Work-related stress (including burnout and occupational stress) are an increasing threat to people’s wellbeing at work. Despite their common occurrence among staff in healthcare settings, little effort has been put into researching unregistered care staff. This is a group of healthcare employees who are exposed to significant stressors while executing frontline care tasks in health and social care settings, and who are not registered with a governing body. The first chapter explores the effectiveness of different interventions aimed at easing work-related stress in care staff. This chapter reviewed thirteen published studies and identified the emotional exhaustion component of burnout, involving tension, irritability and fatigue, as the most significant factor. Research is varied and often not based on evidence-based factors, such as organisational factors, known to contribute towards work-related stress. The significant design and methodological limitations of the studies reviewed limit the conclusions that can be drawn regarding the effectiveness of such interventions. In response to this, the second paper explores the influence of individual factors on burnout in a sample of care staff for looked after children, a currently under researched population who work with vulnerable and traumatised children. This study used multiple regression to analyse a range of predictors of burnout: attachment styles, beliefs, secondary trauma, previous traumatic events and time worked with looked after children. Results indicated that secondary trauma, and secondary trauma avoidance specifically, is a highly significant predictor for all burnout dimensions. These findings were explored in relation to their clinical implications, including their contribution towards the development of interventions for those working with looked after children. The final chapter provides a first person reflective commentary on the process and completion of this project, and further considers the findings of the literature review and the empirical paper.

User involvement within healthcare settings has been increasingly prevalent in recent years, where individuals accessing services contribute to their development and delivery. This thesis describes the process of exploring user involvement in adult mental health settings. A review of the literature highlighted that despite government calls for additional emphasis on user involvement to improve services, a number of barriers stop meaningful involvement from being enacted. To avoid tokenism in user involvement practices, power differentials need addressing, and users need to see tangible change as a result of their involvement activities. There has been limited research into users’ motivations for taking on an involvement role within an organisation, yet this is key to understanding criteria for successful involvement. To explore the role of user representatives, including motivations and personal gains, a study informed by action research was developed in collaboration with users of mental health services. Semi-structured interviews with thirteen user representatives were analysed using constructivist grounded theory techniques. The resultant themes highlighted initial motivating factors for user representatives including wanting to give back to services, and making a difference for future users. Experiences of involvement depended on wellness and whether user representatives felt valued. The theme of transition captured shifts in identity, yet staff ultimately governed user involvement activities. Clinical implications are discussed in light of findings, with particular emphasis on the clinical psychology profession. However, development of infrastructure and teams to address specific areas of service development should include staff, user representatives, and users from all levels of an organisation. Further research is suggested to examine the links between user involvement and wellbeing, and dynamics between staff and user representatives to address power relations.

Objectives: Team formulation is expected to support multidisciplinary team members to work effectively with their clients, meet their clients’ needs and broaden their psychological knowledge. There remains a lack of research evidence regarding the perceptions of team formulation among Community Mental Health Team (CMHT) members. This study addressed the following research questions; (1) what are considered helpful or unhelpful aspects of team formulation? (2) what are the processes or mechanisms that lead to unhelpful or helpful aspects of team formulation? (3) what is the impact of team formulation on professionals’ clinical practice? and (4) what are the factors that may influence these outcomes? Design: An inductive qualitative design was used, utilising a contextualist, critical-realist paradigm. Methods: 12 CMHT members who attended team formulation were recruited from three sites within the British National Health Service. In each site, an individual interview with a clinical psychologist and a focus group with three professionals were conducted. An inductive thematic analysis was used. RESULTS Attendees across the three teams reported that although team formulation was optional, a low priority and outside of their usual way of working, this was engaged by those who perceived a value in it. Participants reported that this process required a safe environment which would not threaten attendees’ job securities; and identified factors that enable this. Although attendees predominately reported helpful aspects of engaging in team formulation, these could also be perceived as unhelpful (apart from validation). The helpful aspects of team formulation involved other professionals’ contributions. Attendees reported that team formulation impacted on their clinical practice by (1) Page 3 of 273 providing alternative ways of working with clients and meeting their clients’ needs and (2) justifying discontinuation of clinical work. Across all teams, participants reported that ideas derived from team formulation, integrated into care plans (CPs) were integral and that these CPs were valued outcomes/products of team formulation. Participants reported that CPs were helpful in justifying attendees’ engagement in team formulation, prioritising ideas and making these achievable, and providing a rationale for professionals to flexibly test ideas. Participants did not report unhelpful aspects of CPs as products of team formulation. There were conflicting perceptions across the teams regarding the factors that influenced the use of CPs e.g., psychologists expected CPs to be used but also reported that this was not required as attendees adopted alternative perspectives. Conclusions: This study found that attendees reported that other professionals’ contributions enabled them to work effectively with their clients and meet their clients’ needs. Attendees did not outline broadening their psychological knowledge as suggested by the professional document published by the Division of Clinical Psychology (2011). This study’s findings suggests that each CMHT may benefit from discussing (1) clear expectations of team formulation, as this process can be perceived as different for attendees, (2) what aspects enable team formulation to be safe and ascertain how this could be achieved, (3) the unhelpful aspects of engaging in team formulation and ways of managing these, and (4) agreeing on their expectations of the outcomes or use of the products of team formulation i.e., are professionals expected to use CPs, adopt alternative perspectives, or both. If CPs are expected to be utilised then CMHTs may require support from their managers.

