Whilst the majority of adolescents receive support from mental health services in community settings, some have problems that reach a level of severity and complexity that requires admission to hospital. Little is known, however, about how the young person adjusts and reintegrates back home following discharge from an inpatient unit. Part 1 is a literature review evaluating the evidence-base of alternative provisions to inpatient care for children and young people with severe and complex mental health problems. A total of 13 studies were identified for inclusion, and five intervention types were classified. The majority of the studies reported positive outcomes, but the strength of their designs varied. Overall, the studies provided promising findings for the effectiveness of community-based interventions for children and adolescents with complex mental health needs. Part 2 is a qualitative study that explored adolescent inpatients’ anticipations about the transition from inpatient care back into the community, that was informed by Self Determination Theory (Deci & Ryan, 1980). Semi-structured interviews were conducted with 12 adolescent inpatients and transcripts were analysed using thematic analysis. The adolescents saw the transition back home as providing both opportunities (e.g. personal growth) and challenges (e.g. re-entering the “real world” and negative perceptions from others). Part 3 is a reflective discussion of the process of developing and carrying out the qualitative study. It focuses on three areas: issues of self-reflexivity, the process of interviewing adolescents, and the tensions of balancing a phenomenological approach whilst being informed by a theoretical framework.

Section One: Literature Review : The literature review investigated the association between income inequality and mental health within Britain. Eight quantitative studies were included within the review. All studies showed support for the notion that there is an association between income inequality and mental health. The results demonstrated the complexity of the relationship between income inequality and mental health. Future research is required to specifically examine the validity of Kawachi & Kennedy’s (1997) conceptual model of income inequality and mental health. Section Two: Research Report : The research report explored mental health staff members’ understandings of the impact of social deprivation on mental health and also how these understandings influence their clinical practice. Data was collected using focus groups and individual interviews. Five focus groups and two individual interviews were conducted. Twenty-seven participants took part in the study. Interpretative phenomenological analysis was used to analyse the data. Three super-ordinate themes emerged from the data which were: ‘unjust circumstances’, ‘division’ and ‘survival’. The findings highlighted the complex nature of working within socially deprived areas. Recommendations were made in relation to how mental health services should address the challenges that working in deprived areas brings for team members and how to ensure that service users receive the most effective care from mental health services. Section Three: Critical Appraisal : The critical appraisal focussed on a trainee clinical psychologist’s experience of conducting this research project. This included a reflection on the overall research process including a critique of the methodology used and the limitations of the research. The critical appraisal also included the trainee’s personal and professional development in relation to completing the research project.

Aims and Objectives: The aim of this study was to explore young adult service users' (18-35) perspectives on mental health recovery. Objectives included the exploration of factors that feature in an individual's perspective of recovery; the investigation of meaning and growth in suffering and the exploration of the 'temporality of being' within young adults' conceptualisation of recovery. Theoretical Perspective: The study was informed by a dual theoretical framework including Eriksson's (2006) theory on "The Suffering Human Being" and Kleinman's (1988) theory on explanatory models to explore young adult service user's understanding of recovery. Method: The study involved a three phased qualitative design. Phase 1: A concept analysis of recovery was conducted using Rodgers' (2000) evolutionary method. Phase 2: Two engagement groups with service users were undertaken to co-produce a semistructured interview schedule. Phase 3: Semi structured qualitative interviews with 25 young adult services users were conducted to ensure an in depth understanding of their recovery. Findings: Phase one findings propose a new conceptual definition suggesting the term "recovery" is not reflective of the identified conceptual characteristics. Phase two developed a collaborative co-production with service users of a semi-structured interview schedule used in phase three. Phase three findings revealed recovery is understood as an unchatted, timely and personal process of engaging and transcending pain. Perceived barriers to mental health recovery and the internal dynamics experienced within the process have been highlighted. Recovery acquires real life relevance when applied to the contextual factors that provide meaning in life. Conclusion: This research study has contributed to the knowledge base by revealing the hidden internal processes experienced within mental health recovery and how it is cognised. A novel comparison has been presented between the conceptual characteristics of recovery and how the concept is understood and lived by young adult service users.

