Crisis Resolution/Home Treatment teams are a recent addition to UK mental health services, and offer rapid, around-the-clock response to people in mental health crisis. This review addresses conceptual understandings of crisis, and the model and effectiveness of team intervention to resolve crisis. The literature reviewed reaches some consensus in describing the crisis phenomenon, but theoretical understandings of the concept stand in opposition rather than complement one another. While unitary, the team configuration comprises crisis resolution work and home treatment. Some well-designed outcome studies have clearly shown the teams can successfully reduce hospital admissions through home treatment. However, outcome studies have somewhat limited themselves to this measure of success, and measures of crisis resolution are neglected.

Foreword Tracy Dryden was a mental health nurse deeply concerned that the value of nursing practice - and patient care - was being undermined by policies that constrained colleagues to work in a rigid manner. Tracy's doctoral thesis explored in painstaking detail the insecurity which threatens to destabilise mental health nursing expertise and the risks for service users which restrictive and exclusive use of 'evidence-based' resources can incur. In doing so she found a way to trace, make visible and give value to mental health nurses' skills. Her tragic and untimely death means that this work is unfinished. Tracy died only a few months before the expected submission of this thesis, therefore, we as her supervisors have collated the drafts of each chapter and present them here for examination. We have given these drafts only a cursory edit to improve the presentation of her ideas. We have purposely refrained from developing these ideas in any way. There are sections which Tracy had highlighted as requiring development or clarification. These notes to herself, and the accompanying sections of text, we have left unchanged so as to allow the examiners further insight into the level at which Tracy was working. The argument of the thesis may lack the finesse it would have attained in the final revisions, as Tracy worked with the thesis as a whole, but we believe that even as it stands, it is strong and coherent. We would like to see Tracy's work published in the near future, and available to those she writes so passionately and thoughtfully about. We would welcome the examiners thoughts on this matter. Although it is impossible for us to write Tracy's acknowledgements, we know without question that she would have wanted to express her deepest thanks to her family - her children Lee and Owen, and her mum, dad and sister - without whose love, help, unfaltering support and understanding, she could not have even attempted this work. Dawn Goodwin and Maggie Mort Preface I walk into the large open-plan nurses' office at the community mental health resource centre, one week before I am due to return to work as a community mental health nurse (CMHN). It has been three years since I left to take a career break in order to pursue my Ph. D. Lynda, one of my colleagues (who has worked as a CMHN with this team for over ten years) greets me enthusiastically with a smile and asks me if I am returning to work. She then informs me that she is leaving her position shortly. She has secured a place on the Behavioural Therapy IAPT (insert explanation of this) course Cognitive Behavioural Therapy (CBT) training course. This course will enable her to gain a position as a CBT specialist. I ask her whether she will return to the CMHN team. She replies: Don't be silly, Tracy, I am through with all this stuff we receive as nurses. I want to do something that is ... She searches for a word but fails to find the right one. Instead, she holds up her hands as if trying to make the shape of something tangible. She continues: ... And something that I can say what it is that I am doing. It's ridiculous. What on earth have you been doing for the last three years that only brings you back to this? I can't believe you're coming back. There must be something better you want to do! We both laugh. But I am sad: Lynda has always been a valued member of staff within the community mental health nursing team. However, I remember how she, alongside other nursing colleagues used to express frustration and anger inferring that, as nurses they were always given what I often heard described as the 'dirty work'. In one sense it is shameful to describe it this way; clients do not chose to have problems and needs that do not fit into well-defined, 'clean' categories. However, I think that these nurses mean it more in the sense that it is the work that their multi disciplinary mental health colleagues, for example psychologists (who may specialise in art, drama and psychodynamic therapies) and clinicians that specialise in specific therapies (such as, cognitive behavioural or solution focussed approaches), will not accept - the leftovers. These nurses perceive the psychologists and other specialists as taking all the 'clean' and 'tidy' work that can be neatly categorised into their specialist protocols. The untidy work that remains - the clients that are referred to the nursing team - have complex issues that cannot easily be categorised. These clients are often vulnerable, they may be at risk to themselves and others, they sometimes have a history of committing crimes, and many have a number of 'working diagnoses' as opposed to one confirmed diagnosis. That is, a client is thought to be depressed and so the clinician works towards treating this, yet it is questionable as to whether they may have another disorder such as a personality disorder.

