Background: The cause of patient aggression is a very complex question, and it continues to be a challenging phenomenon in psychiatric inpatient services. This thesis provides a broad investigation into nursing staff attitudes towards inpatient aggression. Individual factors such as the history of violence are well studied. However, staff-level factors have received less attention. Aims and Objectives: The main purpose of this thesis was to explore and expand the knowledge base of nursing staff attitudes toward patient aggression in secure psychiatric hospitals. The four questions of this thesis were; 1. What does the literature suggest about the psychological and emotional effects of inpatient aggression on nurses working in psychiatric settings? (Chapter 2). 2. What are the factors associated with nurses’ attitudes towards patient aggression in UK secure psychiatric hospitals? (Chapter 4). 3. Is the Attitude Toward Aggression Scale (ATAS; Jansen et al., 2006a; 1997; 2005b) a suitable measure for assessing nurses’ attitudes towards patient aggression? (Chapter 3). 4. What are the benefits of using a direct staff-level intervention that utilises the positive behavioural support (PBS) philosophy when targeting attitudes towards patient aggression? (Chapter 5). Method: To answer the first research question a systematic review was completed to explore current literature focusing on the psychological and emotional effects of patient aggression (Chapter 2). A critical review was then conducted to explore the psychometric properties of the ATAS, a tool commonly used within psychiatric services to help monitor and evaluate attitudes towards patient aggression (Chapter 3). An empirical research study using quantitative measures was developed to explore nursing staff attitudes towards patient aggression in UK secure psychiatric hospitals (Chapter 4). Finally, a case study presents the effectiveness of a direct staff-level intervention on nurses’ attitudes and the management of patient aggression in a secure psychiatric hospital (Chapter 5). Overall Findings: 1. The systematic review (Chapter 2) identified several psychological and emotional effects when exposed to inpatient aggression. Psychiatric nurses were found to suffer from occupational stress, psychological strain and post-traumatic stress disorder symptoms. State anxiety was found to be the main emotional effect. 2. The psychometric review of the ATAS (Chapter 3) raised questions regarding the face validity, content validity, predictive validity, concurrent validity, and construct validity. The internal reliability was deemed satisfactory, whereas the test-retest reliability is yet to be explored. 3. The results from the primary study (Chapter 4) showed that the respondents viewed patient aggression as destructive. Verbal aggression was the most prevalent predictor for the communicative, protective, and intrusive attitude domains, whilst working with the female population was associated with having a destructive attitude. 4. This case study (Chapter 5) highlights the benefit of conducting a direct staff-level intervention when targeting attitudes towards patient aggression. There was a positive shift in how staff evaluated patient aggression following this intervention. The data also evidenced improvements in the patient’s ability to cope with anger-provoking situations, along with a reduction in the frequency and intensity of aggressive incidents. Conclusion: Nurses’ attitudes towards patient aggression have been found to influence the type of management strategies used. A better understanding of the sources of them may provide a useful guide when designing and developing cost-effective organisational interventions aimed to reduce the need for restrictive interventions in inpatient settings. This can help promote positive and proactive care and create a safer environment for both patients and staff.

Purpose: The aim of this research was to investigate perceptions of child sexual abuse (CSA), particularly the perceptions held by CSA perpetrators and the public. Given the influence perceptions can have on a CSA victim’s wellbeing and disclosure behaviour, and a CSA perpetrator’s sexual recidivism risk, gaining insight into these perceptions was considered important. Method: To facilitate this investigation, a multifaceted approach was adopted. This commenced with chapter one, a systematic literature review, which aimed to identify which factors influence English and Welsh perceptions of CSA victims. The second chapter comprised an empirical research project which aimed to investigate the influence of a victim’s abuse history, victim-perpetrator relationship and a perpetrator’s gender on British perceptions of CSA. These three factors were selected due to their hypothesised influence on perceptions and lack of investigation. Following this, chapter three was completed which involved a critique of the Gudjonsson Blame Attribution Inventory-Revised (GBAI-R). This was to assess the inventory’s suitability for chapter four and to inform practitioners of its utility. Finally, chapter four entailed a case study which aimed to investigate whether a CSA perpetrator’s offence-specific minimisation could be reduced. This was facilitated by completing a six-session intervention on an individual basis. Results: This thesis revealed various findings. Specifically, chapter one revealed respondent gender influences public perceptions of CSA victims as males perceived CSA victims more negatively than females. Regarding chapter two, a victim’s abuse history, victim-perpetrator relationship and a perpetrator’s gender were not found to influence British perceptions of CSA. However, similar to chapter one, females were significantly more pro-victim compared to males. In chapter three, the critique identified some evidence of the GBAI-R being psychometrically sound and utilising an efficient administration methodology. Despite this, some concerns were raised regarding the representativeness of its normative data and the inventory’s susceptibility to extreme scores. Finally, chapter four revealed some evidence of the intervention reducing the perpetrator’s offence-specific minimisation although it was not possible to firmly conclude this. Conclusion: The findings highlight the need for further research into perceptions of CSA. This should include investigations into why males are less pro-victim compared to females and the impact this might have on CSA. Research should also continue to investigate the influence of a victim’s abuse history, victim-perpetrator relationship and a perpetrator’s gender on perceptions of CSA. As part of this research a more representative sample should be recruited to enable the generalisation of findings. A more comprehensive critique of the GBAI-R should also be facilitated as well as further investigations into minimisation.