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This qualitative study aims to explore how risk management practice impacts upon the implementation of recovery-oriented care within community mental health services. Semi-structured interviews using vignettes were conducted with 8 mental health worker and service user dyads in order to explore understandings, perspectives and attitudes on how risk management practice impacts upon service users' recovery within the community. Data analysis took part in two phases. In the first phase, data were coded into categories using a framework and grounded analysis approach. 8 overarching categories emerged from the data. In the second phase, queries were run on the data in order to explore how: 1) RMP issues impacts upon perceived responsibility for recovery; 2) tensions in responsibility for recovery in the context of RMP impacts upon the mental health worker and service user relationship; 3) attitudes towards service users' exposure to risk impacts upon service users' opportunities for social inclusion; 4) mental health workers' own working environment impacts upon the way RMP was addressed within a ROC context. The findings suggest an absence of RMP in ROC policies result in mental health workers describing how they would ideally use a positive risk taking approach to support ROC, this over-rides considerations of managing risk. However, in real life situations mental health workers and service users were uncertain about who should hold responsibility for recovery. Mental health workers and service users expressed a mutually perceived need to manage risk of relapse resulting in a more traditional concept of 'recovering from' contaminating discourses of 'recovering in' a mental illness. Mental health workers retain responsibility for recovery in the context of RMP and as such, service users comply with conditions set by mental health workers to gain some responsibility for recovery. It is a diluted 'risk-contaminated' form of recovery that is implemented in to practice. The thesis concludes by considering implications and making recommendations for future policy, practice and training.

Objective Recovery has become integral within mental health service delivery in the past decade. However, much of the policy on recovery has been based upon research with adults, specifically clinical populations with severe mental health difficulties. There is very little empirical research on young people's recovery from mental health difficulties and little guidance for staff on implementing recovery within Child and Adolescent Mental Health Services (CAMHS). This study aimed to explore how staff conceptualise and support recovery in their work with young people. Design A mixed-methods Delphi survey was used, conducted over a series of three rounds. Participants In total, 36 NHS health care professionals with expelience of direct clinical work with children and young people with mental health difficulties took part. Results A high level of consensus was provided on a number of elements that define recovery and how it may be supported for young people. There was high consensus that recovery for young people related to self-empowerment and hope, as well as young people's identity, separate from mental health difficulties. There was no consensus for aspects of recovery related to service user involvement. Regarding how recovery can be supported for young people participants placed emphasis on recovery as an ongoing process, the therapeutic relationship, and working with families and the network around young people. Conclusions/lmplications Further research is needed to explore staff views of service user involvement in CAMHS, as well as to investigate how staff might understand recovery across the developmental range in CAMHS. The findings form the beginnings of a conceptualisation of what recovery is for young people and how it can be implemented, however, this is the first study of its type and research is required to further investigate the implementation of recovery-Olientated practice in CAMHS.

Borderline Personality Disorder (BPD) is considered to be a complex and difficult disorder to treat effectively due to manifestations that affect many aspects of social and psychological functioning. Of most concern for services treating BPD is the frequency of suicidal and parasuicidal behaviour that requires inpatient hospitalisation. NICE guidelines (2009) currently recommend psychological therapies for BPD that are not brief (less than three months). Two of these are Dialectical Behaviour Therapy (DBT) which is rooted in the principles of Cognitive Behavioural Therapy and the psychodynamically orientated Mentalisation Based Therapy. Randomised Controlled Trials (RCT) examining clinical 'fficacy of each therapy reveals evidence that both treatments are potentially successful in reducing suicidal and parasuicidal behaviour compared to standard psychiatric treatment. RCTs ofMBT and related follow-ups were conducted by the Oliginator ofMBT so require independent replications. Isolation of the individual components of MBT is also recommended in order to examine the influence of each component on improvements in functioning of BPD clients. Additional examination of clinical efficacy and cost effectiveness requires RCTs of both treatment modalities that utilise larger sample sizes and consistent measures so that cost effectiveness can be more accurately predicted. An RCT that directly compares MBT with DBT is recommended in order to make more meaningful conclusions about relative clinical and cost effectiveness.

Background: The Care Programme Approach (CPA) was introduced in 1990 by the Department of Health as an approach to provide care to people with mental health problems in secondary mental health services. It aimed to improve partnership working across health and social services. However CPA faced problems from early on in its introduction to front-line services. These issues were not confronted and the policy frequently struggled at the implementation stage. Although never clearly indicated, clients with learning disabilities and concurrent mental health problems were meant to have their care provided through CPA. (For the purpose of this study the term ’dual diagnosis’ is used to refer to this client group). However as they were under the care of social services they were managed through care management models instead. More recently policy statements have made it clear that these clients should have their care provided through CPA. Meanwhile, CPA has become established practice in mental health care and care management has become the standard model of care in learning disability services. Service providers are now expected to work in partnership to integrate these entrenched modes of care delivery into a single approach, namely CPA. Study aim: This study aimed to explore the factors shaping the local implementation of the adoption of the Care Programme Approach for clients with a dual diagnosis from a meso-level perspective. Methods: The study was carried out using a case-study approach in a Mental Health NHS Foundation Trust which was working across five separate localities to implement CPA. A total of 26 semi-structured interviews were carried out with key stakeholders and members of local Steering Groups responsible for CPA implementation across the five localities. Documentary analysis of relevant Trust documents and Steering Group minutes was also undertaken.

