A dissertation submitted to the Faculty of Humanities, University of the Witwatersrand, Johannesburg, in fulfilment of the requirements for a Masters degree with the Faculty of Humanities (Health Communication and Music). Johannesburg, May 2017 / This dissertation synthesises the fields of narrative medicine and music composition to address the experience of delirium, and to learn whether music has a role to play in understanding and communicating its nature. My submission takes the form of a written dissertation accompanied by a new musical composition, Delirium Part II. Both written and composed texts are based on interviews and small discussion groups with people who have experienced delirium, their families, and healthcare professionals who are familiar with delirium in people under their care – as well as observation and recording from a hospital intensive care unit (ICU). The composition incorporates both interviews and ambient hospital sounds as audio components, and was performed first on 2 March 2017 at the Music Room, University Corner, University of the Witwatersrand. The study addresses significant gaps in our understanding of delirium, from its definition to the qualities of the experience for all those affected by it. Violence is shown to be inherent to the experience, driven by a cycle that imposes it by turns on HCPs and patients. Delirium is, moreover, characterised by losses of numerous kinds: orientation, dignity, control, and ultimately personhood. This study suggests, however, that it is within our grasp to limit significantly the impacts of these losses through re-evaluating our interactions with patients and families and challenging the dehumanising aspects of care. The music of Delirium Part II, moreover, is shown to have the capacity to contribute to this re-evaluation. There are clear indications here of the potential for music and the arts more broadly to convey complex health experiences, and to be of use in training and education. Music contributes centrally to the development of this research, as a tool both for data analysis and for provoking discussion of a complex, emotive topic. The possibilities for creative practice in narrative medicine are illuminated by this cross-disciplinary study, which demonstrates both that narrative-based musical composition can teach us much about delirium; and that delirium can teach us much about care. / MT2018

Thesis advisor: Thomas O'Hare / Two primary community-based programs currently in use for people who suffer from severe, persistent mental illnesses are staffed group-homes, or intensive outreach residential programs, where the consumer lives independently and services are provided in vivo. This study utilized a cross-sectional relational design and employed a consumer survey to examine how the well-being of people with severe and persistent mental illness and who receive one of these residential services. Well-being refers to the general quality of a person’s life and living situation, including their own perceptions of the quality of their life. For the purposes of this study, well-being was operationalized as the product of three domains: 1). demographic/diagnostic characteristics, including age, gender, race, length of service, educational level, marital status, diagnosis, and intensity of residential support; 2). objective life satisfaction indicators, such as immediate social network, extended social network, independent living/self care, working/productivity, global functioning, freedom from crisis/hospitalization; and 3). subjective life satisfaction indicators, including satisfaction with living arrangements, money, leisure time, family, social life, and health. An analysis of demographic and diagnostic variables indicated that with the exception of education level, respondents living in group homes are very similar to their counterparts receiving supported housing. Independent functioning ability was significantly higher for respondents receiving supported housing services in eight areas, including cooking, shopping, housekeeping, personal finances, use of medications, active use of services, pursuit of recovery goals, and ability to find and use health care. Group home residents were significantly more likely to have substance abuse problems than respondents receiving supported housing, and were more likely to have problems that could put them or others at risk. Respondents living independently with supported housing services reported higher satisfaction with their living situation and with their relationship to their family. Group home residents were more satisfied about the availability of money for leisure activities. Exploratory analysis of the data using logistic regression suggested that such an analysis might be useful in identifying which qualities of applicants for residential services would provide a better “fit” to a particular model of treatment. Implications for policy, practice, and future research are addressed. / Thesis (PhD) — Boston College, 2008. / Submitted to: Boston College. Graduate School of Social Work. / Discipline: Social Work.

