Aim This research programme aimed to investigate issues relating to the management of patient non-adherence with antipsychotic medication. The findings from the patient-related studies and the systematic literature review informed the development of a medication management staff training programme; which was evaluated in terms of the effects on mental health professionals’ understanding and clinical practice in Hong Kong. Background Medication management interventions which are designed to maximise the potential benefits of antipsychotic medication for severe mental illness have shown promise in improving symptoms, reducing relapse rates and addressing non-adherence. Subsequent medication management studies which involve training mental health professionals in similar psychosocial interventions have also demonstrated that improvements in mental health professionals’ knowledge, attitudes and skills can result in improved patient outcomes; however, the studies have not been replicated outside western general psychiatry settings and therefore the effects of training mental health professionals in other clinical contexts have not been established. Methods This research programme consists of a series of five studies that utilised a variety of methodological approaches. Three cross-sectional surveys were used to identify and explore clinical problems central to medication management in order to refine the staff training programme; the first investigates the extent of, and associations with, antipsychotic medication non-adherence in prisons. Qualitative interview data from the prison study provides additional context to the requirements for medication management training interventions by exploring prisoners’ experiences of taking antipsychotic medication. The second survey ascertains and explores the problem of non-adherence with antipsychotics in an Asian population, and the third provides an estimate of potential treatment-related physical health problems. A systematic literature review investigates studies which measure the effects of medication management training on clinicians’ knowledge, attitudes and skills. Finally concept mapping and clinicians’ narratives are used in a longitudinal case series 2 study in order to establish the transferability of medication management training to an Asian setting and evaluate the effects of training on clinicians’ understanding and clinical practice. Results Patients’ positive attitudes towards antipsychotic medication, particularly awareness of the need for treatment predicted higher levels of adherence, and concerns about the adverse effects of these medications are closely related to the environmental context of treatment. Concerns associated with antipsychotic side effects appear to be less prominent when patients are not working or in prison but they may influence adherence when demands on functioning change. The modified medication management training was effective in improving clinicians’ understanding and was felt to be transferrable to an Asian setting, but patients’ and families’ traditional cultural beliefs about mental illness and concerns about the effects of western medication on physical health were found to be particular challenges when implementing adherence interventions. Patients with severe mental illness in Hong Kong are twice as likely compared to the general population to have developed metabolic syndrome, consequently medication management interventions could require greater focus on the identification and management of physical health problems; which may help to address patient and family concerns about long-term treatment. The staff training programme requires psychopharmacology teaching, provision of clinical supervision and side effects management content in order to improve clinicians’ confidence when implementing medication management interventions. Conclusions Concerns about the adverse effects of treatment that influence adherence are environmentally bound. As influences on medication adherence are different in different settings, staff training programmes should place more emphasis on the local context in order to improve efficacy and the feasibility of implementation. The results suggest that in Hong Kong medication management interventions should have an increased focus on families and that treatment satisfaction could be a suitable target for interventions. The findings also present a question about whether previous medication management studies have given due consideration to predicting and managing concerns about the impact of side effects on functioning over the longer term and the potential effects of medication on patients’ physical well-being. The outcomes of this programme also demonstrate that future medication management training studies need to use robust study designs in order to more certainly attribute clinicians’ improvements to the training intervention and could consider measuring treatment satisfaction as a primary patient outcome measure.

