Section A is a review of the literature on Community Treatment Orders (CTOs) in the context of their recent introduction in England and Wales. A critical review of the literature in relation to CTOs’ effectiveness is presented, followed by available evidence on service users’ perceptions of CTOs. Consideration of ethical issues that surround compulsory community treatment is also offered. The review highlights gaps in the literature regarding CTOs’ impact on service users’ interpersonal relationships and on how service users who are based in the UK perceive CTOs. Further qualitative research is recommended. Section B describes a qualitative study investigating male service users’ perceptions of their CTOs and the impact of this intervention on their interpersonal relationships. Grounded Theory was used to analyse interview data from 15 participants. Five higher-order categories and 15 categories were identified which contributed to a preliminary model of how service users develop their CTO perceptions. The factors that appeared to influence participants’ perceptions of their CTOs were: i) past and present social living conditions, ii) view of self in relation to mental health, iii) view of the CTO service, i.e. view of medication and mental health professionals. Finally, the model showed that CTOs had a limited or no impact on participants’ views of their relationships with their families, friends, partners and local communities. Results are discussed with reference to potentially relevant psychological theories. Clinical implications, including raising professionals’ awareness about the impact of coercion on the therapeutic relationship, and directions for future research are also presented. Section C is a critical appraisal of the study presented in Section B. It provides reflective responses to four questions in relation to the following areas: research skills acquired through conducting the study; what improvements could be made if repeating the study; clinical implications; and directions for future research.

Literature suggests that there are a growing number of ‘mental health professionals’ speaking out about their own experiences of using mental health services. Research suggests that these professionals face dilemmas when constructing their identity because they are drawing on two identities that are viewed as fundamentally different, i.e. ‘mental health professionals’ as powerful and ‘mental health service users’ as powerless. This study aimed to explore how ‘mental health professionals’ who are/have been ‘mental health service users’ construct their identity using a social constructionist epistemology, which views identity as fluid and continuously renegotiated in social contexts (Davies & Harré, 1990; Potter & Wetherell, 1987). Ten participants who self-identified as ‘mental health professionals’ who are/have been ‘mental health service users’ volunteered to take part. Interviews were transcribed and analysed using discourse analysis. Participants constructed their identity in a variety of ways, including as separate identities, i.e. a ‘professional identity’ and a ‘patient/mental health service user identity’ constructions, switching between the two in different contexts, therefore developing an ‘un-integrated identity’. Participants also developed an ‘integrated identity’ construction in some professional contexts. These results are discussed and implications for clinical practice and future research are explored.

Research shows that the integration of physical and mental healthcare in paediatric settings is beneficial in terms of clinical and cost effectiveness (Kahana, Drotar, & Frazier, 2008; Douglas & Benson 2008, Griffin & Christie, 2008). Due to the high rates of mental health problems within this population, several studies have shown that referral to paediatric psychology should be increased (e.g. Wagner & Smith, 2007). However, there are few studies investigating factors influencing healthcare professionals’ referral behaviour. The current study used theory of planned behaviour (Ajzen, 1988; 1991) to develop a questionnaire which explores factors influencing the referral of children and families to paediatric psychology. Psychometric properties of the questionnaire were examined. Findings indicate that the questionnaire holds good reliability and validity and that the main constructs of theory of planned behaviour are useful in predicting intention to refer to paediatric psychology. Specific beliefs about referral were also shown to influence intention to refer. Findings that individual referrer factors such as attitudes and beliefs can impact healthcare professionals’ referral behaviour indicates that multidisciplinary interventions and inter-professional education relating to the psychological aspects of illness are required. Recommendations for future research are discussed.

There is a growing research interest into investigating why NICE (National Institute for Health and Care Excellence) guidelines are not consistently followed in UK mental health services. The current study utilised grounded theory methodology to investigate clinical psychologists’ use of NICE guidelines. Eleven clinical psychologists working in routine practice in the NHS were interviewed. A theoretical framework was produced conceptualising the participants’ beliefs, decision making processes and clinical practices. The overall emerging theme was “considering NICE guidelines to have benefits but to be fraught with dangers”. Participants were concerned that guidelines can create an unhelpful illusion of neatness. They managed the tension between the helpful and unhelpful aspects of guidelines by relating to them in a flexible manner. The participants reported drawing on specialist skills such as idiosyncratic formulation and integration. However, as a result of pressure, and also the rewards that follow from being seen to comply with NICE guidelines, they tended to practice in ways that prevent these skills from being recognised. This led to fears that their professional identity was threatened, which impacted upon perceptions of the guidelines. This is the first theoretical framework that attempts to explain why NICE guidelines are not consistently utilised in UK mental health services. Attention is drawn to the proposed benefits and limitations of guidelines and how these are managed. This study highlights the importance of clinical psychologists articulating and advertising their specialist skills. The findings are integrated with existing theory and research, and clinical and research implications are presented.