Background: The aim of the study was to explore the role of significant others1 in problem disclosure and help seeking in adults with anorexia. Existing literature on help seeking is predominantly focused on anorexia in children and adolescents (Honey & Halse, 2005; Tierney, 2005; Thomson et al. 2014). Anorexia becomes more chronic the longer it is left untreated, and delays in seeking treatment are associated with poorer recovery outcomes (Ficher, Quadflieg & Hedlund, 2006). Therefore, early intervention is key. This study sought to explore an under researched area and map the territory for future projects. Methodology: Participants were recruited from a carer group in the UK for carers of individuals with an eating disorder and B-eat, a charity that supports individuals in the UK with their eating disorder. Ten individuals self-selected to participate in the study and took part in a one retrospective semi structured interview. Interviews were audio recorded and transcribed verbatim. The data was analysed using thematic analysis, following the guidelines by Braun and Clarke (2006). Results: Six superordinate themes were identified: (1) First Response, (2) Confrontation and Confession/Denial, (3) Stepping In, (4) “Stepping Back”, (5) Care Context and (6) Flexible and Persistent Approach.

Objectives: The cognitive model offers a useful framework to understand the emotional and behavioural consequences of voice-hearing experience. Substance use can be viewed as a way of coping with these emotional and behavioural consequences. This research explores how substance use as a coping strategy may affect voice-hearers‟ beliefs about their relationships with the voices, how they cope with the voices and compliance with command hallucinations. Design: This research used a qualitative design to analyse the experiences of participants that have used substances as a way of coping with hearing voices giving commands. Participants were recruited from early intervention services and community mental health services within a local NHS Trust. Methods: Semi-structured interviews were held with nine participants and analysed using a thematic analysis to identify themes amongst the accounts of their experiences. Participants also completed a Beliefs About Voices Questionnaire (BAVQ-R) as a triangulation measure of the appraisals of the voices. Results: Six themes in total were identified during the analysis and a theme of control was interpreted as central to the research question. These themes were: Control; emotional moderation; relationships; self-concept; understanding of psychosis and function of the substance use. Many participants viewed themselves as passively using substances which took control of themselves and their voices. Participants also used substances to disengage from the emotional effect of hearing voices Conclusions: The research suggests that people who hear voices may use substances to lessen the control of the voice. For some this may mean remaining passive and attributing substances (including anti-psychotic medication) as having control over the voice. This has implications for how services can successfully engage individuals in treatment. The effect of substance use on compliance with commands remains unclear.

Given a post-structuralist critique of the metaphysics of presence within western thought, It is surprising that much contemporary theory that discusses fetishism still subscribes to concepts of substitution and disavowal which uphold a notion of self-present value. This study offers an original critique of traditional views of fetishism via a consideration of the role of surplus and equivalence within the production of value. Rather than describing fetishism in terms of a disavowal of a self-present determination of value, this critique recognizes that what is ultimately denied within traditional accounts is the artificial surplus production upon which its value is premised. An original account is proposed in which fetishism is perceived as an immanent productive process where difference generates signifiers of value. The fetish can be perceived as the means by which established measures of value are both endorsed and transgressed in relation to a restricted economy. This theory supplements the Bataillean notion of the fetish as an untransposable object of desire and considers the implications of a Deleuzean metaphysics of difference. The work of Deleuze offers a means to resolve the contradiction in which the fetish can be perceived as both an instigator and transgressor of value. As such, fetishism is found to be the archetype of value, rather than its substitute. An original contribution to the corpus of Deleuzean theory is made via an understanding of fetishism in relation to the Body Without Organs. Whereas fetishism has been discussed in terms of a reifying tendency, a wider consideration of Deleuze and Guattari’s work allows the notion to be considered from the point of view of transgression and becoming. Such a conception is found to have greater efficacy than current theories in that it allows the fetish to be understood as either a reified or transgressive value.