Living with diabetes can present a number of challenges for individuals concerned. Managing diabetes day to day involves a complex medication and behavioural regime which interrelates with various important psychosocial factors. Previous research suggests that people living with diabetes are as much as two-three times more likely to experience mental health difficulties compared with the general population. However evidence is emerging that many of these difficulties may in fact be a direct result of feeling distressed about living with a complicated and stressful chronic health condition, and not necessarily resultant from co-morbid psychiatric illness. These experiences are known by the term diabetes related distress. To date psychosocial factors related to living with diabetes have mainly been explored quantitatively. However, qualitative approaches have increased in popularity in diabetes research in recent years and can add valuable and rich information to existing data from quantitative research. Extant qualitative research in diabetes has mainly focused on people living with type 2 diabetes or children with type 1 diabetes, leaving adults living with type 1 diabetes as a relatively under researched group. This study aimed to answer the following research questions:Primary: What are the lived experiences of adults with type 1 diabetes? And secondary:What aspects of living with type 1 diabetes are experienced as distressing? ; and What are the potential implications for health services? Eight adults living with type 1 diabetes were interviewed about their experiences. Interviews were transcribed and analysed using interpretative phenomenological analysis. Six major themes emerged from participants' interviews. These were: Experiences of diagnosis, Physical impact of type 1 diabetes, Psychological impact of type 1 diabetes, Social impact of type 1 diabetes, Influence of healthcare teams and Ways of coping. Example subthemes are; Feeling frustrated and restricted by treatment regimes, psychological and emotional distress, constant awareness and worry, impact on development and sense of self, stigma and lack of understanding from others, support from diabetes team and experiences of a simplistic view of diabetes. Participants reported a wide variety of experiences related to the biological, psychological and social components of type 1 diabetes. Some of these were experienced as highly distressing whilst others were more easily managed. This was often dependent on individual differences and was not necessarily static over time. Further awareness of this in practice and a focus on diabetes and its treatment within the context of people’s unique psychosocial circumstances is highly important in supporting people to reduce diabetes related distress, which can improve glycaemic control, health related quality of life and wellbeing.

Despite the number of best practice guidelines for working with those at risk of suicide, there remains a paucity of research pertaining to the realities of clinical practice. The aim of this study was to develop a grounded theory of how clinicians respond to those at risk of suicide in UK community mental health settings. Semi-structured interviews were conducted with eleven members of staff including social workers, nurses, psychologists, psychiatrists and occupational therapists. A theory grounded in the resulting data was developed. Results: Anxiety, uncertainty and practitioners’ perceived responsibility for preventing suicide influenced their attributions in relation to a client’s distress. Findings indicated that clinicians most often attributed low responsibility to clients for both the cause and the solution. Therefore, clinicians sought solutions to suicidal presentations within services, rather than attending to contextual or environmental ‘triggers’ to offer a resolution, potentially increasing dependency on services. Feeling supported and an environment of psychological safety enhanced professionals’ capacity to tolerate the uncertainty inherent in this work which allowed professionals to ‘hand the responsibility back’. This highlights the importance of services creating an environment of psychological safety in order for clinicians to tolerate the uncertainty of working with those who present with suicide risk.

In any year, one in four British adults will experience a mental disorder (Singleton, Bumpstead, O’Brien, Lee, & Meltzer, 2001), but barriers to accessing treatment remain, one being fear of stigmatization. In this study perceptions of the stigma associated with mental illness were experimentally manipulated and perceived public stigma of help-seeking, attitudes to mental illness, self-stigma, and attitudes to help-seeking were measured. Results indicated that lowering perceived social stigma of mental illness reduced perceived public stigma attached to help-seeking, but also resulted in less positive attitudes to help-seeking, when compared to a neutral condition. The relationship between perceived societal stigma of mental illness and attitudes to help-seeking was mediated by perceived public stigma of seeking psychological help. This research raises questions about the effect of anti-stigma campaigns, which aim to change perceptions about stigma but may have a negative effect on attitudes to help-seeking.

