Firefighters have a high likelihood of being exposed to a variety of traumatic events. The psychological cost of this exposure may be an increased risk of long-term problems such as PTSD symptoms, depression and anxiety. Saudi firefighters in Makkah province are often exposed to elevated levels of potentially traumatising events through the course of their work which can affect them physically and psychologically. However, providing sufficient mental health professionals is difficult due to the absence of psychological trauma care in Saudi Arabia and Saudi culture associated with the psychological support. The aim of this thesis is to understanding the psychological impact of being a firefighter and seeing whether narrative exposure therapy (NET) is an effective treatment for traumatised Saudi firefighters. Three studies were conducted In order to achieve these aims. The first administered questionnaires to 200 Saudi firefighters; the second was a qualitative study comprising of semi-structure life story interviews with 9 traumatised Saudi firefighters, whilst the final randomized control trial (RCT) examined the effectiveness of NET with 34 Saudi firefighters with PTSD. A high prevalence rate of PTSD (57%), anxiety (44.4%), and depression (53.3%) symptoms with limited mental health support were reported. Single firefighters reported PTSD symptoms and the use of passive coping strategies more than the married firefighters. The results also revealed that marriage was associated with low levels of PTSD, while high levels of PTSD correlated with anxiety, depression, and with passive coping strategies. The qualitative study illustrated themes and subthemes reflected family life, education, experience of being firefighters, traumatic, coping strategies. Two narrative analysis cases presented with the life plot trend with the positive impact of the individual’s life story interview which inform the using of narrative technique in the intervention study. The RCT study demonstrated a significant reduction in PTSD, anxiety, and depression symptoms after 6 weeks, but this was not sustained at 3 and 6 months. The research provides evidence for the applicability and effectiveness of a narrative intervention for traumatised Saudi firefighters. It tried to facilitate the wider dissemination of psychological intervention to promote recovery from traumatic stress for the first responders. Four sessions might not give firefighters sufficient time to process all the relevant information, and they therefore reported an increase in PTSD symptoms in the follow-up time. It would be preferable for firefighters to receive two or three NET sessions after a 3 and/or 6-month follow-up. The findings help advance current knowledge in the management of PTSD among firefighters, in-depth understanding the psychological, coping, and cultural backgrounds, in developing countries, contribute to the validation of PTSD theories, and inform future research. The implications of developing a multi-factorial and holistic approach to the treatment of first responders’ traumas are presented and a case is made for the use of narrative methods in the treatment of complex trauma.

The emergence of recovery as an important philosophy in contemporary mental health care, alongside increasing levels of coercion has drawn attention to the potential for conflicting influences in mental health practice. This thesis examines how such conflicts may be situated in the historical, legal and professional foundation of mental health services, presenting an argument to suggest this exposes mental health professionals to tensions in decision-making. Inspired by my own experiences as a mental health nurse, this qualitative interpretive inquiry employed multiple case studies to explore whether and how mental health practitioners perceive and experience potential tensions that may arise from delivering care and enforcing control. Data was collected using interviews with mental health professionals and observations in an acute in-patient ward and assertive outreach team. Data analysis using a theory building approach in case study research was adopted to develop an explanatory model which suggests service users are constructed as objects of risk. Hilgartner’s (1992) theory has been employed to support explanations that people with mental health problems are defined and treated in terms of risk. Such a process is enabled by a spatial, narrative and moral distance that is created between service users and professionals. The construction of service users as objects of risk is influenced by professional, organisational and social contexts. However, displacement from the status of risk object occurred when some professionals maintained proximity to service users’ subjective experiences. The study has underlined the importance of raising awareness that recovery values are not being realised in mental health practice. It has highlighted problems with the language of risk and proposed strategies that may enhance opportunities for professionals to remain connected to service users’ narratives through dialogue.

