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This thesis examines the implications of the changes introduced by the NHS and Community Care Act 1990 for mental health services. It focuses on two main issues. Firstly, the impact on mental health services of the 'market' system of purchasers and providers introduced by the 1990 Act. Second.ly, the extent to which the 1990 changes had led to any increase in user participation and involvement in the planning and delivery of psychiatric services. Analysis of the existing theoretical literature found that there had been little research which focused on the specific implications of health care 'markets' for mental health services. In addition, much of the work on the development of psychiatry had not focused on the role of the local context in influencing the nature of mental health service provision. In this thesis these issues are explored through a case study of the mental health services of one English county. Semistructured, qualitative interviews were und.ertaken with managers, professionals and individuals in purchaser, provider and voluntary sector organisations. People using community mental health services in the county were also interviewed. This contrasts with many previous studies which have tended to concentrate exclusively on users of in-patient services. The study found that local circumstances played a significant role in the relationships between those purchasing, providing and participating in mental health services. The imminent closure of a large Victorian psychiatric hospital and the uncertainty about which services would replace it had been a source of tension between the newly formed purchaser and provider organisations in the county under study. The lack of any strong existing groups in the local area representing users of mental health services was also significant. It meant that increased user participation in the county after the 1990 Act was reliant on initiatives by managers and professionals rather than organised pressure from user groups and users themselves. The variety of different local mental health agencies purchasing and providing mental health services in the county called for a degree of cooperation between organisations which conflicted with the competition encouraged by the 'market' system introduced by the 1990 Act. The focus, first, on psychiatric services in the examination of 'markets' and, second, the importance of the local context in mental health service development provides the basis for the study's contribution to theoretical and policy debates both about the 1990 Act and psychiatric services in general.

The aim of the study is to identify and map the process of transformation of the practice of a mental health nurse from everyday practice to desirable practice (that is, the realisation of mental health Recovery) through self-inquiry into a series of narratives derived from that practice. Recovery is desirable in terms of clinical governance and is also desirable practice for mental health nurses as a standard to which they should practice. A series of reflexive narratives signposted the transformative journey and also captured the lived experience of transformation. Experiences from practice were captured as spontaneous stories. Guided reflection obtained insights from these stories, and the insights derived from the stories were subsequently reflexively deepened by inquiring into them. In time the cues in the model of guided reflection became internalized to the extent that practitioner narratives arose that already embedded insights. Self-inquiry into these practitioner narratives indicated the nature and the felt affect of constraints met within practice. The affect of these constraints upon the individual practitioner and upon the ability of the individual practitioner to achieve desirable practice is indicated by self-inquiry into them. The result of the study was the realisation that transformation is unable to take place without the individual practitioner being fully aware of who one is, in order that s/he may effect transformation and change. Whilst self-inquiry into the narratives indicated the constraints upon the individual practitioner, the psychological unpreparedness also indicated by that self-inquiry indicated why that the tension between the reality of practice and desirable practice could not be adequately explored. The thesis takes the form of a narrative about writing narratives. The narratives illustrate the norms and values that affect individual practice both vertically (that is, from the organisation and the government), and horizontally (that is, from colleagues and managers), and how an individual practitioner experiences these as obstructive to delivering the service they desire. There have been no narratives written by practitioners about the journey to realise Recovery in their practice; and the structure of the narratives as performances is unique to this subject of thesis by a mental health nurse.

This study was designed to investigate 1) the cultural factors involved with Mexican citizens' attitudes toward seeking professional psychological help and 2) Mexican citizens' explanatory models of mental distress. Questionnaire data from 110 Mexican college students indicate that those who report a higher tolerance for stigma report lower endorsement of both the construct of personalismo and the machismo. Respondents who reported more interpersonal openness also reported a lower endorsement of the machismo construct. Participants from a large city reported significantly more stigma tolerance than those from a small city. Regression analyses reveal machismo as a significant predictor of stigma tolerance. Qualitative data was collected to provide additional in-depth information. Study results could be used to provide culturally appropriate mental health services.

The transgender population is makes up about 0.3% of the U.S. population (Gates 2011). The term transgender is both an identity and an umbrella term used to describe people who do not adhere to traditional gender norms (Institute of Medicine 2011). Transgender people experience many barriers to services, negative health outcomes, and discrimination (Fredrikson-Goldsen et al. 2013; Institute of Medicine 2011; Eliason et al. 2009; Hendricks & Testa 2012). Mental health clinics are an important site for understanding transgender peoples' experiences due to being a gatekeeper for other medical services and their role in helping transpeople with issues surrounding coming out, victimization, and discrimination (Grant et al. 2011; Youth Suicide Prevention Program 2011). The mental health field has a contested relationship with the transgender population due to a history of pathologizing gender variance, barriers to accessing services, and insensitivity from mental health providers (American Psychiatric Association 2013; Eliason et al. 2009). I conducted secondary data analysis using the National Transgender Discrimination Survey (2008) in order to understand the relationships between gender non-conforming identities, others' perception of one's gender identity, and discrimination at mental health clinics. Results suggest that there is an association between gender identity, others' perception of one's gender identity, and discrimination. This association depends on which gender identity, the degree to which an individual identifies with each term, and the type of discrimination. Logistic regression results reveal that identity and others' perception are not significant predictors for experiencing discrimination. Rather, income and race are significant predictors for experiencing discrimination at metal health clinics.

