Chronic lymphocytic leukemia (CLL) and non-localised low grade or indolent lymphomas (LGL) are two of the common cancers that individuals are diagnosed with in the UK. Both of these chronic illnesses are considered slow growing and these individuals are often diagnosed when one is not exhibiting any symptoms from the cancer. For a high proportion of individuals who are diagnosed with these forms of cancer, they are subject to a form of care known as “watch and wait”. As conventional chemotherapy treatments do not cure the disease nor prolong survival, a policy of watch and wait is utilized until the patients become symptomatic from the disease. For those patients who have been given a diagnosis of CLL, the watch and wait approach will include periodic medical examinations and laboratory analysis to determine whether the disease is stable or beginning to progress. The goal is of course to maintain QOL by not administering unnecessary treatment rather than ‘least invasive treatment’. Such an approach is due to the fact that the research has not evidenced a medical benefit for early intervention. Since being given a diagnosis of cancer and being told that there would be no immediate intervention may be contrasting to how an individual would conceptualize cancer, the researchers questioned the impact that such a diagnosis and form of care can have on the individual’s well-being. Participants with a diagnosis of CLL or LGL were recruited to complete psychological questionnaires (uncertainty in illness, anxiety, depression posttraumatic stress). These questionnaires were administered 4 times over a 12-month period to determine the impact of the diagnosis and what being placed on watch and wait has on their psychological well-being. Results indicated that a high proportion of participants were above clinical cut-off at time-1, but that there was also not much group or individual change over the 6-month time period. Results also highlighted that posttraumatic stress at time-1 was the strongest predictor of psychological distress at 6-months, and a number of strong relationships between the psychological variables were also found at time-1, following the participants’ initial diagnosis. Although preliminary, the findings were not in keeping with initial hypotheses that psychological distress would decrease over time-1, as participants developed greater understanding and had less uncertainty about their illness as well as watch and wait as a form of care. The findings suggest that the there is an impact that such a diagnosis and form of care can have on an individual psychologically, and more research needs to be undertaken to understand this effect and how to better support these individuals with their diagnosis of cancer.

Aims: To explore female secure forensic mental health (FMH) patients’ therapeutic relationship (TR) quality; the impact of witnessed, or perpetrated, violence upon psychological wellbeing and TRs; and perceived beneficial support following exposure to violence within the units. Background: Female FMH patients possess unique vulnerabilities, psychological and offending profiles; have commonly experienced early childhood trauma, attracted Borderline Personality Disorder diagnoses, and by definition appear highly likely to witness or perpetrate violence. In other settings, strong TRs are consistently associated with positive outcomes, their significance is highlighted within FMH literature yet it is unknown how female FMH patients experience TRs with their clinical teams, or how witnessing or perpetrating violence affects these relationships. Methodology: Qualitative methodology was employed within an interpretivist paradigm. 8 females were recruited through purposive homogenous sampling, across low and medium secure units. In-depth semi-structured interviews were conducted. Data was analysed by means of thematic analysis. Results: Twenty themes, and accompanying subthemes, were extracted from participants' data. TRs are experienced as challenging, complex, multi-faceted; and impact upon wellbeing and recovery. Violence is perceived as ‘normal’, however incidents have a profoundly negative psychological impact, and affect journeys of recovery. Managing exposure to violence involves the need for patients to take care of themselves. Staff were perceived as trying their best but often getting it wrong, participants expressed the need for pro-active staff involvement. Participants perceived the damage caused to TRs by incidents, as predominantly due to negative changes in staff behaviours. Conclusions: TRs serve a variety of important functions for female secure FMH patients. Witnessing or perpetrating violence negatively impacts upon TRs, wellbeing and recovery. Findings are discussed in relation to previous research, psychodynamic and systemic theories. Implications are discussed regarding: the development and maintenance of TRs, improving psychological containment, FMH workforce development, and the broader management of violence.

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.

Deliberate firesetting causes a significant cost to society in terms of human life and economic loss. However, compared to other areas of offending, firesetting is one area that has received relatively little attention by academics and practitioners in both the psychiatric and psychological literature. Even though a significant proportion of existing research has been conducted with psychiatric populations little is understood about firesetting by mentally disordered offenders, particularly in terms of their characteristics, risk factors, offence process, and treatment. The purpose of this thesis was to extend current knowledge of mentally disordered firesetters by exploring the offence process, treatment needs, and effectiveness of treatment with this population. Four exploratory studies were conducted to address this. Study one examined the characteristics of male and female mentally disordered firesetters in comparison to non-firesetting mentally disordered offenders and also the ability of these characteristics to predict offence status (firesetter or non-firesetter) and repeat firesetting. Studies two and three examined the offence process and the pathways mentally disordered firesetters follow to offending. Finally, study four evaluated the effectiveness of the first standardised treatment programme for male and female mentally disordered firesetters. The studies in this thesis highlighted the importance of fire interest in distinguishing between firesetters and non-firesetters and also for the predicting of repeat firesetting. Further, the development of fire-related risk factors appeared to be important for influencing the offence process for a sub-group of mentally disordered firesetters. The role of mental health in the offence process was also highlighted as being important. Finally, evidence was found to support the need for specialist interventions examining fire related factors with mentally disordered firesetters. The results of all four studies are discussed in terms of the assessment and treatment of mentally disordered firesetters and the clinical implications and utility of the findings are considered.

The dementias are illnesses which have significant cultural prominence and feature in a wide range of contemporary writing, often as a trope for old age. This thesis examines how stories of dementia are told in fiction and in the clinic. To do this, the work uses Arthur Frank's socio-narratology to examine twelve selected texts in which a key protagonist has dementia. Three of the selected texts have been written by authors with direct experience of dementia within their family and form a subset of texts, memoir fiction. How stories of dementia are told is considered by examining the clinic as a storytelling venue, the creation of faux medical notes from information in the texts and a Triple Analysis of the memoir fiction using three reading templates. The templates have been created from clinical practice, using the questions posed by Frank's socio-narratological practice of Dialogical Narrative Analysis, and using the parameters of Rita Charon's version of Close Reading drill in Narrative Medicine. The work is informed by autoethnography which uses my position as a clinician and reader to examine how fiction has been used in my clinical practice and how it informs my reading of the selected texts.

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.