Whilst the positive relationship between neuroticism and burnout is well-established within the extant literature, it is also acknowledged that neurotic individuals may differ in the extent to which they experience such detriments in well-being. In concordance with dual-processing theories of behaviour, it was suggested in this thesis that executive functions may enable one to enact in a ‘goal-orientated’ manner, and thus overcome one’s instinctive neurotic tendencies towards burnout. Through the four studies of this thesis, a research model was constructed and examined in which the core executive functions of working memory, active inhibition and task switching were proposed to reduce the extent to which neuroticism positively predicted burnout (which in studies 2 and 3 was suggested to occur via negative affect). Although the overall neuroticism-burnout relationship was not found to be conditional upon any of the three executive functions, there was some evidence that the constituent paths of an indirect neuroticism-burnout model (via negative affect) were moderated by executive functions. Specifically, active inhibition significantly decreased the negative affect-burnout relationship in study 2, and this relationship was found to be conditional on task-switching in study 3, to the extent that lower task-switching reduced the moderating effect of active inhibition on the relationship between negative affect and burnout. In study 3 it was also found that higher levels of working memory capacity were associated with a reduction in the neuroticism-negative affect relationship. The findings of this research did not support an overall moderating effect of executive functions, whilst only partly supporting the broader suggestion that executive functions may regulate the negative outcomes that occur when vulnerable individuals experience stressors. In light of the results of this thesis, limitations of the research were discussed (including methodological differences across studies and the use of unitary executive function measures) and suggestions made for future research (e.g. longitudinal study designs).

Arts and health are international fields of practice with stakeholders from various disciplines. It is known that the UK has an established practice of collaboration in the form of interdisciplinary partnerships in arts and health (Clift et al., 2009, White, 2009), whereas in Denmark initiatives exist ad-hoc and there is no such established field (Jensen and Wille, 2015). This thesis is a qualitative study investigating the interdisciplinary relationships between stakeholders engaged in arts and health practice in the UK and in Denmark. The identified stakeholders in the study are: health professionals, museum educators and mental health service users. Semi-structured interviews were conducted with 36 participants including health professionals, museum educators and service users. Data were collected in Denmark and in the UK. A thematic approach was used to analyse the data and theoretical lenses of sociological theories of professions and institutional logics were employed to explore the findings. There were two stages to the data collection in Denmark; the first was a small-scale pilot study where the findings identified that arts engagement have health and wellbeing benefits for mental health service users. These benefits are perceived to include empowerment and meaning in life, which are two of the core principles of recovery; arts engagement can therefore be a useful tool in recovery and although this was a small-scale pilot study, the findings are not dissimilar to findings from other studies examining this issue. However, the pilot study also highlighted some further issues with the interaction between museum educators and service users that had unintended negative effects. The larger scale study was then conducted in Denmark to explore the interaction between service users and museum educators. The findings illustrate, similarly to the pilot study, that arts engagement is perceived to be beneficial for service users. The findings also show that the experience of visiting a museum was not always positive and depended upon the interaction with the museum educators. The service users identified points about the museum educators as a professional group which gave the idea that if museums in Denmark want to engage positively with people with mental health problems, then the training of staff and the improvement of institutional approaches to support working with vulnerable people are essential. In order to further understand and explore the professionals in arts and health practice and what contributes to an effective partnership, the next part of the study took place in the more established arts and health field in the UK. In this way, this part of the study was conducted in the UK and was chosen in order to explore a setting with health professionals and museum educators working together in an interdisciplinary collaboration. This stage of the study reveals that interdisciplinary work in arts and health is complex, given the different disciplines and institutions involved. However, findings throughout the study (in Denmark and in the UK) illustrate that competing institutional logics play a vital and ambiguous part in the work of the professions involved in arts and health practice and that this presents a challenge for interdisciplinary working in the field. The UK part of the study also illustrates that aspects of practice, such as risk management, are approached from different perspectives depending on the profession involved and are interpreted in various ways according to the disciplinary background. Working in unfamiliar settings creates professional vulnerability and ambiguity and the interdisciplinary setting illustrates that professionals have territories that they want to uphold. However, the study also shows that there is an agreement among the professionals that an interdisciplinary approach to the field is necessary. The conclusion of the study has, from the perspectives of the participants, served to highlight some benefits and challenges in the interdisciplinary field of arts and health practice. The study suggests that an awareness of the existing complexities of logics, a pragmatic framework in which multiple and competing logics can co-exist and that recognising the differences between disciplines and institutions could benefit practice in the field. In addition, offering various arts activities in diverse health settings and for different health issues, including health promotion, treatments and recovery, can strengthen a patient-centred approach of healthcare that both the UK and Denmark strive to achieve. Furthermore, the study makes recommendations for the field of practice.