Background: Smoking in pregnancy is a major cause of morbidity and mortality, with a significant cost burden to the NHS. An estimated 26% of women still report smoking at the beginning of, or just before, pregnancy, with 12% reporting smoking throughout. While economic evaluations of cessation interventions in the non-pregnant population are well developed, similar evaluations of within-pregnancy interventions are not. Because of the special circumstances associated with pregnancy, general smoking evaluations cannot be applied in these settings. This thesis outlines the development of an improved economic model designed to capture the healthcare costs and benefits associated with smoking and cessation within pregnancy. Methods: A series of scoping reviews of the electronic resource Medline were conducted to identify either within-pregnancy or childhood morbidities which had potentially causal associations with smoking during or after pregnancy, as well as the incidences of morbidities and health related quality of life (HRQoL) scores attributable to those identified. A systematic review appraised the previous economic literature on cessation during pregnancy, to determine where improvements were needed. To ensure that relapse to smoking could be accounted for, a second systematic review generated pooled estimates of abstinence from smoking in the postpartum period. This information was used to develop and construct the improved economic model. Results: 11 conditions were identified as having a causal association with smoking during pregnancy. The systematic review of previous evaluations identified 17 studies; however, only three were considered high quality, suggesting the need for an improved model. The pooled estimates of abstinence suggested that by two years postpartum, most women had restarted smoking, with most relapsing after three, but before 12, months postpartum. The Economic impacts of Smoking In Pregnancy (ESIP) model consists of two linked decision trees which capture the within-pregnancy aspects, while two linked Markov chains capture the post-pregnancy smoking behaviour for both the mother and her child. ESIP was also extended to control for uncertainty. Conclusion: ESIP improves on the previous literature since it directly captures the impact of the mother’s smoking behaviour on the health of her offspring, both within-pregnancy and childhood, using the most accurate data currently available. Future extensions to ESIP include an adult component for the infant to capture their smoking behaviour.

Purpose and Background This mixed methods study explored the importance of therapist body-confidence and gender upon the Eating Disordered client and recovery. Examination of previous literature highlighted a lack of research exploring negative treatment experiences from the perspective of individuals who have an Eating Disorder. With reference to socio-cultural theoretical models, initial findings in the literature indicate that aspects of therapist appearance may be an important factor in treatment experience. The potential sensitivity of exploring therapist appearance is considered as one reason that this topic remains largely unexplored in the literature. Method 143 males and females with self-reported current or historical experience of an Eating Disorder completed an anonymous, online survey which was designed by the authors for the purpose of the study. Questions exploring body-confidence and recovery were analysed using Thematic Analysis incorporating Saliency Analysis. Questions pertaining to therapist gender and body-confidence were analysed using statistical tests. Rationale is provided for the epistemological stance, methodological approach and design of the current study. Results Thematic Analysis revealed three overarching themes about body-confidence and three overarching themes about recovery. The body-confidence themes suggested that individuals who have an ED progress along a continuum of beliefs about body-confidence, initially believing that it is linked to body-size, before acknowledging that their Eating Disorder is unrelated to body-confidence and finally realising that body-confidence is possible regardless of size. The recovery themes indicated that individuals who have an ED go through a cycle where they feel restricted, begin to reconcile self and culture and achieve resilience on the path to recovery. Statistical analysis revealed that participants rated therapist body-confidence as highly important and showed a strong preference for a gender-same therapist. There was also some indication that participants judged the body-confidence of male and female therapists differently, although the effect size of this finding was small. The results are discussed within the context of previous literature and in keeping with the epistemological position of the current study. Conclusions These findings offer further support for the continued investigation of therapist appearance, in particular body-confidence and gender, and how it might impact upon the therapeutic experience of Eating Disordered clients. Further contribution is the addition of the perspective of individuals who have an Eating Disorder to the literature about recovery from an Eating Disorder. There are important implications for services, how they are organised and how therapists are trained to work with this population. Future research should further explore the ways in which aspects of therapist appearance impact upon therapeutic experience for Eating Disorder clients and whether there are mediating factors. Finally, the principle researcher’s critical reflection about theoretical, scientific and ethical aspects of the research process is provided.

