Comprising a collection of seven published papers, this body of work explores methods of involving the public in the development of health services, as well as furthering the understanding of their attitudes to stress, depression and help-seeking. An exploration of the ‘messy reality’ of health research in practice is also included, both in terms of undertaking the research and also of publishing it within a doctoral journey. The work demonstrates a significant and original contribution to the literature in the following ways: - Establishing the prevalence of common mental health problems and help-seeking: A large scale population survey demonstrated that one in three people had a mental health problem, and although only 25% had sought help from their general practitioner, most (78%) had sought some form of help from friends or family - Further development of a theoretical framework for mental health literacy: Health panel discussions demonstrated that the ways in which people prefer to seek help do not match current service provision. It also showed that it is more challenging for people to recognise symptoms as they emerge than when viewed 'with hindsight' and, furthermore, that accumulated adversity is perceived to be a key risk factor - Development of a new emergent model of self-disclosure: Two main styles by which people disclose personal stories were conceptualized and validated – ‘announcers’ and ‘confessors.’ The concept was refined to show how a variety of factors not only hinder or facilitate disclosure but also how they impact on the style by which people disclose.

The published work presented in this submission examines the nature and form of psychosocial processes that lead towards and away from mental health, social security and community and organisational cohesion. It demonstrates the application of psychosocial research methods to the problem of living and working with violence in a range of clinical and educational settings. The emergent work is described in 14 pieces of work; 8 peer-reviewed articles, 4 book chapters and 2 edited volumes. Each of these pieces of work is accompanied by short discussion and commentary on its impact and dissemination. The published work presented extends over a 15 year period and demonstrates learning derived from a 30 year professional and academic commitment to an in-depth exploration of the ways in which structural and cultural processes of inclusion/exclusion give rise to personal and interpersonal violence that poses significant risks of psychosocial harm. The work also explores the reciprocal nature of the violence played out between ‘identified clients’, the systems of care tasked with helping them and the wider society from whom these systems of care take their authority. A central concern of the presented work is to consider the often distressing and traumatising ways in which this reciprocal structural and behavioural violence impacts frontline workers and teams that comprise these organisations. The submission also draws upon psychosocial, group analytic, systems psychodynamic and educational theories of practice, to explore the ways in which reflective practice and team development interventions may be deployed to equip multi-disciplinary teams with the necessary resilience and reflective capacity to work with this psychosocial violence in more creative, thoughtful and collaborative ways. The impact of the published work and the implication for future professional clinical, educational and consultancy practice is also discussed.

The issue of service user involvement in mental health research is currently a top policy priority. Participatory Action Research is an approach to research that aims to work alongside oppressed groups with the intention of enacting social change and pursuing empowerment agendas. This study aimed to explore the experiences of a group of young mental health service users who participated in a Participatory Action Research project looking at stigma in mental health. The meaning that the young people attached to their experiences was of principal interest in this study and so qualitative methodologies that privilegec participants' perspectives were employed.

Paper one reviews the qualitative literature that focuses on services users' personal experiences of sports and exercise participation. Despite the small number of studies with some methodological limitations, this review provides an important insight into the personal experiences of sports and exercise for people with mental illness. A number of common themes are identified and discussed. Paper two offers a qualitative account of the 'Coping through Football' project, (a community based football project for people with enduring mental health problems), based on the experiences of various stakeholders. Semi-structured interviews with service users, football coaches and facilitators were analysed using a grounded theory approach. The following categories emerged from the data: Identifying with past self; Service with a difference; Opening up the social world; Safety; Empowerment and Feeling good. These categories were then conceptualised within an overall model according to whether they represented an aspect of structure, process or outcome. Findings are considered in relation to existing research and theory. Clinical relevance and methodological limitations are also discussed. Paper three provides a critical appraisal of the study, reflecting on the overall research process and considers the merits and limitations of the methodology used.

