Although it is understood that stigma about mental ill-health emerges in middle childhood, and that parental communications are highly influential in children’s developing attitudes, almost nothing is known about the messages parents communicate to young children about mental health problems and how these might contribute to the perpetuation of stigma. This study aimed to address this gap in the literature by exploring parents' communications to their primary-school aged children around mental health and ill-health. Semi structured interviews were carried out with ten parents of children aged 7-11. Data collection and analysis was performed according to a Grounded Theory approach; a theoretical model was developed. The model highlights factors that govern parents’ communications to children about mental health issues, and the impact of this on communication purpose and approach. Parents’ communications were governed by the extent to which parents’ representations of ‘Them’ (mental illness) and ‘Us’ (mental health) overlapped or remained distinct. Communications about mental health were deliberate, comfortable, and aimed to promote child wellbeing, whilst unconscious processes driven by taboo meant communications about mental illness were characterized by avoidance, awkwardness, and ambivalence. Factors such as parent experiences, communication context, and child characteristics, fluidly influenced parents’ overlap of ‘Them’ and ‘Us’, and hence the purpose and approach of their communications to their children. Parents’ context-dependent conceptualizations of mental health and ill-health mean children are receiving complex verbal and non-verbal messages from parents, which may contribute to children’s development of stigmatized views via conscious and unconscious processes. Interventions and policy that harness parents’ existing understandings of mental wellbeing to promote a spectrum model of mental health and ill-health may lead to more open parent-child communication, increased help-seeking, and reduced stigma.

Whilst differing perspectives can be an asset, they have also been found to lead to conflict and misunderstanding in multidisciplinary practice. Evidence suggests that different mental health disciplines hold differing attitudes towards mental disorder, reflecting differing implicit models held. To contribute to our understanding of this problem the present study investigates psychologists’ concepts of mental disorder, building on a pilot study conducted by Harland et al. with psychiatrists (2009). The Maudsley Attitude Questionnaire was used in an online survey of trainee clinical psychologists (N = 288). Principal components analysis was used to investigate implicit models. It was hypothesised that psychologists’ understandings of mental disorder would differ from psychiatrists'. The findings showed that psychologists endorsed different models for different diagnostic categories of mental disorder. Psychologists favoured the social realist model overall. Principal components reflecting a biological-psychosocial continuum, and scales of cognitive/behavioural and psychodynamic/spiritual model endorsement were revealed. The study concluded that, when compared to the findings of Harland et al. (2009), psychologists appear to make more use of psychosocial and less use of biological factors in their understanding of mental disorder than do psychiatrists. There appear to be fundamental differences in psychologists' and psychiatrists’ implicit models of mental disorder. A greater emphasis on multidisciplinary training initiatives is recommended.

The study aimed to investigate childhood adversity in a sample of clients with first-episode psychosis. The mediating impact of dissociation and early maladaptive schemas and moderating effect of social support were investigated. The study (N = 42) assessed childhood adversity using the Parental Bonding Instrument and the Childhood Trauma Questionnaire. Early Maladaptive Schema were measured using the Young Schema Questionnaire (Short form), the Dissociative Experiences Scale (2nd Edition) measured Dissociation and the Social Support Questionnaire assessed the quality and size of each participant’s social network. Correlational, mediation and moderation analyses were used. There were high levels of childhood adversity within this sample. Dissociation did not mediate the relationship between childhood adversity and psychosis. Some early maladaptive schemas concerned with unrelenting standards and insufficient self-control mediated the relationship between adversity and psychosis, in particular hallucinations. Social support, in terms of both quality and quantity was an important moderator between childhood adversity and psychosis. The study supports the notion that childhood adversity is a risk factor for psychosis and highlights some evidence about specific mediating and moderating mechanisms.

Dominant narratives about psychosis portray individuals as lonely, dangerous and unable to contribute to society. Such views may be incorporated into an individual’s personal story and are associated with negative outcomes for personal and clinical recovery. Art-making is associated with personal meaning-making and alternative forms of expression. It is therefore considered potentially relevant to narrative modification. Adult service-users with psychosis participated in a gallery-based art-making intervention. At interview, participants used their self-created images to help tell their story. Literary, experience-centred and culturally-oriented lenses were used to analyse narratives. Turning-points as modifiers of stigmatised dominant narratives were explored, as was how the intervention supported recovery. Art-making was associated with achievement, challenge and satisfaction. Story-telling using visual and verbal means opened up stories and alternative perspectives for participants. Recovery-principles including hope and aspiration were supported, identified through goals and recognition of achievement. Sharing experiences with others with similar experiences was viewed as impacting positively on mental-health. The intervention represented effective partnership working between NHS services and a gallery in overcoming barriers to accessing the arts, for people with psychosis. Achievements in art-making and narrating experience using visual and verbal means offered alternatives to personally limiting and illness-dominated narratives.