In 2004 it was reported that up to half a million elderly people may be victims of abuse at any one time. Studies have shown that elder abuse can have devastating effects upon service users and can often lead to long-term health problems. It is vital that health care service providers acknowledge the importance of recruitment decision-making when employing carers for work involving vulnerable adults. In 2002 the Criminal Records Bureau (CRB) was established in the UK to ensure safer recruitment decisions could be made. The CRB check is utilised to facilitate safer recruitment decisions by providing employers with wider access to an applicant’s criminal record information through a Disclosure service. However, how these changes are impacting upon recruitment decisions and its implications for the protection of vulnerable adults is yet to be examined. Therefore, the research presented here, sets out to explore how recruitment decisions are being made by individual decision-makers using CRB Disclosure information. The implications of these decisions for the protection of vulnerable adults and the ex-offender are examined. Organisations from the National Health Service, Social Services, Higher Education, Further Education and Care Home sectors whose employees have contact with vulnerable persons were recruited to take part in this research. A mixed methods approach was utilised to investigate research objectives. The research objectives were as follows: 1. To analyse exactly who is responsible for making recruitment decisions in an organisation 2. To discover whether or not recruitment decisions are informed by any guidance 3. To assess what impact the knowledge of convictions has upon perceived suitability for employment of individuals working with vulnerable persons 4. To examine how trade off decisions for employment are made 5. To identify how easy or difficult recruitment decisions are to make 6. To examine the implications for the protection of vulnerable persons and 7. To evaluate the implications for human rights, civil liberties, discrimination and social exclusion. The findings indicate that recruitment decisions are being made inconsistently both within and between organisations. Both the actual recruitment decision made and the reasons for these decisions varied. In addition, results suggested that the organisation to which an ex-offender applies to for a post could determine the success of their application based on the recruitment decision-maker/s involved in the process. Moreover, there was no general consensus on what constituted a problematic offending profile. In order to aid data collection, a software package named Survey Software was created. This allowed the administration of a series of vignettes, whilst recording and sorting the inputted information.

This thesis is based on 13 papers published in peer reviewed journals. These include studies on epidemiology and treatment of major psychotic disorders, and metanalysis of studies on Duration of Untreated Psychosis (DUP) and its relationship with the Gross Domestic Product and the outcome in Low and Middle Income (LAMI) countries. Based on this research that highlighted the extent and impact of untreated psychosis, a series of papers presented a novel approach for early intervention in psychosis in LAMI countries. The final paper presents the randomised controlled trial evaluating this approach. Seven publications on puerperal psychosis, homicide by patients suffering from Schizophrenia, and the impact of cannabis use on symptomatology and course of schizophrenia highlighted significant gaps in the care of schizophrenia in developing countries. Only 12 patients (24%), charged with homicide had received some form of treatment before the index crime, despite the fact that duration of illness was more than 5 years in most cases. In a clinical sample of 35 patients suffering from acute episode of Puerperal psychosis the mean time between the onset of symptoms and receiving psychiatric care was almost a month. Two third of mothers suffering from Puerperal psychosis could not breast feed, most showing almost total lack of concern for the baby and also other behavior which could result in harm to baby. The publications on Puerperal psychosis argued that prevention of the disorder should be feasible in developing countries in view of high incidence of the disorder following an identifiable life event (childbirth) and the fact that most of the risk factors could be screened in the antenatal period. A paper published in British Journal of Psychiatry estimated the Duration of Untreated Psychosis (DUP) and its impact on the outcome of psychosis. Based on metanalysis of 98 studies (23 from LAMI countries and 75 were from high-income countries) the DUP of LAMI countries (125 weeks) was twice as long as the DUP in high-income countries (63 weeks, p=0.012). The relationship between DUP and the gross domestic product (GDP) purchasing power parity was also examined using the data from International Monetary vii Fund (IMF) and the World Bank. There was a strong negative correlation between DUP and GDP ppp, indicating that for every thousand dollars of additional GDP (purchasing power parity), mean DUP was reduced by 8 weeks and median DUP was reduced by 5 weeks. A study published in Schizophrenia Research examined the association between DUP and at least one of the following outcome measures; psychotic symptoms, cognitive function, social disability or mortality. Patients with a longer DUP had a smaller reduction in symptom scores after treatment when compared to patients with shorter DUP. The pooled estimate indicated that longer DUP was negatively associated with the degree of reduction in symptom scores (random effects Meta analysis; r=−0.290, 95% CI=−0.483 to−0.069, z=−2.559, P < 0.011) and longer DUP was associated with greater level of disability (fixed effects Meta analysis; r=0.195, 95% CI=0.126 to 0.262, z=5.498, p<0.000; heterogeneity Q-value 1.245, p=NS, I2=0.00). These studies clearly established the case for Early Intervention in psychosis. However, an entirely different approach was needed for this in resource poor settings. This approach is described in three papers. This approach termed as ‘Supervised Treatment of Outpatient Schizophrenia’ (STOPS) was evaluated in a Randomized Controlled Trial. The paper describing this RCT which provided proof of the concept will soon be published by British Journal of Psychiatry. In this RCT, fifty five patients were recruited in each arm. Ninety five (86.36%) patients completed the study; 49 in STOPS and 46 in Treatment As Usual (TAU) group. At one year follow up, 37 (67.3%) patients in STOPS group had complete adherence with medication compared to 25 (45.5%) in the TAU group (P<.02). The patients in STOPS group also showed more improvement in symptoms (P=0.003) and functioning (P<0.011).

