Thesis (Ph.D.)--The Wright Institute (Berkeley), 1981. / Includes bibliographical references.

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.

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.

Policy initiatives are calling for mental health services to change their ways of working to prioritising the promotion of service users’ personal recovery. This requires a major re-negotiation of working practices and the relationship between service users and staff/services and their respective social positions. Preliminary research has shown that change has been problematic. The present study aimed to explore the construction of recovery and the positioning of service users and staff during the adoption of recovery-oriented practices in a community support and recovery team. Transcripts of two rounds of focus groups with service users (n=9) and staff (n=5) held six months apart, service user care plans and Recovery Star notes were analysed using a Foucauldian Discourse Analysis. The study found that recovery was constructed as clinical/medical and personal recovery, at different times and in tension with each other. These constructions positioned service users as dependent, passive and hopeless or empowered and hopeful, and staff as helpless or facilitative. It was also apparent that a discourse of personal recovery was not available to service users. Staff oscillated between the constructions of recovery as medical and personal resulting in different subject positions and opportunities for action. The study concluded that adopting a recovery-orientation in services should lead to service users being positioned as more influential in decisions about their treatment and modes of support from the service, and services less likely to dictate their treatment. However, this can only happen if the recovery-orientation constitutes a widely shared discourse with all its assumptions and associated practices. The problematic aspects of the medical discourse and how it can position people socially and how those positions impact on the potential for personal recovery needs to be highlighted.

This work considers the nature of therapeutic relationships between nursing staff and patients on acute mental health inpatient wards. Section A is a literature review, exploring the psychological theories behind the care delivered by nurses through the medium of therapeutic relationships in inpatient settings and providing a meta-synthesis of studies investigating the nature of therapeutic relationships between nursing staff and patients from the perspectives of nurses. Section B presents a phenomenological study in which nursing staff completed in-depth interviews providing descriptions of their therapeutic relationships with patients. The results suggest a great variance in the nursing staff ability to get to know and understand patients and their needs from a psychological perspective. The knowledge gained about patients through the medium of relationships did not seem to be shared by the staff team and did not seem to be integrated into a coherent treatment plan.

The area of mental health distress is one that crosses many disciplines including; psychiatry, critical psychiatry, psychology, critical psychology, history, politics, economics, philosophy, sociology, culture and human geographies (Thrift, 2006). Consequently, there are a complex set of issues to consider when discussing the experiences of being a mental health service user. Notwithstanding this diversity, such representations of mental health have a tendency to position service users as a fairly homogenous and static group of bodies – in other words, they are the stable ‘other’ (Conradson, 2005; Parr, 2000). As a way of exploring the complexity, this thesis sets out to explore the multiplex constituents and heterogeneous ways in which daily service user life is played out within everyday mental health spatial contexts. These spaces incorporate the psychiatric institution, the mental health day centre and the home. Using interviews, ethnography, poetry and visual ethnographies, service users’ experiences are analysed by exploring the relational aspects of the discursive and the non-discursive, such as receiving a diagnostic label and subsequent treatments and the ways in which these practices permeate the embodied and spatial experiences of every day service user life. This corpus of research data suggests that rather than the experiences of mental health distress operating as a stratified set of factors awaiting analysis, there were divergent accounts incorporating positivity, negativity and ambivalence in the ways which service users made meanings of their daily lives (Brown & Tucker, 2010). Consequently, this thesis is framed around the ontological realms of creativity, potentiality and of becoming within and through space (Deleuze & Guattari, 2004; Massumi, 2002). Finally, some implications of the current political changes and how these may impact upon daily service user life are discussed to highlight that mental health service users’ are always on the move.

A literature review examines how mental health difficulties may differ for people with learning disabilities (PwLD) and the general population; with respect to their vulnerability to mental ill-health and the definition, presentation and treatment of mental health problems. Factors which have been found to positively impact on the mental health of PwLD are then explored. The review considers methodological limitations and gaps in our understanding, highlighting a need for further research focusing on mental health recovery for individuals with learning disabilities. Section B presents a study exploring what recovery means for people with learning disabilities and mental health difficulties. Interviews were conducted with nine individuals and Interpretative Phenomenological Analysis used. A model was developed which described participants’ entry to the therapeutic service and their progression towards recovery. The model firstly describes how participants felt entering the service, their Mental Health/Therapy Experience, and explains how these experiences were validated and the recovery process enabled through the therapeutic alliance. Once enabled, the second dimension of the model is detailed, that of the Client Recovery Experience which extends across three phases of recovery. The first phase, Feeling Better describes elements perceived as integral to improved mental health. The second phase, Recovery Ongoing identifies that more input is required. Thirdly, Attainability?: Reality, Ideals and Fantasy, reveals PwLD’s perceptions of recovery and the techniques used in striving to achieve this. Salient features of recovery specific to PwLD are recognised as important to clinical practice, and results suggest there is a need to openly discuss LD identity, and address idealisations surrounding a non-LD one. This would involve setting realistic goals and managing expectations accordingly and focussing on social integration as a way of enabling ongoing recovery.

Criticism of NHS acute psychiatric care has been high within patient experience research, compounded by critical press coverage of inpatient wards. Government policy requires staff to deliver compassionate, personalised care, but there is little research considering staff’s perspectives and experiences of the work. This study aimed to construct a grounded theory of acute psychiatric staff’s experiences, with particular attention to what might facilitate or block compassionate patient care. Semi-structured interviews were conducted with ten ward staff (three men, seven women) across a range of disciplines. Data were analysed using constructivist grounded theory. The model constructed captures the dynamic interactions between eleven categories: Being in a chaotic environment, Feeling limited, Struggling to improve without support, Building patient relationships, Enjoying the work, Staying vigilant, Taking an emotional toll, Putting up a barrier, Supporting each other, Seeing tensions and differences, and Acting as one team. The study concluded that staff described feeling motivated to engage with patients but restricted by practical and emotional demands. While support was provided by colleagues and formal structures, staff could not always make full use of them. Suggestions for future research and clinical practice include changes to practical demands on staff, as well as attitudes towards reflective practice.