Changes in demographic characteristics and modernisation in Malaysia have contributed to relocation of many elderly people to an elderly institution which is rapidly growing in number in Malaysia in spite of traditional cultural values and the personal beliefs towards elderly people. Living in elderly institutions is often associated with deterioration in well-being as a result of negative issues in institutions such as occupational injustice, loss of meaningful relationships, loss of autonomy and individuality which lead to psychological problems such as depression. Subsequently these issues affect several domains in life including future orientation towards ageing (ERA), general self-efficacy (GSE) and quality of life (QoL). Various lifestyle redesign programmes based on occupational therapy have been conducted to prevent such deterioration. However, such programmes are conducted in Western countries and were design for elderly people in the community. To date, there is no substantial work exploring the applicability of such programmes to elderly people in institutions and in different sets of cultures, values and beliefs such as in Malaysia. This provides justification for the need for such a study. The aim of this concurrent embedded experimental mixed methods study was to explore the effect, and identify the ideographic experience, of forty-six elderly people living in a public funded elderly people institution in Malaysia before and after participated in a new lifestyle redesign programme known as the Lively Later Life Programme (3LP) on ERA, GSE and QoL. Another thirty-six elderly people in a control group participated in an ‘in-house’ programme. After six months of taking part in the 3LP, there were statistical significant changes in the scores of the study measures for the participants in the experimental group. In addition, the participants provided ideographic experiences exemplified in various themes relating to the experience of taking part in the 3LP which supported and elaborated the changes in the scores of the study measures. Findings from this study contribute to evidence based practice in occupational therapy, validate and expand previous lifestyle redesign programmes. In addition, the findings demonstrate that a lifestyle redesign programme based on occupational therapy can be successfully transferred to a different setting, transcend cultural barriers and philosophies of life.

This thesis focuses on the relationship between the visual arts and psychotherapy in post Revolutionary Cuba. The material on which it is based was collected over a fourteen month period and three visits to Cuba between April 1999 and August 2001. The study opens with the presentation of two brief histories, that of Cuban Art and Art Education and that of Cuban Mental Health Care. In this context the Revolution is taken as a useful reference point in terms of thinking about change and historical developments in both fields. Naturalistic Inquiry and Grounded Theory respectively were used to collect and analyse the data presented. These approaches allowed the researcher the degree of flexibility necessary to undertake research in a potentially delicate situation full of unknowns and to be able to modify and develop the course of inquiry as new evidence emerged. The main descriptive themes emerging from an analysis of the data pertain to the relationship between artists and mental health care professionals. These are (1) therapeutic work undertaken by artists, (2) artists working collaboratively with mental health professionals and (3) psychologists working with art as a therapy. The story which emerges pertains to a series of largely unrecorded histories spanning a forty year period. It begins with the work of Antonia Eiriz, who emerges as a key figure in the early development of art as a therapy and concludes with the work of the psychologist, Aurora García Morey, who takes centre stage in its continued development. This snapshot of Cuban art therapy is specific and unique and demonstrates the development of a very particular Cuban practice. However an analysis of the analytic themes which emerge from the data suggests that certain concepts such as responsiveness and pragmatism resound within a wider picture. These themes are discussed in chapters 7 and 8 with reference to the wider international context and specifically to the development of the profession in the United Kingdom. In my conclusions I suggest that these themes may be applicable to other areas of research and practice outwith and beyond Cuba and that while the concept of art therapy cannot be narrowly defined when it is applied to understanding practices in other, social, economic and cultural contexts, there are common factors which can be identified.

In recent years there has been growing interest in arts therapy work with older people who have dementia. This has happened despite a paucity of UK research and writing on the aims of practice. Furthermore, there is little knowledge about the professional background of practitioners, the client group, care settings, theories and methods underpinning their work. This qualitative mapping study employs a methodology from nursing called interpretive description (Thorne et al. 2004). Interpretive description advocates a pluralistic approach for understanding the complex dialogue between clinical and research knowledge. The research design involved thirty-one semi-structured interviews with arts therapists from art therapy, music therapy, dramatherapy and dance movement therapy, participant observations of thirteen care settings and formal and informal interviews with ten medical/care staff who work with the arts therapists. The descriptive map was analysed using template analysis (King, 1998) and was interpreted using an integrative interpretive analysis (Heidegger, 1927; Smith et al.1999) The findings suggest that many arts therapists are pioneers in terms of being the first from their profession to work in the care setting. Issues around the arts therapists being unheard and staying unheard relate to their newness within these established settings. In terms of therapy work, theory and practice were being adapted in order to accommodate the temporal nature of the work. Despite distinctions in the art form, the study found that there is reciprocity of experience in terms of the arts therapists’ feelings about the work and some in-session practices. These united the disciplines beyond the norms of mainstream practice.