This thesis aimed to investigate how visual working memory takes advantage of long-term knowledge in order to allow semantic elaboration in the form of chunking and the role of the central executive in this process. Two leading theoretical frameworks of working memory which both emphasise the role of long-term memory are discussed. One of which views working memory as consisting of multiple discrete, modality specific subsystems (Baddeley, 2000) and one which views working memory as an activated subset of long term memory (Cowan, 2005). Both of these models propose the integration of short- and long-term representations to be attentionally demanding. To investigate this assumption, two forms of visual matrix pattern were generated; a high semantic set which lends itself to long-term memory support and a low semantic set which does so to a lesser extent. The initial block of empirical work aimed to establish the characteristics of the patterns sets. Superiority for the high semantic patterns was observed in terms of greater stability across increasing maintenance intervals. The benefit of increased presentation time was also shown to be greater for the high semantic pattern set indicating the importance of time in the semantic elaboration process. A second block of studies was then conducted to identify the implications of the two patterns sets for the functional architecture of working memory. In a secondary interference paradigm the pattern sets were shown to be differentially dependent on visual and verbal interference with low semantic patterns negatively affected by visual and not verbal interference and the opposite pattern observed for high semantic patterns. The use of executive and attentional interference paradigms demonstrated two levels of binding. Firstly, when attentional resources were continually captured by a secondary task, a degree of chunking was observed for both pattern sets, this is discussed in terms of passive binding on the basis of long-term knowledge in the absence of executive resources. In the absence of interference, effortful elaboration of the pattern sets is observed and this is greater for the high semantic patterns. This is discussed in terms of active binding with the involvement of executive resources. These findings are then discussed in terms of both the Cowan (2005) and Baddeley (2000) models and recent observations made by Baddeley et al (in press) to support a modification of the episodic buffer in Baddeley's model to allow for both passive and active binding and how this leads to striking similarities between the two theoretical perspectives.

Caffeine is often described as the most widely consumed psychoactive drug in the world. Despite a substantial amount of research examining the effects of caffeine on mood and cognition, there remain a number of unresolved issues in this field, two of which formed the focus of this thesis. The first pertains to whether caffeine has any behavioural effects beyond a reversal of withdrawal effects purported to exist in habitual consumers following caffeine deprivation. A second relates to the biobehavioural effects of caffeine when consumed in combination with other potentially psychoactive components, as is usually the case in dietary forms of caffeine. This thesis, therefore, firstly compared the cognitive and mood effects of acute administration of caffeine to habitual consumers and habitual non-consumers of caffeine. The effects of combining caffeine with other naturally concomitant compounds were then explored, firstly by examining the impact of combining caffeine with L¬theanine (an inhibitory amino acid found in tea) and then by exploring the effects of guaranâ (a caffeine-containing whole extract). Finally, following on from these latter studies, an attempt was made to establish the lowest active dose of caffeine. Each experiment followed a placebo-controlled, double-blind, balanced cross-over design. In each study, treatment-related changes in cognitive performance were assessed with computerised assessment tools (the Cognitive Drug Research battery, a sentence verification task and serial subtractions), and mood was assessed using both Bond¬Lader and specifically tailored caffeine research visual analogue scales. Where appropriate, salivary caffeine levels and autonomic activity were monitored. Performance was similarly improved for habitual consumers and habitual non- consumers of caffeine following caffeine administration. The administration of caffeine in combination with L-theanine led to some modulation of the effects of caffeine. This was also demonstrated when examining the effects of guaraná. A direct comparison of caffeine and guaranâ with matched caffeine levels revealed differences in the effects of the two treatments. Exploration of the lowest active dose of caffeine revealed (largely impairing) effects of caffeine at doses lower than those found in decaffeinated beverages. These findings may have important implications for caffeine research. Firstly, they suggest that behavioural effects of caffeine cannot be attributed wholly to withdrawal reversal. Secondly, they demonstrate that other components commonly co- consumed with caffeine are likely to modulate its biobehavioural effects. Finally, they suggest that levels of caffeine hitherto thought to be inactive may have (negative) psychoactive properties.