Introduction: ‘Sex addiction’ appears to have been largely accepted within clinical fields and popular culture. However, despite its 30 year history, the concept remains ill-defined and lacking in empirical data. Indeed, proponents of sex addiction continue to debate its terminology, definition, nosology, and aetiology, with a coherent model of the ‘disorder’ yet to be offered. An alternative account presented by the social constructionist model argues that the reason for this contention is because, rather than a pathological disorder, sex addiction represents a social construction. Those who argue from this perspective suggest that sex addiction has been created to pathologize sexualities which fail to promote dominant sexual norms. Whilst this argument appears convincing, it is not clear why some may be more influenced by these dominant sexual norms and thus pathologize their sexuality, whilst others do not consider their sexuality to be problematic. The answer to this may lie in certain individual differences, in particular, personality, thinking dispositions, sexual attitudes, and religiosity. Aims: This was an exploratory piece of research which aimed to compare sex addicts (SAs) to ‘non-addicts’ (NSAs) on the dependent variables: sexual behaviour, the Big Five personality traits, categorical thinking, sexual attitudes, and religiosity. Design: A convergent parallel design was employed, using questionnaires to collect quantitative and qualitative data. Method: A self-selecting sample (N = 214) was recruited via poster and online advertisements placed in general public sites such as pubs and clubs, and sex addiction and sexual interest forums. Participants completed an online questionnaire comprising: a) an assessment of ‘sex addiction’ via participant’s self-identification and a clinical screening tool (the Sexual Addiction Screening tool; SAST); b) a free text box in which participants explained their self-identification; c) a questionnaire collecting demographic data and assessing the variables under investigation. Results: Participants’ constructs of sex addiction largely mapped onto the dominant model of sex addiction. This was particularly evident within SAs’ responses. Conversely, a number of themes within NSAs’ responses diverged from the sex addiction model and expressed a positive view of sex. Subsequent statistical analyses comparing self-identified SAs to NSAs found SAs reported a greater frequency of solo sex and evidenced more categorical thinking. No other significant differences were observed, with the exception of neuroticism whereby SAs scored higher when samples were matched for sexual activity. When the SAST defined the groups, SAs reported a greater frequency of solo sex and anal sex, and reported a higher number of partners for oral sex and anal sex. These SAs also scored significantly higher in neuroticism and were less satisfied with their current sexual activity. Discussion: The study demonstrates the immersion of the dominant model of sex addiction within sociocultural norms and suggests that SA participants in particular have internalised these norms into their interpretive frameworks. The subsequent comparison between the groups suggests that idiographic factors may interact with these discourses, meaning some are more influenced than others by these discourses. In particular, those with a propensity to think inflexibly (categorical thinking) and/or a predisposition to respond with negative emotionality and worry (neuroticism) may be more likely to appraise their sexuality as problematic and this identify as a SA. The study also lends support to the idea that the SAST tools may unduly pathologize sexual behaviours which are considered ‘unconventional’.

Prevalence rates for mental health problems amongst drug and alcohol service users in the UK were 74.5% and 85.5% respectively (Weaver et al 2003). 44% of people with psychiatric problems also had a substance misuse problem (Weaver 2003). Aims and objectives: This study aims to identify what service users with dual diagnosis and practitioners who work in this area perceive to be the factors that foster and inhibit their recovery (a meaningful quality of life). This is a narrative study using unstructured interviews to develop a framework for understanding the experiences of people who have a dual diagnosis and to guide those that help them. Methodology: Ten service users and ten practitioners were interviewed using a narrative approach. These were then transcribed and analysed using Langdridge’s (2012) Critical Narrative Analysis framework (CNA). Goffman’s, Link and Phelan’s and Sayce’s theories on stigma and Frank’s discussion of the role of narrative storytelling in illness were used as hermeneutics of suspicion to study meaning within the narratives. Findings: The study explores how four key themes Stigma, Motivation, Recovery and Tension narratives provide an explanatory framework of recovery and identity for both service users and practitioners. It uncovers the interrelationships between the spoiled identities (double jeopardy) of service users and the influence this stigma has on practitioners. The study develops a perspective of how narrative storytelling can help articulate and reframe identities to aid recovery amongst people with a Dual Diagnosis. Relevance: There have been very few studies that explore the lived experience of people with a Dual Diagnosis or the practitioners who work with them. Meta analyses of randomised controlled trials in Dual Diagnosis have found little conclusive evidence of interventions that are effective. The study suggests that in pursuing empiricist research standards, previous studies have missed the holism provided by seeing individual experience as an important factor in affecting the course and effect on people who experience Dual Diagnosis and those around them who try to help.