The studies described in this thesis aimed to investigate the potential benefits of an online support group (OSG) for participants experiencing depression and anxiety. After a review of the literature (Chapter 1), the first experiment (Chapter 2) analyses the validity of a commonly used text analysis software called Linguistic Inquiry and Word Count (LIWC), which is used later in the RCT to examine the correlates of the outcome measures. In order to prepare for the RCT, two pilot studies were carried out (Chapter 3), one to test the OSG arm and another to test the placebo control condition, an expressive writing task. The main RCT (Chapter 4) adopted a six-month randomised control trial design, with participants randomised to either (1) an OSG or (2) an expressive writing placebo control condition. The hypothesis was that participants randomised to the OSG would show greater improvement on the main outcome measures (reduced depression and anxiety, increased satisfaction with life and social support) than those in the expressive writing comparison group. The results for all four primary outcomes--depression, anxiety, satisfaction with life and social support --showed an improvement with time over the six months of the study. But participants responded similarly to the expressive writing and the OSG, so no evidence was found for the experimental hypothesis. However, the OSG had much higher drop-out rates than the expressive writing condition, suggesting that acceptability was lower. Finally, participants' feedback on the OSG and expressive writing was investigated qualitatively (Chapter 5). The main problems participants perceived with the OSG were a lack of comfort and connection with others, negative social comparisons and the potential for receiving bad advice. In comparison, participants were broadly positive about the expressive writing task. The conclusion is that little positive evidence was found for the benefits of using an OSG for depression and anxiety. Recommendations for clinicians and policy-makers are discussed (Chapter 6).

Background Self stigma has been associated with psychological distress, poorer adherence to treatment and is a barrier to help seeking behaviour in people with mental illness. Little is known about the impact of stigma on people with intellectual disability (ID). In addition, people with ID are more likely to experience disparities in accessing health care, possibly as a result of discrimination and inadequate knowledge of clinicians about the health needs of this vulnerable group. Aims 1. To examine the association between self reported stigma and psychological distress, quality of life, treatment adherence and service use in people with ID 2. To explore experiences of health services by people with ID, particularly in relation to whether people have experienced discrimination from health services. Methods 1. A cross-sectional study of 229 participants with mild to moderate ID, from 12 centres, was conducted to address the first aim. Data was analysed using a random effects regression model. 2. A qualitative study using semi-structured interviews, with 15 service use and carer dyads (29 participants), was used to examine the second aim. Data was analysed using thematic analysis. Results 1. Self reported stigma was positively associated with psychological distress and higher service use, and negatively associated with quality of life. There was some evidence that self reported stigma was associated with lower treatment adherence. Psychological distress mediated these relationships. 2. Half the participants had reported experiencing discrimination from health services. Accounts included negative staff attitudes and behaviour, and failure of services to make reasonable adjustments. Implications There is an urgent need to develop interventions that tackle self reported stigma and psychological distress in people with ID. Health services need to ensure that reasonable adjustments are made in order to reduce both direct and indirect discrimination of people with ID.

This thesis presents an in-depth investigation of the use of participatory photography in qualitative research in a mental health setting in one regional area of England, UK. Whilst the field of visual methods has been growing for several years, there are few in-depth explorations of the ways in which photographs taken by research participants are reviewed and analysed. In particular, very few studies have used participant-generated photography with inpatients and staff at mental health hospitals. This study aimed to address these gaps in knowledge. A methodological review of international studies where research participants took photographs as part of the research process was conducted. This included data extraction on 53 papers (52 individual studies) interrogating how photographs were used in processes of data collection, data analysis and dissemination. Several phases of visual data collection with participants from a mental health hospital followed. Following ethical approval, staff and service users [n=17] took photographs of the hospital environment. Focus group, photo-elicitation and mobile photo-interview data were collected between March 2007 and June 2011. Several participants were not interviewed, leaving some sets of photographs with no supporting text. Photographs [n=5] which could not be anonymised, or which had not been developed properly, were removed. All remaining photographs were analysed using a method of thematic visual analysis. This resulted in a thematic visual ‘thin description’ of the hospital environment. Focus group, photo-elicitation and mobile photo-interview data were coded thematically alongside the visual data and interpreted in terms of the discourses they constructed or reflected. Findings centred upon what these visual methods and forms of visual data contribute to qualitative research in the context of mental health hospital environments. It was found that whilst it is possible to construct a ‘thin description’ of the hospital environment using images alone, the addition of third party speculations, interview data and observational notes served to ‘thicken’ this description significantly. In particular, the sensorial nature of mobile photo-interviews enriched the interpretive process by submerging me in the lived experience of the participant, if only for a very short time.