The following academic thesis explores the links between offender motivation and violence reduction treatment for adult male offenders, with a focus on those with a mental illness. The thesis begins with a systematic review of the literature regarding the impact of motivation on interventions aimed at reducing violence and aggression. The majority of reviewed studies provided tentative support for the theory that individuals with higher levels of motivation stay in treatment longer and have better treatment gains regarding violence reduction. The following chapter includes an empirical study investigating the impact of Stage of Change, as measured by the Transtheoretical Model (Prochaska & DiClemente, 1982), on the outcome of treatment. The focus of this study was the Violent Offender Treatment Programme (VOTP), designed for mentally disordered offenders, and its application within a High Security and a Medium Security hospital. The programme itself was found to be effective in reducing violence outcomes, however there was little support for the Stages of Change model as a form of categorising those who were more likely to improve. Chapter 4 then presents a Case Study of an adult male offender, with a diagnosis of Delusional Disorder, in order to ascertain whether the VOTP could be adapted for individual use. Case study results were not clinically significant but are discussed in light of current research and forensic practice. A critical appraisal of the Violence Risk Scale (Wong & Gordon, 1998-2003) is then presented in Chapter 5, due to this being a primary risk assessment tool referred to throughout the doctoral works. The thesis concludes with a chapter summarising the key points and involving a reflective element by the author.

This thesis will aim to identify the role of protective factors in clinical risk prediction and management of inpatients in secure services. Chapter one provides an introduction to the field of forensic risk assessment, and a justification for the importance of including protective factors to create a more balanced assessment of patient risk. Chapter two presents a systematic review exploring the role of protective factors in various risk assessment tools. The aims of this review is to identify risk assessment tools that incorporate a measure of protective strengths, and the predictive validity of these tools for the outcome of inpatient aggression or violence. Chapter three provides a critical review of the START, specifically focused on its strengths and weaknesses as a risk prediction tool, demonstrating good validity, reliability, in addition to excellent inter-rater reliability. Findings will be reported in terms of the clinical utility of this tool. Chapter four presents the findings from a research project that aimed to identify the predictive validity of the START in female forensic inpatients, highlighting the efficacy of the specific risk estimates. Chapter five utilises a case study to identify how promoting protective factors in the form of coping skills can reduce self-harming behaviours. This case study aims to demonstrate that focusing treatment on promoting patient strengths can be effective in reducing adverse outcomes. Finally, chapter six discusses the overall findings and clinical implications from the present thesis. Future research directions will also be discussed.