Introduction: Despite a growing body of intellectual disabilities literature around the transition into adulthood, most studies have focused upon physical aspects of the transition e.g. from school to employment or into adult services. My study sought to explore the transition into adulthood from a developmental/lifecourse perspective in order to address this current gap within the literature. Given that parents are often regarded as primary witnesses to their child’s transition into adulthood, their views were explored in order to access knowledge around this particular transition. Objectives: My study used a grounded theory approach to explore parents’ views of the transition into adulthood of their child with a severe intellectual disability. A further aim was to understand whether and how parents made psychological adjustments for their child’s transition into adulthood. This included an exploration of the emotional regulation processes that parents engaged in. Method: Twelve parents of 11 children with a severe intellectual disability were recruited from charitable organisations. A Straussian grounded theory methodology was adopted to analyse the data. Results: Parents viewed their child’s transition into adulthood as a process over time. The core process involved making frequent comparisons with their perceived “norms” of adulthood. Parents engaged in a further five processes which included “defining adulthood”, “noticing adult development”, “perceiving barriers to adulthood”, “worrying” and “making adjustments. My study highlighted that parents who defined adulthood as “turning 18” were likely to make adjustments to facilitate their child’s adult development (e.g., “encourage age appropriateness”). Those who viewed chronological age as being unhelpful/meaningless were more likely to be accepting of their child’s difficulties. Contrasting views appeared throughout these processes, demonstrating the diversity of parents’ experiences and adjustments made. Discussion: Parents engaged in a series of interactional processes for their child’s transition trajectory, which was likely to influence how they made adjustments. These processes were explained using existing psychological theory and/or relating them to findings from previous studies. With regards to a grounded theory model, I proposed a transition model of parents’ views and adjustment grounded in the study findings. The visual representation of this model helped to shift away from the staged/linear idea of transition. Future intellectual disabilities studies could seek to explore the types (and function) of comparisons that parents make with others. Additionally, further research could explore fathers’ views which are under-represented within this field. Clinical interventions may aim to challenge parent perceptions; encourage peer support; and embrace systemic working with parents through their child’s transition into adulthood.

This thesis explores the contribution of the Personal Concerns Inventory (PCI; Cox & Klinger, 2000) to the development of treatment engagement strategies with people with personality disorder (PD) in forensic settings. A systematic literature review of evaluated engagement strategies with offenders and people with PD showed little diversity in terms of strategies evaluated with PD, specifically psycho-education and goal-based interventions only (Chapter 2). Furthermore current literature focuses mainly on motivational interviewing (MI) in offenders as somewhat useful in increasing motivation to engage and change. However preliminary support for node-mapping and interactive activities has been found in a small number of studies. The distinct lack of strategies with PD is problematic considering the high treatment non-completion rates with this population and the case study in Chapter 3 discusses the complexity of working with patients with PD. It finds Dialectical Behaviour Therapy (DBT), which embeds motivational strategies in its programme, as improving not only treatment retention but also clinical outcomes, thereby offering further encouragement in focusing engagement strategies with PD. Consequently, a critique of the PCI was necessary in understanding the PCI as both a measure of motivation to change and a motivational intervention. This semi-structured interview demonstrates reasonable reliability and validity however the offender variants’ psychometric properties are weaker. The robust theoretical basis of the PCI and the consistent positive qualitative feedback from participants suggests value in evaluating the tool as a motivational intervention. Thus Chapter 5, an empirical study, evaluates the PCI followed by goal counselling as a motivational intervention with people with PD using a mixed-methods approach and a small number multiple baseline design. The quantitative results offer limited support for the effectiveness of the PCI or understanding of the process of change. However the qualitative data reflects that in existing PCI literature: participants perceived it as effective in focusing them on their goals and the relevance of treatment, thereby enhancing motivation. Therefore further investigations are needed to clarify discrepancies between participant perception and the outcome measure data in order to understand the extent to which the PCI enhances motivation. The final chapter summarises the thesis’ findings, the impact for research and clinical practice, the main limitations of this thesis, and makes recommendations for future research. Overall, the complex and idiosyncratic manifestation of a diagnosis of PD and the numerous external and internal factors affecting the engagement of people with PD recommend tailored assessment and intervention using a client-led approach.

This thesis explores the value of including protective factors in the violence risk assessment and risk management processes of forensic mental health services. More specifically it investigates whether assessment of protective factors improves predictive accuracy of violence risk assessment tools, and discusses the implications for clinical practice. The impact on patient motivation to change is also considered. A critique is presented of the Historical Clinical Risk-20 Version 3 (HCR-20V3; Douglas, Hart, Webster, & Belfrage, 2013), one of the most popular and widely used violence risk assessment tools. Despite its popularity and good measurable properties, the HCR-20V3 does not include an assessment of protective factors. A systematic review examined research investigating the predictive accuracy of the three violence risk assessment tools recommended for use in forensic mental health services in the National Health Service: HCR-20V3, the Structured Assessment of Protective Factors (SAPROF; de Vogel, de Ruiter, Bourman, & de Vries Robbé, 2012), and the Short Term Assessment of Risk and Treatability (START; Webster, Martin, Brink, Nicolls, & Desmarais, 2004). The SAPROF had superior predictive accuracy of absence of violence compared to the other measures; however, limited reliability and validity evidence was found for its use in English forensic inpatient settings. An empirical research project conducted a prospective validation study of the SAPROF, also reporting on the reliability and validity of the measure across a number of domains, and in relation to the HCR-20V3 and START. The SAPROF demonstrated better absence of violence risk predictive abilities than the HCR-20V3 and the START (presence of violence risk); combined use of the SAPROF and HCR-20V3 significantly increased predictive accuracy of presence of violence risk. Finally, a single case study explores the impact of collaborative risk assessment and management training on a patient’s motivation to engage in treatment and interventions to manage risk. Collaborative risk assessment had a positive impact on motivation; however it was not reliably or clinically significant. This thesis provides positive research evidence for the inclusion of protective factors in the violence risk assessment and management process.