Preterm infants born before 37 weeks of gestation constitute up to 10% of all births, and can display development that, frequently, differs from those of full- term infants. Studies indicate that school children born preterm present with a, generally, higher incidence of performing poorly academically. The present study investigated the perceptions of paediatric OTs regarding the type of difficulties with which children born preterm present, and explored the role of OT. In the first, quantitative part of this study, paediatric OTs completed a postal questionnaire (N=353). The second, qualitative part, used asynchronous, online discussions (N=13), by utilising the virtual environment of WebCT, to further explore the topic. The survey was also designed to capture: • information on the extent of this paediatric population within OT services, and how identifiable and accessible it is • OT practices when working with these children • what informs therapists’ clinical decision making. The discussion groups provided a forum for OTs’ “reflexive comment” on the issues emerging from the questionnaire analysis. Despite sensorimotor and attentional difficulties reaching the highest frequencies, the findings revealed rather a combination of problems in most developmental domains. Writing emerged as the predominant problematic area within the school curriculum. A “persistence” of sensorimotor difficulties throughout the preschool years also emerged. More frequent and/or severity difficulties, more medical issues, a higher co morbidity of SLD with other conditions for the preterm group, were other findings. These insights could lead to a further exploration of the need for differentiating assessment and treatment practices for this group. Occupational therapy was highlighted as particularly “advantageous” for this population due to a number of OTspecific contributions e.g. ability to “detect “subtle” difficulties at a young age. The implications of a “shift” of more OTs into the area of early intervention, are discussed. The findings of the study constitute tacit, professional knowledge, and they are based on subjective clinicians’ views. They could, however, help frame hypotheses to be further explored verified with the use of empirical research. KEYWORDS: Prematurity; Specific Learning Difficulties; Early Intervention; Paediatric Occupational Therapy; School; Clinical Decision Making; Assessment; Intervention; Survey; WebCT; Asynchronous Online Discussions

This thesis presents a classic grounded theory study of Condition Management Programmes, which form part of the UK Government Initiative Pathways to Work. Condition Management Programmes provide short, work focused interventions to help people claiming incapacity benefits to return to employment. Delivered jointly between Jobcentre Plus and the NHS, or by providers within the private and voluntary sectors, health care practitioners working in Condition Management Programmes are often faced with competing priorities. This thesis has identified practitioners’ concern with being person driven in a service driven organisation, and presents the emergent grounded theory of Revisioning Service Ideals and Client Realities which explains conceptually the means through which this concern is continually resolved. Practitioners are conceptualised as ‘revisioning’ or making thoughtful, situational adaptations to their practice which either deviate from or retreat within service boundaries. By cycling iteratively between deconstructing and reinstating service ideals, practitioners are able to create a reverberating equilibrium between the expectations and realities of practice, negotiating a person driven approach without compromising service structures completely. The theory has been developed using the full complement of classic grounded theory procedures and is based on interviews with 35 practitioners and observations of 26 practitioner-client sessions. Additional informal observations, programme documentation, client case notes and extant literature were also included as data. The theory adds to current Condition Management literature by explaining the differences across and within programmes, highlighting some important considerations for future development and evaluation within welfare to work. Furthermore, the theory of Revisioning Service Ideals and Client Realities, on account of its conceptual nature, also demonstrates relevance outwith its substantive area. Most notably, offering contributions to current research on treatment fidelity, theories of organisations and bureaucracy, and professional and clinical reasoning by offering a conceptual explanation of the behaviour of practitioners in daily practice.

Aims: To investigate the systemic circumstances required for mental health professionals to engage in the core processes of evidence based practice. Background: Successful evidence based practice is the function of inter-related processes including knowledge acquisition, generation, and application, which occur in complex and dynamic circumstances. Dominant models and approaches to facilitating the use of knowledge in practice by health professionals remain based on linear, technical processes which aim to instigate behavioural changes at the individual level. Emergent conceptualisations argue the need for strategies that consider systemic factors which can impede or facilitate the processes underpinning the operation of evidence based practices in mental health. As yet no efforts have been made to actively apply systems thinking in efforts to improve evidence based practice in mental health. Method: A collective case-study research design was developed by adapting Soft Systems Methodology. Three cases were examined, each selected due to their ability to provide information about one of the core processes under investigation; knowledge acquisition, knowledge generation and knowledge application. Data was collected iteratively from thirteen participants through focus groups and semi-structured interviews. Analysis was undertaken through the inductive open coding of data into sub-categories, following which key categories were identified and considered against individual, group and organisational systems levels. Findings: This study identified twenty-four key categories across the cases and located these against the three systems levels. As anticipated, complex dynamic interactions between different elements at the different levels were identified including, the role of motivation, perception and skill at the individual level, the importance of team wisdom, support and decision making, and the need for organisations to provide adequate infrastructures, ensure access to specialist expertise and a number of elements contributing to a culture of space and support for evidence based practice.

