly aid our historical imagination – a vital element of social historical practice - in understanding the humanity and suffering of the primary subjects of this study. This study aims, therefore, to be a useful contribution to a growing historiography which offers a more nuanced view of the asylums and brings the lives of patients to the forefront.

This thesis explores psychological distress in health care professionals (HCP) and patients in renal settings across three chapters. Chapter one systematically reviewed the quantitative literature on burnout and job satisfaction in renal HCPs. The chapter pays particular attention to features of the environment which contribute to burnout and dissatisfaction. This paper found moderate to severe levels of burnout in renal HCPs, with multiple environmental contributors, including high workload and poor organisational and leadership support and perceived professional progression. The second Chapter qualitatively explored the lived experiences of patients who received the ‘Moncrief-Popovich Technique’ in preparation for transition to peritoneal dialysis (PD). This cross-sectional study utilised Interpretative Phenomenological Analysis (IPA), with semi-structured interviews. Four participants of equal gender split were recruited. Analysis revealed four interrelated super-ordinate themes capturing the participants’ experience of transition to PD; End of part of your life, Control the direction, not the outcome, Protection of the self and Moving onto the next step. Each super-ordinate theme carried sub themes which elaborated participants’ experience of fragmentation, identity fragility, adaptive coping and relationship forming related to decision making and perceived control. Participants used the embedded period as a time for maintaining normality and feelings of safety and containment; however, distress was present, as was expected when exploring transition. The third chapter explored implications for theory and clinical practice which emerged from the previous chapters. This chapter highlighted the importance of a dual approach to addressing distress in HCPs in order to adequately support patients’ distress. Organisational interventions based on psychological theory and national policy are recommended, including a psychologically informed implementation model. Personal reflections of the research process and outcomes are also considered.

This thesis explores the roles of family and healthcare professionals in type 1 diabetes (T1D) in adolescence. The first paper is a systematic review of literature regarding family-based interventions for adolescents with T1D. Adolescence is known to be a particularly challenging time, associated with deterioration in diabetes management and increased family conflict. A systematic search of three electronic databases plus hand-searches of relevant papers, identified 26 papers reporting on 16 intervention studies that met the inclusion and exclusion criteria. Interventions varied considerably in their content and duration. A narrative synthesis considers the effectiveness of these interventions on health, family-related and adolescent psychosocial outcomes. The most intensive interventions had the most support, however there is also promising evidence regarding less intense, quarterly psychoeducational and problem-solving interventions. The empirical paper explored the lived experience of eight healthcare professionals’ working with adolescents with T1D and poor adherence to treatment. Data was analysed using interpretative phenomenological analysis and four superordinate themes were identified; “empathy and insight”, “negotiating relationships”, “impact on self” and “coping”. Professionals empathised with the adolescents whilst also being driven by insight of the risks of poor adherence that the adolescents could not comprehend. They valued a close relationship with the adolescents but also had to balance parental involvement. Poor adherence had a personal impact on each professional, including a sense of powerlessness and failure, but also reward. Professionals coped with these experiences in different way, including negotiating when to do more and when to let go. Clinical implications include a potential benefit of acceptance-based training and reflective practice. Contributions to theory and clinical practice considers the overall impact of these findings. Particular reference is made to the systemic factors involved in adolescent diabetes management and the role of clinical psychology within paediatric diabetes teams.

According to Frumkin (2001), now more than ever before people need to reconnect with nature. Contact with nature is considered by many as crucial to mental health and wellbeing (Kellert & Wilson, 1993) and there are many ways in which these benefits can be accessed. Wilderness therapy is considered as a popular concept in the mental health field in the USA and Australia (Levine, 1994) and there are many different structured programmes that exist (Crisp, 1997), with similar potentials and outcomes. A review of the literature considers the purposes and meaning of terms like wilderness; mental health and wellbeing in the natural environment, particularly in a UK context; the features of structured outdoor programmes; and theories related to contact with nature. The aim of this research is to examine the relationship between humans and their environments, and what might be therapeutic in these relationships. The thesis seeks to explore the best way to work with the features of the natural environment, in order to identify the qualities that contribute to people's experiences. A custom-designed walking and solo experience (WSE), suited to UK conditions, is presented. Two WSE's were run, to explore university students' perceptions of walking through and being with the environment. The first was a five day journey (n=4; 3 females and 1 male) and the second (n=5; 3 females and 2 males) consisted of the same elements and number of days, but took place over two weekends; with a two week interval in-between. Participants' perspectives were gathered from pre- and post-experience interviews, journal writing, group discussions and a nine month follow-up interview. A thematic analytic approach was taken to analyse the data. Both WSEs were considered together in analysis, but comparisons were made so as to evaluate implications for practice. As one of few UK-based studies on experiences of outdoor structured experiences, this research makes a valuable and essential contribution. Considerations of the WSE structure of the two studies are discussed and suggestions are made for alternative approaches to this kind of research. It infers that if time and cost allow, a longer five consecutive day WSE is better, but using weekends may still be effective. A good balance should also be sought between group and solo elements as the latter aspect was reported to be more beneficial for these two groups.