Spirituality has been increasingly acknowledged in nursing literature as an important element of holistic care provision. The literature to date has investigated the meaning of spirituality in Western cultures, predominantly through positivist methodologies. Spirituality in Middle Eastern countries remains under-researched, and this study aims to address this gap and to better understand this concept. The main aim was to understand and interpret patients’ perceptions, experiences, beliefs and practices associated with spirituality by exploring how spirituality is manifest in the lives of Jordanian End Stage Renal Failure (ESRF) patients. A hermeneutic phenomenological approach was adopted informed by the philosophy of Martin Heidegger (Heidegger, 1962). Participants (n=27) were recruited from four different dialysis units: in a public hospital, a private hospital, an educational hospital and a refugees’ hospital in Jordan. Data was collected through in-depth unstructured interviews. Analysis was guided by the tenets of hermeneutic phenomenology, namely: gaining an immediate sense of what was said both during and after each interview, transcribing data verbatim, translating interviews into the English language, intensive reading and re-reading, seeking meaning units by line-to-line coding, developing situated structures (how spirituality was manifest in each text) and developing a general structure from the individual situated structures (how the phenomenon ‘spirituality’ comes into being). The findings uncovered the phenomenon of spirituality and how the Jordanian ESRF patients experienced it during their illness. The nature of this phenomenon appeared to be complex and multifaceted. The three superordinate themes that emerged from analysis and interpretation of the participants’ accounts clustered around Religion, Relationships and Desperation. The study findings show how language, religion and culture were important elements and cannot be ignored in understanding Jordanian ESRF spirituality. The findings reveal that cultural issues such as losing employability, social stigma, social isolation and being tagged negatively are results of suffering from ESRF and are related to the meaningful way in which Jordanian ESRF patients viewed their spirituality. This has important implications for health care professionals. Should they use spirituality in care, there is a need to address wider issues such as stigma that patients face in society which impacts negatively upon individuals’ spirituality. In addition, findings show a specific and crucial characteristic of spirituality was the conflict between acceptance and rejection of the illness, and a sense of patients feeling that they are human and that life has not stopped. It is also evident that spirituality has played an important role in Nafs (inner self). It was part of the transforming process of Nafs from being Nafs Ammarah (evil inside) to Nafs Lawamah (blaming) to ultimately reach tranquil Nafs (peace and comfort). These were the core spiritual needs of participants, who expected that health care providers, family and community should have the essential skills to address these needs. The role of nurses within the dialysis team is essential in enhancing patients’ spirituality through spiritual and religious engagements. However, few participants highlighted the challenges in nurse-patient relationships, for example being in a busy unit, cultural boundaries, nurses’ characteristics, lack of knowledge, lack of awareness, unbalanced power in such relationships, lack of support, lack of respect, and a lack of attention and psychological care. All these elements may affect a nurse’s role in providing spiritual care. This research prompts us to look at the important role pre-dialysis nurses can play in improving and addressing spiritual needs, increasing awareness, and educating patients, family and the public about ESRF in its early stages. It also highlights the important role for religious leaders, Imams, and psychologists in enhancing an individual’s spirituality. The study argues that a “secular” concept of spirituality had no meaning for the participants in the study in the absence of religion. Spirituality is fundamentally part of religion and vice versa. The findings may have consequences for the use of spirituality in multi-cultural settings in Western countries. Additionally, findings highlight an important emphasis on the practice of spirituality, often underestimated in previous literature for Arab-Muslim Jordanian patients. The study findings contribute to the existing gap in knowledge regarding how Arab-Muslim Jordanian ESRF patients experience spirituality during their illness. It provides valuable insights into the importance of spirituality for this patient group and suggests how nurses, educators and policy makers might help address ESRF patients’ spirituality and spiritual needs in order to provide appropriate spiritual care. The study suggests the findings may have relevance beyond the Jordanian context in educating nurses on the importance of appreciating the religious dimension of spirituality. The study recommends further research in order to understand spirituality from the healthcare providers’ perspective.