"The purpose of this study was to collect and compile data for prognostic purposes in determining which clients probably will not continue in treatment until--in the opinion of the agency--'services are completed.' It was hoped that this guide would be helpful in selecting those clients to whom to offer further service. Also, it might be useful in modifying agency policies and procedures to better meet the needs of those people who cannot use the services as presently offered"--Introduction. / Typescript. / "May, 1958." / "Submitted to the Graduate Council of Florida State University in partial fulfillment of the requirements for the degree of Master of Social Work." / Advisor: David L. Levine, Professor Directing Study. / Includes bibliographical references.

Social workers have no clear professional guidelines about the application of culturally competent mental health service delivery. Without culturally competent mental health service delivery, clients from diverse cultures do not access needed mental health services and they experience less effective therapy treatment outcomes and overall disparity of service delivery throughout the therapeutic process. The purpose of this descriptive case study was to better understand how community-based social workers are delivering culturally competent services to clients. The theoretical framework for the study was multiculturalism and the primary research questions addressed how associate clinical social workers who provide in-home mental health services in Los Angeles deliver culturally competent services to their clients. Through 8 interviews with associate clinical social workers, this descriptive case study revealed that without clear direction on what culturally competent services are, or how to deliver them, social workers are using a combination of personal experience and personal culture, educational and practice knowledge, and in some cases no attention to culture, to meet the mental health needs of their clients. This study emphasized the need for an industry wide understanding of the term cultural competency, so it could serve as the frame of reference by which practice professional skill level could be assessed, practice protocols measured, and could lead to social change through greater access to counseling services for clients.

Interprofessional collaboration among school-based and community-based mental health providers in children's mental has been studied in relation to specific providers and as part of program evaluation; however, limited information exists as to how to overcome barriers to collaborative relationships. This study describes the experiences of school and community mental health service providers and those who supervise them. Using phenomenological methodology, three focus-group interview transcripts were analyzed by identifying recurrent themes relevant to the experience of collaboration from school and community providers' perspectives. Although participants viewed aspects of collaboration positively, barriers frequently interfered with collaborative relationships. Support for collaboration from state, district or organization administration was considered necessary for widespread collaboration across settings. To reduce time constraints on existing school staff, school-based professionals suggested it may be necessary to employ additional staff to manage collaborative relationships. Participants' ideas for funding included cutting costs, reducing risks, and grant writing. Jointly developing procedures, increasing accessibility by having services available within the school setting, and collecting outcome data regularly to share with stakeholders were discussed. Understanding the experiences of collaboration among school and community mental health providers has the potential to ignite social change by helping schools and community agencies overcome barriers to collaboration through improved coordination of services for children with unmet mental health needs.

The mental health literacy (MHL) rates of Christian clergy in the United States remains underinvestigated in the current literature. This gap of knowledge is problematic for the large numbers of individuals with mental illness who seek assistance from clergy and may receive inadequate care for their concerns. As theoretically designated by the behavioral models of health care and MHL research, denomination-type, educational variables, and demographic characteristics were investigated as potential predictors of MHL. A sample of 238 Christian clergy from throughout the United States completed the web-based Mental Health Literacy Scale and demographic questionnaire. Results of analysis of variance (ANOVA) revealed no significant differences among MHL scores of Evangelical Protestant, Mainline Protestant, Catholic, and Historically Black Protestant groups. Results of the multiple linear regressions showed that number of years of postsecondary school, degree-type, age, and geographical location were not significant predictors of MHL scores. Higher numbers of clinical MH training courses and female gender did significantly predict higher levels of MHL scores. The findings provided the first parametric measure of a diverse, national sample of Christian clergy and indicated a need for increasing MHL trainings. Results also provided counselors and counselor educators with information useful for initiating and modeling interprofessional trainings, collaborations, and referral partnerships with clergy who currently serve as front-line mental health workers to millions of U.S. residents. The results may also inform social justice initiatives to reduce mental health care disparities in underserved populations.

This study used a multi-method approach to explore factors associated with high and low depression in a sample of rural mothers living in poverty. From a sample of 117 women with very high or very low CES-D depression scores, 40 cases were randomly selected for in-depth qualitative analysis. Qualitative comments about a variety of issues were explored including health, mental health, childcare, transportation, community, social support, and family of origin experiences. Quantitative data were then used in response to themes that emerged from the literature and the qualitative findings. All 117 eligible participants were used for quantitative analysis to increase power. Analysis of the qualitative data revealed several critical differences between the two groups. Low risk participants mentioned fewer health issues and less severe health problems as compared to their high risk counterparts. Mental health issues were reported more in the high risk group, with this group being more likely to have multiple family members experiencing symptoms. All participants reported receiving social support, however, the low risk group reported positive social support experiences, while the high risk group reported ambivalent relationships with the people who provided them with social support. Reported family of origin experiences were quite different between the two groups, with the low risk group reporting more positive past and current relationships. Quantitatively, several interesting results were revealed, many confirming the qualitative findings. Mothers showing higher levels of depression reported significantly more health problems for themselves, their partners, and their children. Additionally, participant's work status, income, perceived adequacy of income, childhood welfare use, and presence of partner were significantly related to depression. Low risk respondents were more likely to be working, perceive their income as adequate, and have a partner. They were also less likely to have received welfare as a child and had higher incomes. The findings offer important implications for future research and policy. Risk for depression seems to be related to a variety of factors, indicating that something should be done to minimize an individual's likelihood toward experiencing depression. This study ultimately provided a clearer picture of the existence of depressive symptoms among women with children living in rural poverty. / Graduation date: 2003