Offering individuals financial incentives for changing their health-related behaviour is one possible strategy for improving health and reducing morbidity and premature mortality. However, several important aspects of the behavioural and cognitive consequences of this type of intervention remain unclear. First, there is uncertainty regarding the effectiveness of financial incentives in achieving sustained changes in repeated health behaviours, as well as of the factors that might modify any effects. Second, the variables that might confound the impact of incentives on health-related behaviours remain unexplored. Third, the speculated unintended consequences of financial incentives on cognitive processes, including information processing and decision-making, have yet to be examined systematically. This thesis addresses these uncertainties. Study 1 is a systematic review and meta-analysis aiming to estimate the effectiveness of financial incentives in achieving sustained change across repeated health-behaviours (smoking cessation, healthier eating, including reduced alcohol consumption and increased physical activity) and to examine the factors that modify any impacts. Findings indicate that although financial incentives changed repeated health-behaviours, their role in reducing non-communicable disease burden is potentially limited, given effects were not sustained beyond three months after incentive removal. Results also highlight the role of recipients’ deprivation level in modifying incentive impacts on behaviour overall, as well as that of incentive value in modifying impacts on smoking cessation. Study 2 is a qualitative study exploring the variables that might confound the impact of financial incentives on health-related behaviours. The study describes and compares the stop-smoking experiences of pregnant smokers’ who were incentivised for smoking cessation with those of women who were not. Results highlight the need to be cautious about attributing the effects of financial-incentive schemes to incentives per se. Given that incentive schemes are complex behavioural interventions, their impacts could derive from indirect influences, mediated by changes to some aspects of the process involved in their delivery, including the provision of increased support. Study 3 is a randomised controlled trial aiming to estimate further the effectiveness of financial incentives in changing health-related behaviours, by assessing their impact on uptake of the HPV vaccinations. The study also aims to examine the modifying role of recipients’ deprivation level and to addresses the uncertainty regarding the speculated unintended consequences of incentives on decision-making processes. Results indicate that although incentives increased vaccination completion rates, impacts were not modified by recipients’ deprivation level and uptake remained lower than the national target, necessitating consideration of other ways of achieving it. The quality of decisions to get vaccinated was unaffected by the offer of incentives. Knowledge of the vaccination’s side-effects, however, was not assessed in this study. Findings therefore, are not conclusive about the impact of incentives on the processing of risk-relevant information. Study 4 is a web-based experiment addressing the uncertainty regarding the speculated unintended consequences of financial incentives on information processing. It aims to determine the impact of incentives on the processing of risk-relevant information associated with an incentivised behaviour with potential adverse effects, as assessed by participants’ perceived risk related to engaging in the behaviour and their knowledge of its side-effects. The findings provide no evidence for the unintended consequences of incentives on the processing of risk-information. The thesis concludes with a discussion of the main findings and related implications for practice, policy and future research.

This research study describes a journey taken by ten health care professionals on an educational course, the English National Board for Nursing, Midwifery and Health Visiting (ENB) A28, which aimed to enable them to develop the therapeutic skills and confidence to work effectively with the families/carers of individuals suffering from a major mental illness. Their previous education and training had not equipped them to meet the clinical demands now made of them since the focus of mental health care relocated from hospital to the • community' . The course was based in a Family Intervention Service provided in an Inner London Mental Health Trust whose clinicians had developed a treatment model which they termed 'psychosocial' and combined systemic theory. expressed emotion research findings and limited behavioural methods. Grounded Theory was the chosen research method for this study as it was important to be able to access the experience and views of each student as they emerged. The students were interviewed twice, using a semi-structured interview schedule: at the beginning of the course and within three months after its completion. The questions posed at interview were informed following a pilot study of eight of the previous year's students. The students concluded that three elements in the course teaching had most contributed to achieving their aims; theory, practice and live supervision. The role of management and its influence in the clinical life of the students emerged as important. Consequently eight managers were interviewed and revealed the degree to which they supported both the students and the aims of the course. On this depended whether the Trust's clinical services would be able to maximise the benefits from its investment in this educational resource. A retrospective study by questionnaire. and subsidiary to the main investigation. is reported on in Appendices A through F. It focussed on the experience of students who had successfully completed the course during the previous years since its validation. As in the main study. the questionnaire was formulated from information given following a pilot study of eight of the previous year's student group. The aim was to ascertain the long term effects on their clinical practice. The results were analysed using a descriptive analysis technique. Although there had been changes to the original course. the findings were similar to those in the main study and showed the importance of theoretical understanding and supervised practice. Overall. the findings indicate that the respondents valued the systemic approach which was the cornerstone of the educational experience and continued to exert an influence on their practice. They gained an awareness of the extent to which social and family systems impacted on the lives of individuals during the lengthy course of major mental illness.