Thesis advisor: Stephen J. Pfohl / With the decline in college students’ overall mental health over the past several decades, social scientists and policymakers have sought to understand what has led to this increase in mental illness and what resources are most beneficial for students’ coping. This paper uses content analysis of student-run newspapers to investigate how students understand mental health and the resources available to them. By using a sample of four universities in Massachusetts with distinct characteristics, I examine how the rhetoric and content of articles related to mental health changed over time and varied across place. The most prominent changes common among universities over time appear to be a stronger and more apparent focus on mental health on campuses, an increased awareness of resources by students as well as a more diverse set of health resources available to them, and a more opinionated stance and call to administrators to facilitate change. Differences of understanding and context were apparent between universities as well and are linked to specific events and tragedies, campus culture, and prevalent organizations and groups. The topics most discussed at each university suggests the differences in how students should be treated and what resources will be most effective at combating different types of mental illness. The findings from this study suggest that universities are still struggling to keep up with the heightened demands of student mental health issues and that each campus’ unique characteristics must be taken into account when reforming health policy. / Thesis (MA) — Boston College, 2017. / Submitted to: Boston College. Graduate School of Arts and Sciences. / Discipline: Sociology.

Since the 1990s there have been continued drives in England to integrate National Health Services and Local Authorities’ social care within a single mental health service, with the aim of bringing about improvements in health and social care (Local Government Association et al., 2016). This is underpinned by the belief that through bringing the different professional health (such as psychiatrists and mental health nurses) and social care disciplines together, people in need will have a single point of access to a range of skills and knowledge, that no one system could deliver alone (Cooper, 2017). However, the very unique professional approaches that have been stated as the reason to place social workers in NHS Mental Health Services have been the ones that mental health social workers have struggled to hold onto in this setting (Allen et al., 2016). This is a thesis of how mental health social workers constructed a professional self within the context of the NHS mental health services. I used a Foucauldian approach and the notion that professional identity is a socially constructed sense of self, produced from discourses, subject positions and a process of subjectification. Twelve social workers were interviewed; seven mental health social workers and five social workers who held positions as managers or educationalists. I asked social workers questions about their professional identity, their answers provided a rich source of ‘talk’ that I could analyse using Parker’s steps to discourse analysis. The findings discuss the nature of social work as a profession, generic and specialist social work, and suggests a typology of subject positions drawn from the mental health social workers’ discourses. These findings provide a useful resource to support critical social work practice, both as an example of how Foucauldian theory and concepts can be a rich toolbox for understanding practice in complex settings, and through the use of the typology of subject positions as a source to prompt self-reflection for mental health social workers’ practice.

1. There are two major pieces of work (the Code Review and Sutton) and a number of themes that are the subject matter for this submission. The Insurance Council of Australia appointed me as the Independent Reviewer of the General Insurance Code of Practice, under the Code and the Terms of Reference, on 3 May 2012. 2. The Code Review work took about two years and involved the Code Issues Paper in October 2012 of 111 pages and the Code Review Report in May 2013 of 205 pages. The majority of my recommendations were accepted and the report has made a contribution to the rethinking of self-regulation and the place of voluntary codes in financial services. By then I was writing, with Professor Robert Merkin QC Sutton on Insurance Law for its 4th Edition. It is two volumes, 24 chapters and about 2100 pages excluding tables and index; my contribution was 12 chapters totalling about 960 pages. 3. The Code Review work, particularly on government agency regulation and self-regulation, influenced the pervasive material in Sutton on regulation. It was the subject of the AIDA Rome paper in 2014 on Principles for Self-Regulation; the paper was published by AIDA. 4. Sutton was published in 2015. Its themes are set out below. Those themes are in turn influences in the other work for this submission. There are seven main themes in the publications which I present in this submission. 5. The historical influences in relation to my Code Review and the historical contextual material in Sutton stimulated my interest in the wider influences on the development of commerce, insurance and law, with a central interest in the ethical foundations of the law and regulation. This aspect was also developed in the Masel Lecture and the article William Murray, Lord Mansfield: His Life, Times and Legacy – Good Faith and Good Works. 6. There had been a number of issues raised in my Code Review about mental illness, insurance and discrimination. I spoke at AIDA in Rome 2014 on Insurance Discrimination Law and the paper was published by AIDA. Then in 2016, the Australian Centre for Financial Studies commissioned me to write the ACFS MID Paper on the use by insurers of mental illness data. The historical perspective and the regulatory framework were important features of both papers. 7. A number of the Sutton themes were first opened out in my Professional Indemnity Insurance Law. The main themes were, in decreasing order of connection with Professional Indemnity Insurance Law, as follows. The first theme is the identification, development and application of the indemnity principle. The second is the adaptation and application of the analysis of contracts by primary and secondary obligations. This theme is in Sutton on the main concepts in insurance as well as liability insurance issues. The Liability Disputes Chapter condenses this thinking and account. The third theme was a renovation of how life insurance issues should be analysed and presented. This life insurance material was then adapted and infused with practical guidance on the decision making process on some issues for the FOS Life Insurance Manual. I developed an aspect of life insurance in the TPD Article. Each of these themes are in my submission original in concept and execution. Each has influenced the development of the law by legisation and the courts.

