Research suggests that mental health among young people is deteriorating. However, scant attention has been given to young people in Northern Ireland (NIAMH, 2009), despite wide acknowledgement that the people in the region endure significantly poorer mental well-being status than most other parts of Europe. This study aims, firstly, to investigate well-being in a Northern Irish population from the perspective of positive (PMH) and negative (NMH) mental health as measured by the GHQ-12; secondly, to identify routes that contribute to PMH and NMH status. Secondary analyses was conducted on the Young Life and Times Survey (YLT, 2008) which is a Northern Irish Panel survey that examines beliefs and attitudes in 16 year olds (N = 941). Results indicated that participants' mental health was best encapsulated by combinations of PMH and NMH. Overall females were shown to have poorer mental health in middle adolescence than males. Possible routes that contribute to mental health included gender, stress, coping, and communication skills. A second study unpacks well-being as a concept and reviews the PMH instrument Warwick-Edinburgh Mental Well-being Scale (WEMWBS), which was then administered along with a wider range of well-being instruments among a University student sample, mainly aged between 18 and 21 years (n = 388). Similar outcomes to the YLT analyses emerged with even stronger statistical effects. Structural equation modelling examined the influence of stress and resilience constructs; trait resilience, positive affect, coping, social supp011, self-regulation, and mindfulness on well-being. Routes to well-being linked NMH, social supp0l1, resilience, and PMH. Direction of causality is an important issue throughout the thesis both in general and specifically in respect to statistical models - a cause for concern in most cross-sectional studies of this nature. The thesis concludes that the multivariate path analyses which are deployed in Study 2 offer a rigorous approach to understanding the multiple factors which contribute to young people's well-being, facilitating as they do hypotheses that attempt to assess causality. Key words: mental health; adolescence; emerging adulthood; students; well-being; dualfactor model; positive mental health; negative mental health; stress; resilience; positive affect; negative affect; coping; self-regulation; mindfulness

Based on the theory of social representations, the thesis explores how mental health professionals understand mental illness. The principle data source for this investigation is semi-structured interviews conducted with sixty mental health professionals in Britain and France, two countries currently moving towards community-based care for the mentally ill. Systematic qualitative analysis of these interviews (using QSR-NUDIST) is both grounded in the data and guided by previous research findings, theoretical considerations, and other data sources (policy documents and observations). Research explores how the nature, causes and treatment of mental ill health are represented by professionals, and provides an empirical test of the concept of 'professional social representations'. These are conceived as professional practitioners' representations of the object of their work, which consist of five inter-related elements: practice, theory, professional identities, organisational factors and lay representations. Analysis highlights how, despite their 'expert' status, mental health professionals adopt an agnostic stance and their representations are fraught with uncertainty, questioning and debate. Mental illness is understood as a polymorphous category, broadly divided into 'neuroses' and 'psychoses' and understood in essentially social terms. Thus, various forms of difference, distress and disruption are central themes. Professional practice is conceptualised as a social rather than medical endeavour, which involves eclectic interventions in many aspects of clients' daily lives. The dominant role in France of psychodynamic theories and practices is the only major difference between professionals in France and Britain. With contemporary shifts towards community-based care, practitioners experience added uncertainties and difficulties in renegotiating professional working relationships. The findings suggest that professional social representations serve important compromise functions, helping the practitioner community to reconcile the tensions and conflicting agendas of mental health work, and reflecting the unique role of professionals in the development and circulation of social knowledge. This research extends the scope of application and the conceptualisation of the theory of social representations.

This dissertation is an examination of the planning and management issues involved in the implementation of a regional health authority decision to close a mental handicap hospital and reprovide services in seven districts which had used the hospital. Several features made this project worthy of attention: it was among the earliest hospital closures; it involved a very large number of districts and therefore was a complex situation which nonetheless was fairly typical of long-stay hospitals in the London area; all residents, regardless of degree of disability, were to be given the chance of living in the community: local authorities were also involved along with health authorities, and this project could illustrate new principles of joint planning. The project further lent itself to a consideration of the adequacy and accuracy of the academic literature on planning and related activities. The research focussed on three areas. The first set of issues related to the approaches to planning used by regional officers who had responsibility for seeing the project through to completion. The Darenth project tested the new NHS planning system which was based on a rational planning model, and found that it could not deliver what was wanted from it. Regional officers created new types of working relationships with districts which allowed progress to be made. The second set of issues concerned the management of the rundown of the hospital. Aspects of the rundown discussed are: retention and redeployment of staff; physical contraction of the hospital; impact on residents; financing the rundown. The third set of issues related to joint planning. One of the purposes behind the introduction of joint planning into the NHS was creation of a mechanism to bring about a more appropriate balance of social and health care for people who were currently long-stay patients. But it was not joint planning with local authorities which got these residents out into the community. This study documents some of the reasons why government policy intentions could not be met. The main findings of this study point to the inadequacy of a model of planning which is based solely on rational process. Policy and implementation interact over time, as ideas and personalities change, as objectives are redefined in light of current circumstances, and as recognition is given to the competition for dominance of objectives of different participants in the planning process.