Background Type 2 diabetes mellitus (T2DM) and serious mental illness involves major public health problems in the world. People with severe mental illness have an increased risk of metabolic abnormalities and obesity, leading to an increased incidence for T2DM. District nurses with advanced training in diabetes care will in their profession give support to lifestyle changes and healthy living habits. Aim The purpose of this study was to illuminate district nurses´ experience of how they can support people with T2DM and serious mental illness.Method A qualitative methodology based on individual interviews analyzed with qualitative content analysis was used. Twelve informants were part of the study. Results The individual meeting with mutual relations and respect for individuals was important. During periods of worsening mental health of the patient, the district nurses provide support and monitoring, adjusted to the patients' ability. The district nurses felt inadequacy and frustration when the patients' physical and mental health were deteriorating. The strategy was to acknowledge progress when small improvements were made and extended contacts with nurses in out-patient psychiatry were requested. Conclusion Support was designed as respectful treatments and individual meetings were prioritized. District nurses' strategies were to guide the patient by positive attitudes according to the individual, and by giving support adapted to the needs of the patient. Despite feelings of insufficiency the district nurses never gave up and conveyed the message to never let go. Cooperation and extended contact with open psychiatry were desirable to exchange knowledge, giving accordance in decisions and messages.

SAMMANFATTNING Bakgrund: Att arbeta som sjuksköterska i den somatiska vården innebär främst att möta patienter som har fysisk ohälsa, men även patienter med psykisk ohälsa som söker vård. Många sjuksköterskor inom den somatiska vården känner osäkerhet i mötet med patienter med psykisk ohälsa och upplever att de varken har utbildning eller erfarenhet hur dessa patienter ska bemötas. Syfte: Syftet med studien var att undersöka sjuksköterskors attityder, känslor och upplevelser i mötet med patienter med psykisk ohälsa inom somatisk vård samt synliggöra vilka faktorer som påverkar sjuksköterskan i mötet med dessa patienter. Metod: Undersökningsmetoden var en systematisk litteraturstudie. Tio kvalitativa studier analyserades och sammanställdes. Resultat: I resultatet framkom två teman. Det första temat var negativa och positiva attityder, känslor och upplevelser hos sjuksköterskorna i mötet med patienter med psykisk ohälsa. De negativa handlade i många fall om frustration, misstro och osäkerhet medan de positiva handlade om ett ansvarstagande och positivt synsätt i mötet med patienterna. Det andra temat handlade om faktorer som påverkade sjuksköterskorna. De faktorer som påverkade var kunskap och utbildning, tid och organisation samt vårdmiljö och samarbete. Slutsats: Sjuksköterskor i den somatiska vården har flera negativa men även positiva attityder, känslor och upplevelser i mötet med patienter med psykisk ohälsa. Ökad utbildning och kunskap leder till mindre negativa attityder, känslor och upplevelser samt ökar tryggheten hos sjuksköterskorna. Även tid, organisation, vårdmiljö och samarbete är faktorer som påverkar sjuksköterskorna och behöver ses över och utvecklas. Nyckelord Upplevelser, attityder, sjuksköterskor, psykisk ohälsa. / ABSTRACT Background: Working as a nurse in somatic care means primarily to meet patients who have physical illness, but also patients with mental illness who seek care. Many nurses in somatic care feel insecure in the meeting with mental ill patients and feel that they neither have the training or experience how these patients should be treated. Objective: The purpose of this study was to investigate nurses' attitudes, feelings and experiences in the meeting with mental ill patients in somatic care and show which factors affect the nurse in the meeting with these patients.   Method: The survey method was a systematic literature review. Ten qualitative studies were analyzed and summarized. Result: The result revealed two themes. The first theme was negative and positive attitudes, feelings and experiences among nurses in meeting patients with mental illness. The negative was in many cases about frustration, disbelief and uncertainty while the positive was about a responsible and positive approach in the meeting with the patients. The second theme was about the factors affecting nurses. The factors that affected were knowledge and training, time and organization, and healthcare environment and cooperation.   Conclusion: Nurses in somatic care has several negative but also positive attitudes, feelings and experiences in the meeting with patients with mental illness. Increased education and knowledge leads to less negative attitudes, feelings and experiences and increase security among the nurses. Even time, organization, healthcare environment and cooperation are factors that affect the nurses and should be reviewed and developed. Keyword Experiences, attitudes, nurses, mental illness