This thesis constitutes an investigation of the development of community mental health services in Belo Horizonte, Brazil - although information on two other cities, Rio de Janeiro and Sao Paulo, is used for contextual comparison. The study addresses two main issues: a) the possibility of successful psychiatric de-institutiona1ization in a Third World country, where most of the historical conditions which allowed such processes in First World countries are, in general, not yet developed; b) an evaluation of the hegemonic service models being implemented and their appropriateness to the clinical needs, class and cultural background of clients of these new services. The research strategy uses 'multiple and embedded case study design', involving historical, ethnographic and survey methods. First, the historical account traces the development of the mental health movement and of implementation of services between 1978 and 1989 and its political, economic and social basis. Second, the hegemonic service model being implemented is analyzed through original data obtained by fieldwork to assess its determinants and implications for the clientele. The results suggest that services in Belo Horizonte are marked by economic and political constraints and a professional culture strongly influenced by the private clinic liberal practices. The main implication of these is a very low level of care for the very clients who are given formal priority in the programme: the continuing care client, their informal carers, and the poorest, uneducated client groups. This effect is also found in Sao Paulo and Rio de Janeiro using secondary analysis of existing data. However, the effect is lessened by the availability of a more complex service network. The findings suggest also the inappropriateness of services to the cultural background of the target clientele, and alternative service models inspired by the popular representations of mental life and community practices are examined. Finally, the prospects for the de-institutionalization process in Brazil are discussed, with some suggestions for political action and policy making.

This thesis focuses on a comparative analysis of Community Psychiatric Nursing in Britain and Italy. The nursing role is examined cross-nationally in relation to the development of community care in the two countries. The central role acquired by nurses in developing and implementing deinstitutionalisation is the starting point for the investigation of professional attitudes and experiences in relation to institutional changes. The purpose of the study is threefold: a) to investigate similarities and differences between community psychiatric nursing practices in the two countries in relation to organisational models, ideological approaches to care, and professional cultures; b) to analyse whether there are universal elements in the nursing profession which are central to the process of change in both countries; c) to identify contextual factors which can constrain or facilitate the professionalisation of psychiatric nursing in Britain and in Italy. The methodology is based on case study research methods. Two samples of nurses have been interviewed, in Britain and Italy, by means of two sets of questionnaires. The thesis is organized into two main parts. First, the theoretical chapters provide an historical account of community care and psychiatric nursing developments in the two countries. A conceptual framework for the empirical study is built through the discussion of contributions from the sociology of professions, the sociology of knowledge, and organizational analysis. Secondly, the empirical chapters describe and analyse results obtained from fieldwork. Whilst the empirical investigation has been limited to England, the literature review includes the whole of Britain. The results suggest that both British and Italian community psychiatric nurses are professionally at a turning point. The advent of community care significantly changed nursing practices and models of intervention, influencing also the self-perceived professional role and identity. The findings also indicate that the different organization of labour, of nursing training, and of ideological approaches to psychiatric care are explanatory variables for the diversity in nurses' practices and experiences in the two countries. Despite these differences, both British and Italian nurses seem to enjoy a considerable degree of professional autonomy, which makes psychiatric nursing into a particular case within the overall nursing field. Finally, the prospects for the professionalisation of community psychiatric nursing are discussed by comparing the national situations with indications from the literature on professions.

This thesis explores equity issues in the mental health field in Britain by initially developing a conceptual structure to define equity in mental health and then analysing data from three national psychiatric morbidity surveys to measure inequalities and inequities in both mental health and in the use of services. Standard methods are used for measuring income-related and social class-related inequalities with reference to many indicators of mental health which represent 'normative' or 'felt' needs for services. Inequity in the use of mental health services is also examined by relating use of services to needs. Analyses of income-related inequalities and equity are carried out with reference to the general population using data from the Psychiatric Morbidity Survey 2000 and with reference to the minority ethnic groups in Britain using data from the survey of Ethnic Minority Psychiatric Illness Rates in the Community 2000. Changes in social class-related inequalities and equity for the general population between 1993 and 2000 are examined using data from the Psychiatric Morbidity Surveys for those two years, in order to see if the policy and practice changes that took place since the beginning of the 1990s in the health and social care sectors had exerted any impact on equity in mental health. The three mental health surveys being cross-sectional do not permit the study of causal pathways between income and mental health. Therefore, in order to understand the links between living standards, health and health care utilisation patterns further, data from a longitudinal study, the British Household Panel Survey on general health are examined using robust theoretical and empirical models. The assumption is that many of the factors associated with general health are also associated with mental health and much of the model that links income, health and health care utilisation behaviour is likely to be relevant for mental health as well.