The Department of Health and National Institute for Clinical Excellence (NICE) have recommended the use of self-help as an important intervention in a stepped care approach, for mild to moderate mental health problems. However, there has been little attempt to guide the primary care practitioner in the appropriate use of such materials. The `Cardiff Book Prescription Scheme' was set up in 2002 in response to this need and to enhance the availability of psychology in primary care services, helping primary health services identify alternative routes to psychological help, in the form of self-help manuals. The current study aimed to evaluate this new and innovative service, looking at prescribers' (GPs, counsellors and psychologists), dispensers' (librarians) and users' (those who have been prescribed books) experiences of the `Cardiff Book Prescription Scheme'. A two-stage mixed-methodology design was used. At stage one, a questionnaire was sent out to all prescribers and dispensers in Cardiff asking for basic information regarding their experience of the scheme. Prescribers and dispensers were also supplied with questionnaires to give out to users of the scheme (a specially designed `Users Questionnaire' and the Client Satisfaction Questionnaire - 8; CSQ-8). Prescribers and dispensers returned sixty-three questionnaires (50 prescribers and 13 dispensers; 24% response rate) and users returned six questionnaires. Out of the 50 prescribers who returned the questionnaire, 37 prescribed books from the scheme, and all reported finding the scheme helpful. The main reason for not prescribing books was due to being `unaware of the scheme'. The CSQ-8 scores for users indicated a satisfaction level comparable with similar services. All users rated the scheme as a good idea and reported finding the book helpful for their problem. In the second stage of the research, interviews were conducted with prescribers and users to explore their experience of the `Cardiff Book Prescription Scheme'. The interviews were analysed using a grounded theory approach. From the analysis, information regarding choice to use the scheme, characteristics that might be associated with a good response to self-help and beneficial and non-beneficial aspects of the self-help approach, amongst others were discussed. Theoretical, clinical and research implications are discussed in relation to these findings.

The thesis examines the impact of leaving a psychiatric hospital, which is due to close, on a group of long-stay patients. Using anthropological method, the study provides a small scale, in-depth analysis of the transition processes involved. It aims to examine the differing perceptions produced from different positions within an institutional setting, focusing particularly on the residents' perspective, and to compare the experience of transition from the clients' viewpoints with the carers' knowledge and assumptions. The first two chapters outline the context of the study, the historical and sociological background to community care policy and the methodological and theoretical approaches taken. Chapter three uses a 'life history' approach, which recounts the experiences of the residents of a particular group home project. These accounts are compared qualitatively with the official summaries of their case histories, suggesting that rehabilitation requires a different method of understanding the patients experiences, abilities, problems and needs. Chapters four and five outline the processes of selection and preparation for leaving the hospital. The experience of leaving hospital is analysed as a 'life crisis' and the professional handling of the move is examined. In chapters six and seven, group home life is described in detail and compared to hospital life, bringing out key features of the environment, routines, and interactions within the home and beyond it. I focus on several areas of change and continuity in the lifestyles of the residents, their use of time and their relations to staff and others. The final section explores the conceptual models of the group home, as an aspect of community care philosophy. I focus particularly on the 'family model' of care, its bases and its implications for the quality of life of the residents, in terms of rehabilitation, social integration and the personal and social identities of the residents.

This study explores the process of decision-making in central government health policy. It also documents the history of the pressure group Aid for the Elderly in Government Institutions (AEGIS) and thus the career of its Chairman Mrs Barbara Robb as a social reformer. There are two major arguments in the thesis. Firstly, the study demonstrates that AEGIS played the key role in initiating and sustaining the extraordinary succession of scandals in the mental hospital service between 1965 and 1975 and that these were one of the major determinants of policy between 1970 and 1980. There are two broad areas of policy. The establishment of mental illness and mental handicap as priority services. Empirical evidence is presented to support the argument that the policy has achieved a considerable measure of success. The second area is the redress of grievances in the NHS through the development of formal complaints procedures, special inquiries and the Health Commissioner, where the conclusions are that reforms have been largely cosmetic and largely unaffected the established autonomy of the medical profession to investigate allegations of performance failure brought against its members. Secondly, none of the major competing models of state activity gives a complete understanding of the process of change in the study. The policy process in mental health thus emerges as an example of the professionalised state thesis in neo-pluralism, set within an ideological framework which establishes medicine as the dominant profession.