This thesis contributes new knowledge to the field of arts therapies and their relevance in the treatment of depression in adults. The global burden of depression means that available treatments do not address all areas within the complexity of the condition and arts therapies may potentially present a relevant alternative by offering opportunities for non-verbal expression and exploration of creativity. Literature up to date does not offer comprehensive enough description of arts therapies practice and therefore establishing of credible evidence has not been possible. This thesis addresses the gap by exploring the nature of arts therapies practice and its value in the treatment of depression. The research consists of two phases: phase 1 provides a description of arts therapies practice with depression in the UK based on data collected from 395 survey respondents, while phase 2 evaluates group brief art therapy for adults experiencing mild to moderate depression. The project employs mixed methodologies within a creative research design incorporating surveys, interviews, arts-based inquiry and a pilot clinical study to examine multiple perspectives and offer findings meaningful to diverse audience. This project establishes that depression is a common condition among arts therapists’ clients while some of the practitioners consider work with depression their main area of professional interest. It further finds that the therapists address depression through the use of humanistic, psychodynamic and integrative approaches and discovers that certain areas of the therapy process have particular relevance in the treatment of depression (e.g. time, group work, motivation, reconnecting). The pilot clinical study concludes with decrease of depression levels and increase of subjectively perceived wellbeing in all participants immediately after nine sessions of art therapy and in the follow-up. Participants’ experiences, researcher’s observations and arts-based reflections on the therapy process highlight the potential value of arts therapies in areas relating to, among others: connection and sharing, awareness of others and self, sense of achievement, self-expression and regain of meaning. The findings are integrated in the final discussion, which proposes a set of concepts particularly relevant to the treatment of adult depression through arts therapies. This research provides the first comprehensive description of arts therapists’ work with depression in the UK and confirms the potential of this practice to be effective, which is relevant to health professionals and may lead to increased involvement of arts therapies in mainstream healthcare. The particular value of this project lies in shaping the basis for further explorations in the form of larger RCTs as well as demonstrating relevance and superiority of creative research designs in evaluating arts therapies.

Background: Research exploring occupational therapists’ knowledge, beliefs and practice associated with alcohol misuse in physical health care settings is scarce, despite the recognition that professionals are likely to work with people who misuse alcohol irrespective of practice context. Furthermore, the relationship between pre-registration occupational therapy education and practice in the area of alcohol misuse is currently poorly understood. Aims: This critical appraisal aims to (a) frame the knowledge gaps and existing knowledge of occupational therapists related to alcohol misuse in physical health care settings, through the findings of five prima facie case papers and; (b) align this framed knowledge to wider professional literature in order to extend professional understanding of the relationship between education and practice, associated with alcohol misuse in physical health care settings. Methodology: A gap analysis approach was selected and modified to provide a way of critically introspecting and occupationally classifying the gaps in, and existing knowledge of, student occupational therapists, practitioners and educators linked to physical health care settings and alcohol misuse, as reported in the five papers. The introspective data linked to gaps and existing knowledge was unified and general inductive qualitative analysis undertaken. One practitioner working in physical assessment for older people in an acute hospital, and one occupational therapy educator provided stakeholder feedback of the tentative themes generated, further refining the analysis of data. Findings: Two themes emerged from the analysis of data; delimiters of professional education and conceptual contradictions. These indicate there is a need to educate ‘educators’ concerning the value of teaching alcohol-related policy as part of educational programmes, and in raising the visibility of alcohol as a topic. Therapists valued the Person Environment Occupation Model (PEO Model), however the essence of ‘transaction’ fundamental to this model, lacks fidelity in practice. Practitioners appear to separate out the entities of person and environment, placing greater emphasis on the observable aspects of the environment rather than the person, to support timely discharge. Thus, current practice in physical health care supports a process of occupational evaporation connected to alcohol misuse. Conclusion: These findings help to inform the future direction of educational and practice developments connected to patients’ alcohol misuse in physical health care settings, and in so doing, advance and re-emphasise the importance of the centrality of occupation to service delivery.