In recent years, food addiction has become a popular construct believed to have serious behavioral, emotional and physical consequences. However, its scientific validity is still under investigation. This dissertation evaluated whether food addiction is a valid mental disorder, substance-related disorder, and addiction in three parts. Part 1 reviewed the phenomenological, animal and neurological evidence to assess whether food addiction has face validity and conducted a systematic literature review of studies estimating the prevalence, validating measures, and/or assessing correlates of human food addiction to evaluate construct validity. Part 2 used two community-based convenience samples to assess whether operationalized measures of food addiction are reliable and valid. Part 3 used two large cohorts of nurses to evaluate whether food addiction is associated with potentially positively reinforcing nutrients, food items and food groups. The literature review established that food addiction has face validity, and to some degree, construct validity. The first analytic paper found that the internal and test-retest reliabilities of both scales were moderate to good, and the shorter Modified Yale Food Addiction Scale compared with the original Yale Food Addiction Scale had good sensitivity and negative predictive value. The second analytic paper found strong positive associations between food addiction and consumption of fats and sodium, non-sweet fatty foods, diet foods, and some salty and sweet foods, no association with most starchy and salty food items, and an inverse association with fruits and vegetables. It also found unexpected strong inverse associations between sugar and food addiction, contradicting the popular “sugar addiction” hypothesis. Prospective analyses should reexamine these findings to eliminate potential reverse causation bias. Taken together, this dissertation supported food addiction as a valid mental disorder, substance-related disorder and addiction, although some findings contradicted a priori hypotheses, and gaps in the literature remain.