This research examines how social workers view the use of guardianship to meet the needs of clients with mental illness. It is the first empirical study of social work perspectives on guardianship and of social workers' decisions to select particular clients as appropriately placed on guardianship. An historical review confirms current relevance of 'tutor' and 'curator', forms of guardianship for this care group since Roman times, in contrast with the commonly held view that guardianship was introduced by the Mental Health Act, 1959. The nature of 'committee', as English equivalent to the Scottish tutors, is given particular attention. The survey part of the research employed a standard questionnaire which explored key guardianship concepts, sought to compare the role of social worker with that of guardian, and looked to future possibilities for the development of guardianship. The fieldwork took place in two adjacent London local authority social services departments. The profile of guardianship clients indicated that guardianship was used mainly for clients living alone in socially isolated circumstances, particularly women. It was used to help to gain access to the client to provide care and services, or to enable the person to move into residential care, often direct from hospital. For the most part, the present research confirms previously available data on clients. However it contests the view that guardianship is mainly used for people suffering from dementia, as clients with schizophrenia were in the majority in the survey sample. Different models of guardianship were used to assist in the analysis of data: the 'legal/substituted judgement' or 'advocacy' model; the 'parent/child' or 'social casework' model; and the 'therapeutic welfare' or 'case management' model. There was clear support for these and for core guardianship concepts, including authority, continuity, personalised care and surrogacy - irrespective of the model considered. Arguably, the idea of trust (as in trusteeship) was endorsed as being at the heart of guardianship. The position of social services departments as 'host' agencies for providing guardianship was seen as equivocal in that directors of social services have few incentives (and a number of disincentives) for taking on the responsibility. If social workers themselves have to shoulder the responsibility in the new community care climate, the absence of management back-up could seriously undermine the care given to clients and limit possibilities for effective adaptation of the guardianship concept. Social workers' verdict' on guardianship was that it has potential which so far has not been realised. There was general agreement that guardianship needs to change so as to be more adaptable and enforceable to meet clients' individual needs. It is anticipated that a revised guardianship formulation on this basis would be widely supported.

The thesis addressed two research questions: 1) Why has community care of long term mentally ill people been so difficult to implement. and 2) Do Community Mental Health Teams (CMHT s) provide an intellectually viable and practically sustainable model of service provision. These questions were approached by an analysis of the wider literature and a multi-method case study evaluation of an innovative CMHT in one inner city area of London from 1979-1992. The thesis concentrated on interchanges between theory, policy and local practice. It was found that community care of the long term mentally ill was difficult to implement during the 1980s because adoption of new approaches depended on their delayed acceptance by the psychiatric profession and even then, the required social and environmental approaches to care were only partially adopted. Policy became dominated by professional and managerial influences and clients continued to have a low political profile. Administrative inadequacies were severe and deep rooted and there were unreconcilable differences between Health and Social Services. The collectivist ethos of CMHTs was undermined. The CMHT approach can provide a practically sustainable approach to service provision when certain conditions are met. The CMHT service must: be comprehensive, or supported by a full range of complementary services in the local community; receive genuine political commitment to the long term mentally ill client group and an on-going level of adequate funding; be introduced with a clear acknowledgement of where lead responsibilities rest; and harness the enthusiasm of professionals and catalytic individuals. The CMHT approach is a system of care and in so far as a new care model emerged during the 1980 s, it was the Care Programme Approach. Yet the CMHT approach provided a vital source of experimental energy during the 1980 s and now needs to be formally recognised by central government as a valuable vehicle for change.

This doctoral thesis has three main sections: a systematic literature review, an empirical research paper and a critical appraisal. The literature review considers the factors associated with burnout in community mental health staff. Having synthesised the results of 28 papers, eight domains were identified that were associated with burnout. These included socio-demographics, work demographics, job stress and demand, support and supervision, individual characteristics, team context, client characteristics and role perception. Poor methodological rigour restricts the conclusions drawn from the reviewed papers, however a number of organisational factors were found to be of importance. The empirical paper considers the process behind the loss and maintenance of compassion in community mental health staff. Having interviewed 11 participants and utilised a grounded theory informed methodology, four core categories were identified; adopting a compassionate stance towards others, the uphill struggle, accessing a reflective space and working within a threatening system. The findings of this paper highlight the importance of reflective practice for mental health professionals and the influence of wider systemic factors. Lastly, the critical appraisal offers an extension of the study findings and reflections about conducting research in the field of compassion, as well as considering a number of decisions that were made with regard to the project.

Staff working with individuals with a diagnosis of personality disorder may experience difficulties within this work (Cleary, Siegfried & Walter, 2002; Fraser & Gallop, 1993). This may impact on service users’ experiences of mental health care. Thus, understanding more about the experience of this work may help improve staff’s experiences and provision of health care for service users. Correspondingly, a meta-synthesis exploring staff’s experiences was conducted using guidelines outlined by Noblit and Hare (1988). From the analysis, four themes were developed: the value of caring; the paradigm of caring; the need for containment; us and them. An overarching theme of moving between extremes was also established. The meta-synthesis highlighted the dynamic nature of this work and difficult experiences in providing care. The research paper explored the process of change in non-residential therapeutic communities using grounded theory methodology. Eleven participants were interviewed and shared their perception of the process within the therapeutic community. A model was developed which highlighted a difficult process of joining the group, which required commitment to continue. As group members began to feel more comfortable they learnt how to talk within the group and used this to create a safe place. Group members integrated into the group and took on the identity of a group member, through which a reciprocal process was described where individuals used the group for themselves and acted as the therapeutic input for others through challenging, offering advice and sharing their own experiences. This enabled individuals to develop an increased understanding of their own difficulties and utilise the safety of the group to initiate change. Finally, the critical appraisal considered themes of invisibility and marginalisation apparent across the experience of conducting the literature review and research paper.