Abstract Introduction This thesis develops an interpretation of the impact of mental health nurse prescribing in NHS Greater Glasgow and Clyde. This interpretation is developed through application of an original methodology: concurrent analysis. The purpose of this thesis is therefore twofold 1. To justify and evaluate concurrent analysis as a methodology 2. To analyse the construction of competence in mental health nurse prescribing It was found that concurrent analysis generated a coherent account of mental health nurse prescribing. The most significant empirical finding is that registered mental health nurses were not as competent in medication management as they believed themselves to be. Without change this situation will perpetuate itself. Method 1. In phase 1, 365 (55%) nurse prescribers responded to a questionnaire on their practice and perceptions of nurse prescribing. 2. Phase 2 used a constructivist grounded theory methodology to explore these findings in more depth. Twelve in-depth interviews and all current literature on mental health nurse prescribing were concurrently analysed in order to provide a coherent substantive theory of mental health nurse prescribing in practice3. This theory was verified in the third and final phase of data collection. Thirty two practicing mental health nurse prescribers completed a questionnaire regarding the coherence of the theory. Results Phase 1 found that mental health nurse prescribers were younger, more likely to be male, less experienced as nurses and more likely to work in diverse settings. They were more likely to look up drug reactions and interactions. They had a different perspective on the value of the therapeutic relationship. All nurses viewed prescribing duties as largely positive and felt it saved patients time, improved clinical skills and increased autonomy. Phase 2 developed a grounded theory of the construction of competence in mental health nurse prescribing. In practice it was found that nurse prescribers construct competence through an iterative process of owning and demonstrating competence. Owning competence consists of the categories ‘understanding vs. UNDERSTANDING’ and ‘managing ambiguity’. They demonstrate competence through ‘concording in action’ and ‘delivering better medicines management’. These categories and their integration are discussed in detail. The theory was strongly endorsed in phase 3 as being consistent with 32 mental health nurse prescribers’ experience of prescribing in practice. This theory suggests that mental health nurse prescribing meets the UK government’s stated aims of nurse prescribing

SYNOPSIS This thesis has two objectives: ( i ) to place on record work on the therapeutic community published between 1976 and 1994; ( i i ) to substantiate the argument that therapeutic community approaches offer a well defined and empirically established (but perhaps neglected) method of treatment in the mental health and related fields. In respect of the first, the printed work comprises four book chapters, seven papers from the professional literature and fifteen signed editorials from the International Journal of Therapeutic Communities. Some hitherto unpublished pieces have been added in support of the second objective. Concerning the second, the previously printed work is not presented chronologically but is organised in the following sections: The Characteristics of the Therapeutic Community Evaluation Applications of the Model in Practice Contributions to Therapeutic Community Theory Staff Issues. In addition there is a general introduction (The Writer to the Readers) and a separate Introduction to each Section designed to make clear my thesis that (i) therapeutic community approaches can be soundly characterised; (ii) substantial efforts have been made to tackle the question: does it work?; (iii) there is well-described experience of the application across a range of situations of therapeutic community principles; (iv) an intellectually convincing set of theories underlying this approach exists; and (v) the problems of equipping staff to function in a demanding form of social therapy can be adequately addressed.

There has been relatively limited research on the mental health of people with a learning disability, in spite of the high prevalence of disorder in this population. Anxiety disorders are among the most common psychological difficulties, and comprise a considerable proportion of research effort in the general adult field. However there is a dearth of research involving people with a learning disability. Consequently models of anxiety are based on the general adult population and there has been little consideration of the way in which anxiety in people with a learning disability should be conceptualised. One reason for this, may be the difficulty in developing relevant assessment tools due to communication problems and lack of procedural standardisation in a relatively heterogeneous population. However the recent development of a DSM-IV based psychiatric interview represents substantial progress in this area. In this review the need for the development of self-report measures of anxiety is considered in some depth. Such measures are widely available in adult mental health and are useful for symptom screening, outcome measurement and as an aid to diagnosis. The development of a reliable and valid scale for use with people with a learning disability is long overdue.