In psychiatry, the Diagnostic and Statistical Manual of Mental Disorders (DSM) is the standard classification system used by clinicians to diagnose disorders. The DSM provides criteria sets that are quantifiable and directly observable measures or symptoms associated with each disorder. For classification, a minimum number of criteria must be observed and once this threshold is met, a disorder is considered to be present. For some disorders, a dimensional classification is also provided by the DSM where severity of disorder increases as the number of criteria observed increases (i.e., None, Mild, Moderate and Severe). While the criteria sets provided by the DSM are the primary assessment mechanisms used by clinicians in psychiatric disease classification, some criteria sets may have too many items making them problematic and/or inefficient in clinical and research settings. In addition, psychiatric disorders are inherently latent constructs without any direct visual or biological observation available which makes validation of psychiatric diagnoses difficult. The present dissertation proposes and applies two empirical statistical methods to address lengthy criteria sets and validation of diagnoses. The first proposal is a data-driven method packaged as a SAS Macro that systematically identifies subsets of criteria and associated cut-offs (i.e., diagnostic short-forms) that yield diagnoses as similar as possible as using the full criteria set. The motivating example is alcohol use disorder (AUD) which is a type of substance use disorder (SUD) in the DSM-5. A diagnosis of AUD is made when two or more of the 11 possible criteria associated with it are observed. Relying on data from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC-III), the new methodology identifies diagnostic short-forms for AUD by: (1) maximizing the association between the sum scores of all 11 criteria with newly constructed subscales from subsets of criteria, (2) optimizing the similarity of AUD prevalence between the current DSM-5 rule and newly constructed diagnostic short-forms, (3) maximizing sensitivity and specificity of the short-forms against the current DSM-5 rule, and (4) minimizing differences in the accuracy of the short-form across chosen covariates. The second method introduces external validators of disorder into the process of identifying and validating short-forms. Each step in the first methodology uses some type of comparison (i.e., maximizing correlation, sensitivity, specificity) with the current DSM rule assuming the DSM is the best diagnostic target to use. However, the method does not itself assess the validity of the criteria-based definition but instead relies on the validity of the original diagnosis. For the second methodology, we no longer assume the validity of the current DSM rule and instead introduce the use of external validators (antecedent, concurrent, and predictive) as the target when identifying short-forms. Application of the method is again AUD and the NESARC III is used as the data source. Rather than use the binary yes/no diagnosis, we use the dimensional classification framework provided by the DSM to identify and validate subsets and associated severity cut-offs (i.e., dimensional short-forms) in a systematic way. Using each external validator separately in the process could prove difficult in determining a consensus across the validators. Instead, our methodology offers a way to combine these external validators into a singular summary measure using factor analysis that derives the external composite validator (ECV). Using NESARC-III and following principles of convergent validity, we identify dimensional short-forms that most relate to the ECV in theoretically justified ways. Specifically, we obtain nested subsets of the original criteria set that (1) maximize the association between ECV and newly constructed subscales from subsets of criteria and (2) obtain associated severity cut-offs that maximally discriminate on ECV based on R-Squared. Substance use disorders in the DSM-5 include alcohol use disorder (AUD), nicotine use disorder (NUD) and drug use disorders (DUDs). Each of these substances is associated with a single underlying SUD construct with the same 11 diagnostic criteria used across each substance and the same diagnostic classifications. Cannabis and non-medical prescription opioids are two examples of DUDs and both have recently been identified as major public health priorities. Due to their diagnostic similarity to AUD in the DSM-5, these substances were ideal to also test our methodologies. Using data from the NESARC on criteria for cannabis use disorder (CUD) and opioid use disorder (OUD), we forward applied the diagnostic short-forms that accurately replicated AUD and also applied the methods to each substance separately. Overall, the new methodology was able to identify shorter criteria sets for AUD, CUD, and OUD that yielded highly accurate diagnosis compared to the current DSM (i.e., high sensitivity and specificity). Specifically, excluding criteria “Neglected major roles to use” and/or “Activities given up to use” created no marked change in ability to diagnose or measure severity the same way as DSM-5. When applying the method for identifying the most valid dimensional short-forms using external validators, different severity cut-points compared to the current DSM-5 were found and different cut-points were found across AUD, OUD, and CUD. There were dimensional short-forms with as few as 7 criteria for AUD, CUD and OUD that demonstrated the same or better level of validity as using all 11 criteria. We discuss the implications of these findings and propose recommendations for future DSM revisions. Lastly, we review limitations and future extensions of each of our proposed methodologies.