The personality disorder (PD) concept has attracted widespread criticism (see Cromby, Harper & Reavey, 2012). Research suggests those who receive this diagnosis are often stigmatised by mental health professionals. Psychological approaches to understanding staff views about PD have been dominated by realist methodologies which are limited in their capacity to attend to the complexity, contradictions and context of health professionals’ views. Recently, studies have explored the ways that mental health staff talk about their work and account for their treatment decisions; these studies show how dominant categories and practices are produced and maintained through staff talk (see Harper, 1995; Parker, Georgaca, Harper, McLaughlin, & Stowell-Smith, 1995). A central aim of this thesis is to contribute to the body of research which has explored staff discursive practices, their function and their relationship with wider discourses. This study set out to explore the PD construct and how staff make sense of distress within this diagnostic framework. This research is informed by a social constructionist perspective. Semi-structured interviews were used to elicit talk regarding PD, diagnosis and what staff constitute as key elements of their work. Staff were recruited from across a multidisciplinary (MDT) team; all participants (n = 11) worked in a secure, inpatient PD ward in an independent hospital. The analysis was informed by discursive psychology (Potter & Wetherell, 1987) and Foucauldian discourse analysis (Foucault, 1979). Staff both drew on and resisted the practice of diagnosis. Staff foregrounded a biopsychosocial framework for understanding PD and variably questioned the status of PD as a mental illness. Staff talk about the challenges and goals of their work centred on constructions of emotion and emotional control. Implications are discussed in terms of staff decisions about care, the role of clinical psychologists within MDT’s and the wider socio-political context around PD. The current findings draw attention to the construction of psychological concepts in understanding PD, and the essentialist treatment of diagnosis, as well as the complexity and flexibility of implementation of these strategies to justify decisions. There is a need to foster space to explore staff values, mainstream categories and to reflect on dominant ideologies which will influence staff work with people with a PD diagnosis.

This thesis explored whether patients in high security hospitals are more ‘Complex Cases’ or more ‘Difficult Cases’ than their counterparts in lower security settings. Herein, case complexity is associated with co-morbid diagnoses or clinical needs, whilst case difficulty refers to challenging, violent and aggressive behaviour. A systematic literature review examined institutional violence and aggression in different security settings within healthcare and prison environments. No clear differences were found in frequency of incidents between the security levels, and a suggestion that the severity of incidents were greatest in lower security had limited generalisability. The results were confounded by data incompatibility, meaning that it could not be concluded that higher security sites house the more ‘Difficult Cases’. An empirical research study examined differences in clinical complexity between personality disordered (PD) patients living in high and medium security units (MSUs). Statistical differences were found on several clinical and forensic variables between settings, including age at first conviction, and difficulties with affective instability, paranoia and depression (assessed with the Personality Assessment Inventory; PAI). This led to the development of a Model of a Complex Case of PD. The results suggested that higher security sites do treat a greater number of ‘Complex Cases’ of PD. Interestingly, they were also found to house a greater number of physically violent patients than the MSUs, ie. more ‘Difficult Cases’. A case study examined a high security PD patient, ‘Andrew’. His assessment, formulation and violence relapse prevention treatment were presented and discussed. It was identified that on admission Andrew was a match to the Model of a Complex Case of PD, and that a lowering of his PAI score profile over time reflected his treatment gains and lessening of his clinical difficulties. When preparing to transition to an MSU, Andrew could no longer be classified as complex, according to the Model. Finally a critique of the PAI psychometric was presented. The tool was assessed for reliability and validity as a measure of clinical psychopathologies, interaction styles and treatment needs, and was praised for its utility with PD patients. The findings from the thesis chapters were reviewed, and the application of the Model of a Complex Case of PD was also discussed. It was concluded that the high security hospital currently provides treatment services to more ‘Complex Cases’ of PD and more ‘Difficult Cases’ than the investigated medium security counterparts. Please note that Chapter 3, which details a confidential patient case study, has been redacted.

Schizophrenia is a lifelong disorder that affects 1% of the population worldwide and often begins in late adolescence or early adulthood. It is characterised by positive, negative and cognitive symptoms. Negative and cognitive deficits are more difficult to measure in rodents but may be a better predictor than positive symptoms of the long-term outcome following treatment of patients with schizophrenia. One of the major challenges in schizophrenia research is the development of suitable models for these aspects of the disorder. In this regard, one model we have studied in some detail is the methylazoxymethanol (MAM) neurodevelopmental model. MAM is a neurospecific antimitotic agent that prevents cells from dividing for a short time after injection. It can be administered intraperitoneally to pregnant dams on gestational day 17, theoretically causing neuroanatomical and behavioural alterations in offspring that are akin to core symptoms seen in schizophrenia. Our findings confirm that MAM model offspring exhibit several neurodevelopmental and pathological changes that bear similarities to schizophrenia. These include reductions in cortical thickness and hippocampal size,and enlargement of ventricles. Behavioural consequences of MAM, largely emergent after puberty, include increased locomotor responsiveness to NMDA antagonist administration, and also pre-pulse inhibition and cognitive flexibility deficits. However, the robust neuropathological and neurophysiological findings found in the MAM El7 model do not always translate into behavioural deficits. This is of critical consequence for model validation and use in discovery research. The variability in behaviour effects will be discussed, taking into consideration factors such as litter effects, study design and statistical analysis. Overall, our data suggests that maternal treatment with MAM on embryonic day 17 leads to persistent alterations in the adult offspring of SD-CD rats that are relevant for modelling aspects of schizophrenia - but revised methods for study design and statistical analysis are crucial to avoid misinterpretation of findings.

