This doctoral thesis begins with a literature review that explores how individuals who meet criteria for borderline personality disorder (BPD) experience health services. Following a comprehensive literature search, a metasynthesis of 14 papers was conducted utilising Noblit and Hare’s (1988) meta-ethnographic approach. Findings indicate that the attitudes of professionals are exceptionally important to service users but are often experienced by them as judgmental and dismissing. Service users highly value communication, consistency and input into their own treatment and sometimes search for containment and meaning within health services. Barriers to treatment are highlighted which include negative attitudes from professionals, lack of input into treatment and insufficient security and support for service users in the community. Implications for health services are explored. The research paper that follows this is an interpretative phenomenological analysis (IPA) study on the experience of mentalisation-based treatment (MBT) for BPD from the perspective of adult service users. Seven participants were interviewed and findings illustrate that the group component of MBT was experienced as challenging and unpredictable. Trust was identified as key to benefitting from MBT and was much more difficult to obtain in group sessions than in individual therapy. However, participants attending MBT for longer than three months appeared to make progress with this. The structure of MBT generally worked well for participants but individual therapy was identified as the most important component and specific challenges were highlighted. All participants learned to look on the world differently due to MBT which resulted in a positive shift in experience for them. Implications for MBT are discussed in this paper. The subsequent section in this thesis is a critical appraisal that highlights key learning points and reflections from conducting the research paper.

Background: Accelerated long-term forgetting (ALF) is a novel form of memory impairment whereby some people with epilepsy (PWE) demonstrate ‘normal’ patterns of learning and memory over short retention intervals (i.e. 20-30 minutes) but then experience rapid forgetting over longer delays. Currently, there is no consensus on the measures used to assess ALF and little attention has been paid to how clinicians should assess ALF in clinical practice. The aim of this research was to develop and pilot a clinically feasible nonverbal measure of ALF. Method: Phase 1 comprised the initial development and piloting of the Action-People-Places (APP) test materials and procedure. Six versions were created and each version was piloted on small numbers of healthy adults and/or PWE. Modifications to each version were made in line with participants’ performance and feedback. Phase 2 involved administering the final APP test, as well as a brief battery of neuropsychological tests, to 32 healthy adults and an individual, SK, with a confirmed diagnosis of ALF, to assess its reliability and validity. Comparisons were made to two PWE involved in Phase 1. Telephone follow-ups were undertaken at 24 hours, 1-week and 3-weeks. Phase 3 evaluated its acceptability using a brief structured interview format. Results: Healthy adults demonstrated forgetting on the APP test. There were no floor effects but some evidence of ceiling effects. The test had modest levels of reliability (.67-.83). Older age was associated with increased forgetting over time. There were some associations with existing memory measures. SK demonstrated ALF on the task. The APP test was considered acceptable to participants. Discussion: Despite several limitations to the study, including the use of an unmatched healthy adult group, the APP test appears to be a promising measure of ALF, which is worthy of further development with larger patient groups and a more representative control group.

The research engages with the increasing interest in the application of music in community health contexts. Previous research has tended to have a singular focus (such as on the effects of selected music on individual patients in a clinical setting) and to under-represent the role of the musician. Accordingly, the thesis sought to understand the nature, process and impact of live music in a hospital context from the perspectives of each group of stakeholders (musicians, patients, carers, medical staff and administrators). An initial web-based survey of music in hospitals led to a preliminary observational and interview study of eight musicians working in hospitals for a leading UK charity. The emergent data from these two sources was juxtaposed iteratively with related research literatures to explore the perceived reasons for musical intervention in clinical settings and the reported effects on the different groups of participants. The main fieldwork phase was a month-long qualitative study of a group of nine musicians in an Italian paediatric hospital, selected because it was relatively unique in offering a sustained programme of forty-five hours of music each week across the year for its patients. The fieldwork embraced observations of 55 musical interventions with 162 children (totalling 36 hours and 40 minutes) using a specially designed observation schedule, supplemented by video recordings and 68 interviews with members drawn from each participant group (musicians, patients, carers, medical staff and administrators). Subsequent thematic analyses - informed by grounded theory and systematic content analysis using Atlas.ti software - suggest that provision is generally valued by participants and, overall, having a positive impact on patients and hospital environment. Nevertheless, the Italian data suggest that there are also perceived negatives in such multi-faceted provision, related to the choice and variability of repertoire, musicians' relative status, available monitoring and support, and the often stressful nature of the work. Implications for policy and practice are discussed.

The rates of eating disorders within the UK are ever growing, alongside a cultural attitude of normative discontent with our appearance. This thesis aims to explore resilience and overcoming difficulties around body image and Anorexia Nervosa. The review paper sought to define positive body image, identify its properties, how to promote it, and measure it. The literature review highlighted the dearth of studies that explicitly focus on positive body image as a multidimensional construct. In addition to this, the review illustrated the unique qualities of positive body image, de-constructing its current conceptualisation as merely the absence of negative body image. The review draws attention to the methodological and ideological flaws within the studies concerned. This has made defining positive body image, and subsequent exploration of its properties and measurement, an arduous task. The empirical paper describes a qualitative study using interviews with individuals who are substantially recovered from severe Anorexia Nervosa. Eight individual interviews were conducted across the North Wales region, and data were transcribed and analysed using a grounded theory approach. A tentative model of letting go was developed, demonstrating the factors that have contributed towards recovery. This model highlights the dynamic relationship between intra and interpersonal factors that help let go of Anorexia Nervosa. Findings are discussed in relation to previous findings and offers suggestions for future research. It is hoped that these two papers will contribute to existing lit~rature and inform clinical practice in the areas of promoting healthy body image and ensuring better outcomes for those suffering with 'difficult to treat' Anorexia Nervosa.

Occupational Therapy is a client centred, holistic allied health profession in which the quality of a supportive, empowering therapist-client relationship is seen as having a key and central role in effective therapy. A minimum of a 1000 hours of practice placement education (PPE) must be successfully completed in pre-registration programmes, which are charged with ensuring graduates are fit for practice and purpose. This Work Based Project focussed on how pre-registration education can best equip students for a first PPE in terms of sufficient inter-personal communication skills. Primary data collection was conducted between November 2008 and March 2010. The project firstly employed thematic content analysis of data elicited from two rounds of focus group surveys of practice placement educators (PPEds) to identify a baseline of inter-personal communication skills required prior to embarking on a first PPE. This data was used to formulate an objective structured clinical examination (OSCE) checklist of inter-personal communication skills, which was then utilised as a formative assessment and in role play scenarios in taught sessions with one first year pre-registration occupational therapy cohort. This cohort was surveyed via a questionnaire and in addition five students were interviewed. Subsequently a group of third year students, who role played clients for the OSCE, participated in a facilitated discussion on their perceptions of the OSCE. The data on students’ perceptions and an analysis and comparison of staff and student ratings of performance in the formative OSCE, were utilised in a critical evaluation of the use of this OSCE as a teaching and assessment tool. The findings indicate a level of agreement on the content of the OSCE checklist, providing content validity to this particular assessment. PPEds, and first and third year students are positive about the use of an OSCE when it is used as a formative experience. Students recommend that if used as a summative assessment the OSCE is combined with a reflective piece. Objective structured clinical examinations have long been established in other health care professions such as medicine and nursing. This project has provided evidence indicating that an OSCE of inter-personal communication skills is a valid assessment tool for occupational therapy pre-registration students, and that it can also facilitate student reflection, self-awareness and learning. It has also identified profession specific inter-personal communication skills required for embarking on a first PPE.