Background. Derived from a psychoanalytic and object relations perspective, the development of the internal object through such processes! mechanisms as projection, identification, imitation, and projective identification is crucial to the development of a sense of self (how we view ourselves). Method. In elucidating the relationship between early environmental characteristics and adult mental health, a statistical approach was implemented using the National Comorbidity Survey: Baseline (NCS, 1990-1992; Kessler, 1994, 2002). In doing so, a number of structural equation models were presented to examine the aforementioned relationship. Notably, latent profile analysis (LP A), multinomiallogistic regression in a multiple group context, confirmatory factor analysis (CF A), finite mixture multinomial logistic regression in a multiple group context, and moderated mediation models in a multiple group context were used. Results. Both types of insecure attachment, insecure anxious-ambivalent and insecure anxious-avoidant may act as risk factors for the development of mental health disorders in adulthood; while secure attachment may play a more protective role in this relationship. All aspects of the caregiving environment are influential in creating a vulnerability that may probabilistically lead to the development of mental health disorders in adulthood. Experiencing maternal depression in childhood increased the likelihood of developing mental health disorders in adulthood. Compared to the most secure attachment profiles, extremely insecure individuals were more likely to endorse a range of quality of life indicators negatively. Important findings in relation to gender were highlighted, indicating that males are more likely to develop externalising and females are more likely to develop internalising disorders in adulthood. Conclusion. These findings suggest that the development of attachment insecurity may arise from the caregiving environment, and further highlight the long-term adverse effects of developing insecure attachment in relation to an individual's quality of life. In these terms, the consequences of un-mirrored affect during the earliest caregiving relationships may create a vulnerability to later mental health problems by not facilitating the development of adequate emotional regulatory capacities. Conclusions and key findings are discussed in relation to psychoanalytic theory. Finally, strengths, limitations, implications of the research and recommendations for future research were discussed.

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his PhD study explores mental wellbeing with Chinese people living in Scotland. Chinese people make up the second largest of Scotland’s minority ethnic groups (The Scottish Government, 2004). Yet, there is dearth of knowledge about the health of this group (The Scottish Ethnicity and Health Research Strategy Working Group, 2009), and more specifically, there is a need for increased understanding about mental wellbeing in relation to this group (Newbigging, Bola, & Shah, 2008). In addition, the importance of gaining understanding and awareness about the cultures of different groups in the UK has been brought to attention (e.g. Bhopal, 2012). Indeed culture has been shown to have a strong influence on how people live their lives (Chiu & Hong, 2006; Chiu, Leung, & Hong, 2011) and on perceptions and experiences of health and mental wellbeing (e.g. Gervais & Jovchelovitch, 1999; Newbigging et al., 2008). The current study adopts a qualitative approach to explore both how mental wellbeing is conceptualised, and what the mental wellbeing-related experiences and issues are for Chinese people in Scotland. The theoretical and conceptual perspective underpinning the study is that of cultural psychology, which seeks to understand the relationship between psychological phenomena and cultural life (Ratner, 2002). Qualitative interviews were undertaken with first and second generation Chinese people in order to explore these subjects. The data was analysed thematically using NVivo. The findings illustrate that mental wellbeing is conceptualised in a broad and varied way, and that cultural learning shapes and influences these concepts. The emic, subjective approach emerged as particularly valuable in investigating mental wellbeing within this group, since this allows the viewpoint of the participant, and the different factors which are relevant and important to different people, to emerge. The factors which emerged as important in this study include both individual aspects of mental wellbeing (including achievement and life satisfaction) and social aspects (including relationships with others, and the family in particular). Cultural factors including Chinese medicine (and the holistic approach) and Chinese philosophy were also discussed.