Background: Recovery from severe mental illness, namely schizophrenia, is a contemporary issue. Globally, twenty-four million people live with schizophrenia, men and women being equally affected. Of those diagnosed with schizophrenia, 90% are said to be living in developing countries. However, while Western culture has recognised the centrality of service user expertise within the process of recovery, little attention has been given to those living with such illness in developing countries, such as those in Sub-Saharan Africa, Swaziland being one of them. Schizophrenia is of great concern in Swaziland, as it is most prevalent amongst the 25 to 45 year olds, compromising productivity and adversely affecting the country’s economy. While both men and women contribute to the Swazi economy, and can be equally affected by the illness, there appears to be stigma and discrimination of women in the provision of mental health care. This study explored the perceptions, experiences and meaning of recovery for Swazi women living with schizophrenia with a view to improving the mental health care offered to them in Swaziland. Method: Qualitative phenomenology was used to guide the research process. A convenient purposive sample of fifteen Swazi women, diagnosed with schizophrenia, was recruited from the Swaziland National Psychiatric Hospital (SNPH) out patients’ department. One to one, face to face interviews were conducted, audio recorded, translated and transcribed by the researcher. Interpretive phenomenological analysis (IPA) was used to analyse the data. Findings: More than half of the women defined recovery in terms of remission of symptoms, and acknowledged the importance of taking prescribed medication in promoting their recovery. The majority of participants identified helping others, involvement in community activities and spirituality as important enhancers of their recovery. Health professionals working at SNPH both promoted and hindered their recovery. Conclusion: The findings of this study add to a developing body of knowledge regarding women’s recovery from schizophrenia in Sub-Saharan Africa, having implications for future African/Swazi consumer focused mental health services.

This thesis consists of three parts. Part One, a literature review, provides a thorough examination of current research that has explored predictors of patients* engagement with mental health care. Models of illness perceptions are examined and their potential application to furthering our understanding of the mechanisms underlying engagement in psychosis is considered. Part Two presents the empirical paper, which summarises an original piece of research exploring illness perceptions and perceived stigma in relation to engagement with early intervention in psychosis services. This study was conducted as part of a wider research programme and data collection was shared with another DClinPsych trainee---Tristan Morland. Part Three presents a critical appraisal of the study undertaken. It provides a brief background to the study, reflections on the process of conducting the research and a discussion of pertinent methodological considerations.

Introduction: There has been a wealth of literature that has looked at social functioning in individuals with experiences of psychosis. Most of this has been quantitative research and has tended to suggest that social difficulties may be due to a social cognition deficit such as an impaired Theory of Mind. The present study aimed to give voice to people with experiences of psychosis and explore their own understanding of their relationships with others, including how they make sense of any difficulties they might experience. Method: A qualitative approach was used to explore the experience and meaning of relationships for people with psychosis. Five participants recruited from a local Rehabilitation service were interviewed using a semi-structured format. The data were analysed using Interpretative Phenomenological Analysis. Participants also completed The Hinting Task, a test to measure Theory of Mind ability. Analysis was done on an individual and group level. Results: Three superordinate themes emerged from the group analysis: 1) Feeling connected to important others 2) Having psychosis can get in the way of relationships 3) Being cautious around others. Discussion: The participants seemed to make sense of their relationships in terms of what the relationships provided; this included support and recovery but also a sense of belonging. Negative experiences with important others, for example, experiencing stigma, were blamed on important others’ difficulties in understanding experiences of psychosis. In relation to the existing literature, the present study suggests that it may be too simplistic to suggest that difficulties interacting with others are due to a social cognition deficit. Clinical implications for improving service user’s experiences and further research are discussed.