Disasters are events that challenge both the social and individual ability to adapt, carrying the risk of adverse mental health outcomes. High prevalence rates of Post Traumatic Stress Disorder (PTSD), anxiety, and depression have been found after disasters among affected adults and children, and PTSD is the most distinct and common disorder. However, the challenge of providing sufficient numbers of mental health professionals is the most critical issue facing health-care systems throughout the world, and especially in developing countries. The 2008 Sichuan earthquake in China had enormous destructive power and affected millions of people. Given the large number of people involved – and the shortage of resources in any major disaster – brief, pragmatic, and easily trainable interventions are needed for both adult and child survivors. In the context of the Sichuan earthquake, this thesis describes a research work aimed at: (1) investigating the extent and nature of earthquake-related distress and positive change experienced by the targeted survivor population, and exploring the factors that predict these distresses and changes, (2) examining the effectiveness of narrative exposure therapy (NET) in adult survivors, and (3) examining the effectiveness of written narrative strategies for child survivors in the school setting. To achieve these aims, a cross-sectional survey (N=120) was conducted to explore the psychological morbidities, risk, and protective factors as well as predictive models of PTSD and positive change at 1.5 years after the Sichuan earthquake. It highlights the mental health problems after the earthquake, and provides the background information for the subsequent intervention studies. Sequentially, effectiveness of the narrative exposure therapy was assessed within Chinese adult survivors and modified appropriately via two RCT studies using waiting list control. In the NET-1 study, 22 survivors with diagnosed PTSD were recruited and received the NET treatment. The results supported the effectiveness of NET for treating Chinese earthquake survivors. In the NET-2 study, NET was adapted according to the feedback and practical implications from the NET-1 study. Thirty participants with newly diagnosed PTSD were recruited. Twenty of them were treated by the NET-R, and the other 10 participants were treated by the original NET. The revised NET showed a similar intervention effect to the original NET in reducing PTSD symptoms anxiety, depression, general distress, and negative change, and promoting positive change following adversity. In the child intervention studies, a short, inexpensive and easily applied written narrative intervention called Guided Narrative Techniques (GNT) was developed and evaluated with traumatised children in the school setting through two studies. The first study was conducted with 108 sixth grade children (11-12-years old) from three classes in a single primary school, in the earthquake area. Two classes were randomly assigned to the GNT group, and one class was assigned to the expressive writing group that was given simple verbal instruction. The results indicated that if the writing instructions of the programme were fully followed through by the children, GNT might function better on reducing the posttraumatic symptoms than the expressive writing in a short time. However, a low level of writing adherence was reported, indicating that written narrative strategies may not be suitable for traumatised early adolescents. In the second child study, the GNT protocol was improved to enhance the writing adherence of children. Eighty-two Chinese fourth grade children (9-10-years-old) from three classes were recruited as participants in the writing programme. One class was randomly assigned to the GNT group; one class was assigned to the GNT condition with encouragement (GNTE group); and one class was assigned to the control group with mixed expressive writing and painting (MEWP) without specific guidelines. The results indicated that all three written narrative strategies appeared to be efficient concerning post-disaster resilience for Chinese school children. The GNTE showed most rapid, stable and extensive effects, indicating its advantages over the other two conditions. The research provides evidence for the applicability and effectiveness of narrative interventions in the Chinese earthquake survivor population. It attempted to facilitate the wider dissemination of psychological interventions to promote recovery from traumatic stress after major disasters. The findings help advance current knowledge in the management of PTSD after natural disasters in developing areas, contribute to the validation of PTSD theories, and inform future research.