This thesis describes the process of exploring the understanding of non-psychologists around the use of formulation, and alternative approaches to explaining a service user’s mental health difficulties. This includes uncovering perspectives about the role of the clinical psychologist within the team. Formulation is seen as a key concept in mainstream psychotherapeutic approaches, but it is not widely understood whether psychiatry or mental health nurses use this approach in understanding a service user’s difficulties, or whether they use diagnosis and classification as the mainstay methodology. Current literature suggests that the use of formulation in psychiatry is constrained to being a part of an overall medical summary, but that mental health nurses can use an approach similar to formulation, undertaking comprehensive assessments, and identifying difficulties through alternative therapeutic interventions. Clinical psychologists report sharing formulations informally within MDTs, helping increase staff cohesion, improve team dynamics, and improve relationships with service users. However, literature suggests that service users may feel more confident receiving a medical diagnosis as it provides a stronger justification and validation for their difficulties. To better understand the role that formulation takes within mental health working, a study was designed to explore these areas further. Using a qualitative approach called Template Analysis (TA), which utilises hierarchical coding to extract key themes from the interview transcripts, the researcher was able to find four themes: ‘level of understanding of formulation’, ‘level of benefit of formulation within the team’, ‘limitations of using formulation within the team’, and ‘Role of clinical psychologist’. The researcher used these themes and resultant codes to discuss levels of understanding of non-psychologists working within the teams, around formulation and the role of the clinical psychologist, and areas for development and future research.

This thesis aimed to explore the views held by British Indians towards recovery in mental illness. Indian people in particular are under- represented in mental health statistics which can make it difficult to understand their views of mental illness. Understanding cultural perspectives can provide insight into the way in which Indian people conceptualise mental illness. Research related to Indian people’s attitudes towards mental illness was reviewed. The research demonstrated that Indian people were able to identify signs of mental illness however, lacked knowledge of certain aspects of mental illness and its causes. Differences in attitudes were influenced by gender, age, profession, education and generation. The review demonstrated an absence of research conducted outside of India, examining Indian people’s views of different aspects of mental illness such as recovery. Due to this gap in research, Q methodology was used to obtain the views of British Indian people (from the Gujarati and Punjabi subgroups) regarding necessary factors for recovery in mental illness. A sample of 20 participants were asked to Q sort 52 statements pertaining to recovery based on their personal beliefs. Factor analysis revealed four factors representing a range of viewpoints related to recovery. A number of key aspects necessary for recovery were highlighted. Recovery was seen as a journey of self- discovery requiring insight and positivity and additionally, the importance of acceptance was identified. British Indians also preferred to keep mental health difficulties hidden due to a fear of stigmatisation from the wider community. The role of family members and spirituality was highlighted. Differences in viewpoints of British Indians born in the United Kingdom and those born in India and Africa are significant in understanding the impact of acculturation in help- seeking behaviours. The reflective commentary provides analysis of the research process and a reflexive account is presented.

This thesis focuses on understanding psychological interventions in acute inpatient services. A review of the literature highlights some benefits of psychological interventions on acute wards both for service users (SUs) enhancing their wellbeing and acquiring new learning and also economically, reducing admissions and the number of inpatient beds. It is acknowledged that research in this area is limited and therefore to better understand SUs experience of psychological interventions on acute inpatient wards, a study was completed focusing on SUs experience of a mindfulness intervention. Using Interpretative Phenomenological Analysis (IPA), the resultant themes included a process towards self-actualisation, mentalization, locus of control and cognitive strategies. These findings are discussed in relation to clinical implications for health care professionals on acute inpatient wards. It is highlighted that SUs would benefit from having choices of interventions such as mindfulness, and that these interventions are delivered as a ward ethos in which both staff members and SUs engage in the practice of mindfulness. The researcher mindfully reflected on the research journey considering reflexivity, epistemology and ethical issues.