Pakistani women in the UK have high levels of mental illness, alongside low levels of outpatient mental health service use, compared with women of other ethnic groups. Further, previous studies have suggested that Pakistani women have particularly low levels of social support, and high levels of social isolation which may reduce their chances of coming into contact with mental health services. However, to date, there has been little empirical evidence to support this. This thesis investigated the mental health service use, social networks' structure and function, and the relationship between the two, for Pakistani women compared with women of other ethnic groups. This was done using a systematic review of the relevant literature, and statistical modelling using two large nationally representative datasets from the UK. The first dataset, Understanding Society, was used to formulate latent classes of support networks, subsequently used in regression models to compare the support available in Pakistani women's networks with women of other ethnic groups. The second dataset, Ethnic Minority Psychiatric Illness Rates in the Community (EMPIRIC), was used to ascertain the influence of social networks (perceived social support, contact with relatives and friends, network composition, and size) on the use of outpatient mental health services, using logistic regression modelling. These data were also used to build a structural equation model to test the direct and indirect effects of social networks on outpatient mental health service usage, via their impact on mental illness. Pakistani women (along with Bangladeshi women) had the lowest rate of mental health service use, compared with women in other ethnic groups. Further Pakistani women were more likely to be socially isolated than White majority women, but there were largely no differences between Pakistani women and other ethnic minority women in the structure and function of social networks. Finally, there was evidence to suggest that social networks indirectly reduced mental health service use via their impact on mental illness. There were only small ethnic differences in the indirect effect of social networks on mental health service use, and these differences did not explain Pakistani women's under-use of mental health services.

This dissertation created a model to explore the effect of dominant group status on stigmatization of mental illness and on moral relativism and the interactive effect of dominant group status on stigmatization of mental illness through moral relativism. The model was conceptualized according to social dominance theory. Latent variables were created to measure moral relativism and stigmatization of mental illness. The latent measures were conceptualized according to current theories in the fields of moral relativism and stigmatization. During statistical analyses the latent measure for moral relativism was found to be unreliable. The study then became confirmatory-exploratory in nature by first comparing the fit indices of three alternate models with single-measure latent variables. The model that best fit the data was then used to conclude the exploratory research on the effect of group status on moral relativism and stigmatization of mental illness. The model was not supported by the data based on fit index and standardized residual scores.

Neurocognitive and functional outcome deficits have long been acknowledged in schizophrenia and are considered a core feature of the disorder. Neurocognition has been found to account for functional disability to a greater extent than psychopathology however much of the variance in functional outcome still remains unexplained. How functional outcome is measured also requires clarification. By investigating the relationship between neurocognition and functional outcome in First-Episode Psychosis (FEP), much can be learnt about the trajectory of disability and the course of illness in schizophrenia. Metacognition, or thinking about thinking, has been proposed as a mediating variable between neurocognition and functional outcome. Despite different theoretical backgrounds, authors generally converge on there being higher-order, explicit, conscious metacognitive knowledge and lower-order, implicit metacognitive processes. How these relate to each other requires clarification. The prefrontal cortex (PFC) has been implicated in higher order thought and metacognitive processing, and deficits have been observed in PFC Grey Matter (GM) volume in schizophrenia. These metacognitive deficits may contribute to the relationship between cognitive ability and community functioning. A preliminary meta-analysis demonstrated that a moderate effect size is found between neurocognition and metacognition and a moderate effect size exists between metacognition and functional outcome. The present thesis investigated whether metacognition mediates the relationship between neurocognition and functional outcome in FEP (N=80). Path models were created to investigate the different relationships between neurocognition, metacognition and both capacity to perform everyday tasks and objective functioning in the community. A secondary Voxel-based Morphometry (VBM) analysis was also conducted investigating perceptual metacognitive accuracy and its relationship to GM volume in both FEP (N=41) and a matched healthy control sample (N=21). Current findings support the model that metacognition and negative symptoms mediate the relationship between neurocognition and functional capacity in FEP. Path models also demonstrated a significant mediation effect of metacognition between neorocognition and objective function, and functional capacity and objective function. Significant group differences were found between FEP and controls in perceptual metacognitive accuracy however no significant relationship was found between metacognition and GM volume in the PFC. The present thesis suggests that metacognitive deficits are present at first episode and may account for the relationship between cognitive ability and functioning in the community. Findings also suggest that cognitive remediation programmes may wish to focus on metacognition to maximise the transfer of cognitive skills to community functioning. The findings also suggest the presence of two metacognitive processing routes; explicit, declarable, higher-order knowledge and implicit, intuition-based, lower-order experience which can be accounted for by Nelson and Narens (1990) metacognitive model.