The main purpose of this quantitative and qualitative study A study in crime: about sexuality, ethnicity and mental illness has been to reveal the relation between how the evening newspaper Aftonbladet and the Internet forum Flashback forum represent two men who has been convicted for the murder of two underaged girls. Hence more than one sixth of the swedish population has a lot of confidence in this newspaper it has been important to see how mental illness, sexuality, masculinity and ethnicity is produced and therefore reproduced through its descriptions of these men. The central theories which have been used to visualize the representation of masculinity, sexuality, ethnicity and mental illness is R.W. Conell´s theory of hegemonic masculinity, Judith Butler´s hetereosexual matrix, semiotics, media commodification and framing. In addition, previous studies in the media reporting of the convicted rapist ”Hagamannen” and the terrorist Anders Behring Breivik as well as theory of the ideal vicitim and therefore the ideal perpretator has been relevant. The material consists of a number of articles about the resolution of the homicide of Lisa Holm in 2015 and Helén Nilsson in 2004 in which Nerijus Bilevicus and Ulf Olsson were condemned. Furthermore, comments on Flashback forum where the abovementioned cases have been discussed were analyzed. Denotation and connotation, the heterosexual matrix and the pressethical rules applied as methodological tools. In the current media landscape of 2016 newpapers´ foremost competitors of the readers’ attention are the complimentary websites and Internet forums. The comparison indicated that the users of Flashback forum discussed similar subjects as Aftonbladet regarding the previous mentioned attributes. Also, we identified that the journal more frequentely violated the pressethical rules in the describtions of the perpetrator who suffered from mental illness and was both bisexual, transsexual and also a pedofile. However, the ethnicity of the second perpetrator appeared early in the reporting of the homicide. The results of the study have shown that the mechanisms of the commodification of media were more substantial in 2004/2005, concerning the descriptions of the perpetrator. The journal in 2015/2016 does not seem to have delievered such information to satisfy the crowd in comparison to the comments on Flashback forum. This is in contrary to the admitted opinion by media scholars.

The three studies presented in this dissertation generated new insight about the attitudinal ableism experienced by people with mental illness, substance use, and physical disabilities. First, the purpose of study one was to synthesize existing evidence about the implicit (unconscious) biases toward people with mental illness. Extensive academic database searches were performed and 19 articles were selected for review. Main findings from the review indicated that 63% of the participant samples showed an implicit bias against people with mental illness. Further, the implicit biases were positively correlated with explicit desires for social distance in two studies and were not improved by interventions or prior contact in six studies. Second, the purpose of study two was to investigate potential mediators in the pathway between perceived stigma and internalized stigma among people with substance use disorders. A total of 125 individuals completed the survey packet. Results indicated that overall social support (particularly affectionate social support) and maladaptive coping behaviors were significant mediators of the pathway. Personality characteristics, overall coping behaviors, adaptive coping behaviors, emotional/informational social support, and tangible social support were not significant mediators. Third, the purpose of study three was to validate and expand upon existing research on the microaggressions perceived by people with physical disabilities. The third study was also an initial exploration into the applicability of Glick and Fiske's (1996) theory of ambivalent sexism in conceptualizing ableist microaggressions. Specifically, Glick and Fiske's (1996) theory was used as a framework for conceptualizing ableist microaggressions as examples of ambivalent ableism, characterized by hostility and benevolence toward people with disabilities. Twelve individuals with visible, physical disabilities were interviewed about their microaggressive experiences and the personal impacts of being targets of ableism. Participants' experiences were coded and categorized as representing hostile ableism, benevolent ableism, or impact on the target. Hostile microaggressive experiences included othering, victimizing, and desexualizing; benevolent microaggressive experiences included helping and infantilizing; and impacts on the target included passing/covering and internalizing. Finally, implications related to research, education, and practice for each of the three studies were discussed in the concluding chapter of this dissertation.

published_or_final_version / abstract / Criminology / Master / Master of Social Sciences

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