This thesis aims to explore some of the key perspectives of service users and mental health workers regarding assessment and detention under the Mental Health Act (1983). The first paper is a critical review of the research literature on service user and mental health workers’ perspectives of the Mental Health Act assessment. The main finding of the review is that context, relationships, agency and risk are issues that influence people’s perspectives. A relative paucity of qualitative research may reflect an under-representation of service user perspectives and needs. Qualitative research targeting service user experiences of assessment was recommended. The second paper employs interpretative phenomenological analysis (IPA) (Smith, Flowers and Larkin, 2009) to conduct an empirical investigation of the assessment and detention process. The main aims of this paper were: to determine how people make sense of their experience of being assessed and detained; and, to identify key interpretative themes that can help inform communication in the assessment setting. The main findings were that participants predominantly perceived their treatment experience as negative. This negative perception might be explained by individual psychological factors associated with negative bias and cognitive perceptual disruption, and relational processes associated with labelling theory. The third paper is a critically reflexive commentary of the research thesis process. The epistemologies that underpin the development and application of psychological theory are considered. IPA method is critiqued and suggestions for its development provided. Particular attention is paid to the importance of reflexivity in the gathering and interpretation of data. The paper concludes that IPA, not without limitations, is mainly successful in operationalising its theoretical concepts.

Life story work is a widely used intervention in adoption and fostering. Despite being recommended for use with all children in the care system, the outcomes are underresearched. This review systematically evaluates the scope of the current research into life story work in the looked-after population, investigating the processes used in practice and the benefits and limitations of these approaches. The findings of this review suggest that life story books are a predominant tool within the process of life story work alongside direct work with social care professionals, foster carers and adoptive parents. Although qualitative studies have found many benefits to these varied approaches to life story work, there are limitations to these studies. The findings do not directly correspond with the findings of quantitative studies that have evaluated life story work and have indicated little benefit. Life story work varies in how it is conducted and further research is needed to examine the key components of effective life story work.

Carers of individuals diagnosed with dementia can often experience high levels of stress, anxiety and depression, which can have a negative impact on psychological wellbeing. Research has begun to explore the factors which influence the level of distress that carers experience. In particular, research has shown that coping strategies play a large role in mediating the relationship between caregiving and its associated stress. Given this finding, the aim of the thesis was to explore additional factors related to coping that may be associated with the wellbeing of carers. A review of the literature was undertaken, specifically focusing on the concept known as ‘Sense of Coherence’ (SOC), which is concerned with the extent to which a person perceives stressful life events as comprehensive, manageable and meaningful. The findings revealed that dementia carers with a high SOC were less likely to feel burdened by their situation or experience anxiety and depression, in comparison to carers with a low SOC. However, several limitations were identified regarding the extent to which SOC has a protective effect on symptoms such as depression. The second part of this thesis involved carrying out a research study which attempted to explore psychological acceptance and knowledge of dementia (specifically pertaining to knowledge of Alzheimer’s-type dementia) as possible predictors of anxiety and depression in carers of individuals with Alzheimer’s disease, in order to address inconsistencies in the research and to strengthen the existing evidence base. The findings revealed that psychological acceptance was a significant predictor of anxiety and depression. This has implications for interventions that can enhance acceptance in order to reduce distress, such as Acceptance and Commitment therapy. A reflective account on the process of carrying out the research is offered, which also addresses some of the primary strengths and weaknesses of both the literature review and research study.

Hope has been linked to psychological well-being, resilience and recovery from mental health difficulties. Many recovery-oriented policies have included calls for mental healthcare staff to develop hope-inspiring relationships with their clients. However, guidance and research regarding the clinical application of these recommendations are lacking. This is particularly the case within forensic mental health services, which have been slower to adopt the recovery model. This thesis aimed to develop an understanding of staff perspectives about hope and their experiences of fostering hope with service users, in forensic mental health settings. An initial scoping exercise found that no such studies have been conducted in secure settings. Therefore, Paper One reports a review of qualitative literature exploring staff beliefs of hope, practices to foster hope and the challenges faced by practitioners across a broad range of mental health settings. The therapeutic relationship, helping the client to maintain social connections, uncovering values and goals and working to develop different perspectives emerged as important hope-inspiring practices. Clinicians identified the importance of maintaining their own sense of hope and also the challenges to remaining hopeful. Many of the studies lacked an integration of the themes and categories that emerged from analysis. Paper Two reports an empirical study that utilised a Grounded Theory methodology to develop a model of nurses’ experience of inspiring hope in their clients within one medium secure hospital. The grounded theory that was developed from the data described what it meant for the nurses to hold on to hope for their clients. Two categories (being the intervention and doing reasonable hope) captured the practices through which nurses worked to foster hope. These practices were influenced by the nurses’ beliefs about hope and the context of the secure unit. The model also captured the emotional impact of working to inspire hope and the way in which nurses managed their emotional response. The clinical implications of the findings, particularly to staff recruitment, training and support, are discussed. Paper three outlines the author’s own reflections on the research process.