Voice hearing has a diverse history but is currently understood as symptomatic of a disease within psychiatric frameworks. Alternatives to 'treatment' include peer-support 'Hearing Voices Network groups' (HVNGs) which have grown in popularity and exist alongside treatment-based hearing voices groups. Few studies have investigated processes underlying change in HVNGs. Established research into therapeutic factors and personal recovery may provide frameworks elucidating change processes. This study aimed to investigate how HVNG attendees experienced change within the group and how this change influenced their lives. A qualitative design was employed using interpretative phenomenological analysis (IPA) to elucidate group processes through immersion in the perspectives of group attendees. Semi-structured interviews were conducted with eight individuals who were purposively sampled from two HVNGs. Interviews lasted from 34 to 54 minutes, were recorded on a Dictaphone and later transcribed verbatim. Four superordinate themes emerged: 'healing', connecting with humanity; group as an emotional container; making sense of the voices and me; and freedom to be myself and grow. The study concluded that relationships, safety, exploration of voices and group ownership are key components of HVNG and fit into frameworks of therapeutic factors and recovery processes. Development of HVNGs should take these processes into account. Future studies should further elucidate processes.

Section A reviews the literature which has investigated variables found to relate to recovery style in individuals with psychosis. Studies exploring the attachment, self-esteem, depression and executive functioning are evaluated and conclusions drawn. Section B reports the findings of an empirical study investigating the relationship between metacognition, recovery style, anxiety and depression in a community sample of individuals with psychosis. Objective; Research has shown that individuals with psychosis will either integrate their experience of psychosis or seal the experience over. Little is known about what leads to these different styles of recovery but poor attachment, depression, low self-esteem and poor executive functioning have been linked to a sealing-over style. This study hypothesised that sealing is linked to unhealthy metacognitive beliefs and also to higher levels of anxiety and depression. Method; Forty-three participants with a diagnosis of psychosis were recruited. They completed the Metacognitions Questionnaire-30, Recovery Style Questionnaire and the Hospital Anxiety and Depression Scale. Results; Correlational analysis revealed that only one facet of metacognition linked to sealing over; this being positive beliefs about worry and this was maintained when the effects of anxiety and depression were accounted for. Contrary to the hypothesis, recovery style did not correlate with anxiety or depression but unhealthy metacognition was linked to both anxiety and depression. Conclusions; The findings of this study suggest that a sealing-over recovery style may be linked to one specific area of metacognitive dysfunction. They also cast doubt on previous theories which link low mood to a sealing-over style. Limitations of this study include its cross-sectional design. Future research which expands on these findings is encouraged and longitudinal research is particularly called for. Section C provides a critical evaluation of the project, answering four questions regarding what the author has learnt from the study, what might have been done differently, how the study might affect the author‟s clinical work in future and possible future research directions.

Section A reviews the literature related to compulsory admissions under the Mental Health Act (MHA) 1983/2007 of adults presenting with psychosis. It outlines the legal framework and examines empirical data relating to admissions under the MHA 1983/2007. A brief overview of psychosis, its aetiology and key psychosocial models are provided. Consideration of mental health within the legislative framework is offered and the experience of being compulsorily admitted is explored. Finally, further qualitative research is recommended. Section B: The study’s primary objective was to explore the experience and impact of compulsory admissions (under the MHA 1983/2007) on the psychological functioning of adults with psychosis. The study also aimed to develop a preliminary theoretical model. Design: The qualitative ‘Grounded Theory’ method (Glaser & Strauss, 1967) was chosen since it worked inductively from the data and enabled the development of a model. Method: Seventeen participants (eight service-users with psychosis, nine psychiatrists) involved in compulsory admissions were interviewed. Analysis and interviews were undertaken concurrently so initial findings could influence subsequent data collection. Results: Five higher-order categories and 47 categories were identified. These contributed to the development of the ‘A disturbing journey: To and from detention’ model of compulsory admissions. Conclusion: This small-scale qualitative study achieved its objectives, providing a preliminary model and understanding of the compulsory admission experience for adults with psychosis. Key service and clinical implications are discussed. Despite its limitations, the findings indicated scope for further investigation. Section C: addresses four key questions about the study. The first relates to skills the researcher learnt through conducting the study. The second relates to improvements that could be made if conducting the study again. The third relates to clinical implications, and the fourth to further research.