Purpose – The overall aim of the research is to develop a culturally sensitive arts therapies programme for children with Attention Deficit Hyperactivity Disorder (ADHD) in primary schools in the Kingdom of Saudi Arabia (KSA). This research adapted the UK arts therapies practice to fit these cultural requirements. Design/methodology – The study is a mixed methods design, carried out in two stages. The first stage was to identify the current provision and cultural issues in conducting arts therapies intervention for children with ADHD in KSA. Data was collected using interviews from twelve arts therapists from the UK and nine informants from KSA. The information obtained assisted in the development of culturally sensitive guidelines for the delivery of an arts therapies programme, which was conducted in stage two of the study. The second stage involved a pilot randomised control trial design that took place in an identified school in KSA. This stage involved 12 children aged 6-12, randomly allocated to either the intervention or the control group, with six participants in each group. The programme was carried out three times a week over a period of eight weeks. Data was collected using pre and post-tests (SDQ and ADHD scales) and from interviews of the parents and teachers of the children from both the experimental and control groups. Findings – The findings demonstrate that art therapists in KSA focus on behaviour modification while arts therapists in the UK focus on improving emotional wellbeing. Art therapists in KSA used more structured approaches which are less effective for children with ADHD. There may be cultural problems in using arts therapies in KSA, particularly music and dance. Safety, routine activities and ground rules were adopted from the current practices in the UK and adapted to be appropriate for the cultural context in KSA. A culturally sensitive arts therapies programme may be an appropriate and valuable intervention for children with ADHD. Qualitative and quantitative findings indicate that the intervention of this study achieved specific benefits such as; decreasing hyperactivity/ impulsiveness and inattention. Moreover, this intervention improves relationship/social skills and emotional wellbeing. Practical implications – This programme is found to be beneficial and it may have a significant impact on the treatment of ADHD in KSA. Understanding cultural issues by the therapist increases the value of arts therapies interventions. Value – This study has many benefits as a contribution to knowledge and for the development of services in KSA for this client population. Since children with ADHD currently have minimal access to therapy of any sort, and very limited access to arts therapies, this research has a key role in developing culturally sensitive arts therapies programme for children with ADHD.

Background - One of the most significant changes within healthcare practice and research is a shift from ‘treating’ disability at the level of body function to an ecological approach that addresses the children’s involvement in everyday life, conceptualised as participation. Participation encompasses children’s involvement across home, school and community settings. A complex interaction of personal characteristics, performance skills and environmental factors influence children’s participation. Therefore, assessments that comprehensively and ecologically capture children’s participation and contributory factors are important. Gathering information from parents and teachers may enhance the accuracy of information. Of the currently available assessments, few include multiple informants and provide an overarching portrait of the child’s participation across all settings. The ACHIEVE Assessment is one that does and forms the focus of this work. Methods - Services from across Scotland agreed to participate in the research by implementing the ACHIEVE Assessment and inviting parents to consent to use of their child’s information. Rasch modelling was used to analyse the ACHIEVE Assessment. Parent and teacher questionnaires were also compared. Results – The study includes a large clinical sample ranging in age from 4-17 years old, with an average age of 8 years. The results from the study demonstrate that the ACHIEVE Assessment provides unidimensional measurement of children’s participation and contributory factors. The environment items measure a separate latent trait and are too easy for respondents to endorse. Parent and teacher questionnaires fit on the same dimension. However, self-care and social skills items differ in function between respondents. In addition, there is a low correlation between parent and teacher questionnaires. Overall, items relating to children’s participation in activities are easier than items about contributory factors. Process skills items are the hardest to endorse, despite the sample predominantly including children referred for reasons related to motor difficulties. Items about children’s school activities are relatively harder than items about community activities. Finally, item function differs for children in the youngest age group. Conclusion – Using Rasch analysis allowed exploration of the complexity of factors that interact to influence children’s participation as captured by the ACHIEVE Assessment. The study demonstrates the measurement qualities of the participation items on the ACHIEVE Assessment, however the environment items require further development as a separate measure. The item hierarchy emphasises the importance of further investigating the association between children’s process skills and their participation, in addition to research in the area of school participation. As there are only weak associations between parent and teacher reports, one is not substitutable for the other and multi-informant assessment will be an important strategy for gathering comprehensive information about children’s participation.