As the number of cancer survivors and the duration of survival increases in the UK, there is an increasing interest in psychosocial care, to improve outcomes for cancer patients. Previous literature reviews have focussed on research from around the world. The aim of this review was to look at the evidence for the impact of psychosocial interventions on the mental health and well-being of cancer patients, since the publication of the cCancer Rreform sStrategy in the UK in 2007. The review focused on thirteen studies of interventions, which addressed mental health and well-being in cancer patients. There was no agreement on the best method of intervention, but the studies reported give some support to the use of Cognitive Behavioural Therapy (CBT) techniques, psycho-education and bibliotherapy. There is also also some support for lower level interventions (e.g. self-help interventions,), exercise, less labour intensive interventions, and complementary therapiesinterventions. The quality of the reviewed studies was limited and more research in this area needs to be generated to establish an evidence base within the UK. Limitations are identified with the variety of measures used to assess mental health, well-being and quality of life in these studies, and the use of more standardised measures is recommended to allow easier comparisons between studies for future research.

The number of individuals living longer after a diagnosis of advanced cancer (AC) is increasing. To provide effective care for this population, a sound understanding of the psychological impact of AC is necessary. Cancer has been shown to have a traumatic impact and can precipitate both post-traumatic stress (PTS) and post-traumatic growth (PTG). In individuals with cancer, PTS is manifested through intrusive thoughts and images related to the experience of cancer, avoidance of thoughts and feelings connected with this experience, hyper arousal, and negative changes to one’s mood and thinking. PTG describes the positive changes that can occur in response to managing a challenging life event, such as cancer. While PTS and PTG have been explored extensively in response to primary cancer, the traumatic impact of AC has received less attention. A review of the literature on PTS in response to AC identified 11 studies, which were collated and critiqued. Across studies, individuals reported high rates of PTS, which were influenced by numerous factors. In completing this review, the researcher noted that studies on PTG in response to AC were lacking. There was also a paucity of qualitative research in this area, and few studies with the partners of those with AC, despite evidence of high rates of traumatisation in this group. To remedy these limitations in the evidence base, a Q-methodology study (n=11) was conducted. This study explored patients’ and partners’ responses to living with AC, to determine whether the constructs of PTS and PTG resonated with their subjective experiences. This analysis interpreted four differing accounts of the impact of AC, three of which could be understood as stories involving PTG and PTS. The final paper in this thesis provides a reflective account of the research experience.

This thesis explores the journeys undertaken by families when someone experiences a first episode of psychosis (FEP), and the family seeks help and receives treatment. A review of the literature on families' experiences of help-seeking for FEP provides a focus on the beginning of this time. The literature is synthesised to reveal a journey through the early help-seeking experience, and the extent to which experiences are shared between carers and individuals with FEP is explored. The empirical research paper provides insight into families' experiences further along on their journey; presenting a qualitative study on family narratives of FEP and Behavioural Family Therapy (BFT). Families completing BFT were interviewed, and narrative analysis was used to identify their shared narratives and the subplots within these. A broad narrative of the journey from illness to recovery is presented, with subplots within each broad phase of the journey considered. The extent to which narratives can provide evidence of effectiveness in BFT is explored, as well as consideration of how such narratives may aid recovery. The role of parental power in maintaining family narratives is considered, and further research and clinical implications are discussed. The reflective review paper presents a reflective background and critique of the literature review and empirical research study, as well as an extended discussion of some points within these. The author's journey through the creation of this thesis is presented, within the wider context of clinical psychology research. Decisions made during creation of the thesis are elucidated, and the limitations and value of the thesis are considered. This reflective journey begins with the author's own epistemological position, and consideration of how this influenced the thesis, and ends with consideration of personal learning points gained during completion of the thesis.