Section A explores the role of creative arts therapies (CATs) in assisting recovery from severe mental illness (SMI). It examines the congruence of CATs with recovery models, and critically reviews evidence for the effectiveness of art and drama therapy with adults with mental health problems. It then examines one form of CAT which combines art and drama therapy – therapeutic puppetry. Underlying theoretical models and the existing evidence base with adults with SMI are outlined and critiqued. The review concludes with a summary of proposed arguments and research recommendations. Section B reports on a pilot investigation of group therapeutic puppetry with people with SMI. Background: Therapeutic puppetry is the use of puppets to aid emotional healing. There is no published research investigating the effectiveness of therapeutic puppetry with people with SMI. Aims: A pilot investigation of group therapeutic puppetry with people with SMI tested the hypotheses that this intervention results in improvements in mental wellbeing, self-esteem, and body connection. It also investigated mechanisms of change, and service user acceptability and experience. Method: This mixed methodology study utilised five single AB design case studies with time series data analysed using simulation modelling analysis. Qualitative data was collected via participant observation and participant interviews and analysed using thematic analysis. Results: Three participants experienced statistically and clinically significant changes in either positive or negative directions during the intervention, with all participants describing therapeutic puppetry as powerful and beneficial. Conclusions: Therapeutic puppetry is a potentially powerful medium which could be utilised by various mental health professionals. Service users find therapeutic puppetry acceptable and beneficial despite it being an occasionally difficult and intense experience. Section C is a critical appraisal of the conducted research, examining lessons learnt, identified training needs, changes to clinical practice and future research directions.

The study aimed to develop a theory of the possible links between voice-hearing and self-harm. Twelve semi-structured interviews were conducted with participants living in the community and in a secure forensic setting. All participants had experience of both voice-hearing and self-harm. A grounded theory of possible links was developed from participants’ accounts of their experiences. All participants described self-harm as way of coping with negative voices and of regulating painful emotions. Some described it as a response to a fear of judgement from others, as a form of control or as a means of seeking help. The results suggest that there are numerous links between voice-hearing and self-harm. Predominantly, self-harm seems to function as a way to cope with individual voice-hearing experience. Help should focus on triggers to distress and ways to cope. Training for healthcare staff could usefully be provided by service users, focusing on the importance of being non-judgemental. Future research could examine tactile and visual experiences in relation to self-harm too, clinician perspectives on the links between voice-hearing and self-harm, and service user perspectives on the emotional availability of clinicians.

Section A is a systematic review of the literature surrounding school-based interventions to address the stigma faced by people diagnosed with mental health problems. It asks the question of what the role of these interventions currently and potentially is and what is important for their efficacy. It begins by acknowledging the problem that stigma and discrimination presents, identifying what leads to and perpetuates this stigma. It then presents key theoretical and empirical contributions to our understanding of stigma and also to our understanding of how learning develops and attitudes form. The review goes on to look at what has been done in schools to date and highlights ‘active ingredients’ in these programmes, discussing the extent to which the current picture addresses theoretical and empirical contributions. Suggestions for further research are provided. Section B provides the findings of a grounded theory study investigating how primary school teachers communicate with children about mental health problems. Individual semi-structured interviews were carried out with fifteen teachers in three state schools. A model of communication is presented, which explains why discussions about mental health problems are absent from the primary school classroom. There appear to be a number of reasons for this. Teachers have fears about the implications of talking about mental health problems with children. These are connected to their beliefs and fears regarding those with mental health problems, their beliefs about mental health problems in relation to children and its place in the classroom, and about their professional roles. Relating to theory, teachers perceive themselves as part of a homogenous ‘in-group’ as distinct from a homogenous ‘out-group’ with mental health problems. Fears, beliefs and ingroup perceptions lead teachers to ‘play safe’ and avoid conversations about mental health problems in the classroom. This absence of discussion may reinforce for children that mental health problems are taboo. Greater links are required between schools and mental health services, and clinical psychologists need to be proactive in influencing policymakers by promoting the argument that teaching on mental health problems has an important place within the British school curriculum. Section C is a critical appraisal of this research, including discussion of the experience of being a researcher throughout this process. Consideration is given to the skills developed, areas where they may need to be expanded upon, areas where things could have been done differently, as well as research and clinical implications of the findings.