This study used Interpretative Phenomenological Analysis (IPA) to investigate the experiences of African immigrant mothers living in the UK with a child diagnosed with an Autism Spectrum Disorder (ASD). Six mothers took part in one-off semi-structured interviews. The results indicated five themes: caring for a child we didn’t expect, the pain of stigma and rejection, making sense of our child’s difficulties and diagnosis, negotiating conflicting belief systems and faith as “key”. Many aspects of the mothers’ experiences appear related to their position as immigrants from cultures with very different belief systems regarding child development and disability. Stigma, blame and social isolation appeared to compound the difficulties they experienced. Conflicts between African cultural beliefs and a western, medical understanding of ASD, appeared to create a feeling of cognitive dissonance for the mothers. The strategies they used to negotiate this appear to map onto Berry’s (2005) acculturation strategies, suggesting the experience of having a child with ASD impacts upon the acculturation process. Implications for clinical practice and policy are discussed, including the importance of raising awareness of ASD among immigrant communities, supporting parents to integrate conflicting belief systems and facilitating the development of peer-support groups within minority communities.

Section A: This paper reviews the existing theoretical and empirical literature of relevance to offenders with severe mental illness (SMI) in the UK. Due to the lack of theory accounting for progress through forensic mental health services (FMHS) as currently constituted, the adjacent areas of mental health recovery and forensic rehabilitation are the major focus. Relevant empirical literature is synthesised and critically evaluated and this paper concludes by (a) summarising research challenges that remain pertinent to this area of enquiry and (b) outlining recommendations as to how research can usefully proceed. Section B: The UK’s increasing recognition of offenders with SMI and the lack of a theoretical account specific to this group provided the rationale for this study. The aim was to develop a preliminary model of the ways offenders with SMI progress through FMHS towards reintegration with the community. Semi-structured interviews were conducted with seven FMHS-users and three FMHS staff members. Grounded theory was used to build a preliminary model, which contained six main categories: learning about and managing mental health, establishing facilitative relationships with staff, moving on from prison and early experiences of FMHS, developing self-direction, doing work in therapy, and managing wider support networks. Findings extend existing literature by providing a preliminary theoretical account of the multiple domains that influence progression of offenders with SMI towards reintegration with the community. Results are discussed with regard to the existing literature and clinical implications are outlined. Recommendations for future research are made. Section C: In order to reflect upon the process of conducting this project, the author considers four questions: (1) what research skills have been developed and what skills continue to require development?, (2) what would be done differently were this project to be repeated?, (3) what changes in clinical practice will occur as a consequence of this research?, and (4) what areas would future research focus on and how would this be approached?

The history of psychiatry is littered with serious failures of governance, to the detriment of mentally disordered people, especially those resident in psychiatric hospitals. Current mental health providers, increasingly focussed on community care, have also struggled to develop effective internal governance systems. Nine peer-reviewed research papers, published by the author (mostly with others) and the wider literature, reveal deficits in mental health governance at a jurisdictional, professional, and corporate level. In this thesis new governance solutions are developed against this background, built on contemporary principles in mental health and healthcare management. A new model of mental health governance is presented, based on the key demands of the strategic and regulatory environment, articulated as rights, risks and recovery. This integrated healthcare governance approach, covering provider policy, staff training and service audit, can monitor and ensure the protection of patients’ rights, as well as those of others; it also promotes the management of clinical risks, and of patients’ recovery outcomes. Rights-based risk-reduction training is the core interventional element of the model, whilst the monitoring element can be formalised as part of a Balanced Scorecard reporting system. This thesis makes a contribution to research methodology, theory and practice in mental health, human rights, healthcare management and governance. The model generates specific propositions for testing in mental health governance, with the potential for application in wider settings of service provision.