Working with HIV-positive individuals may present a particular challenge to clinicians because of the phenomenon of stigma. Researchers have proposed that HIV stigma is layered with people's prejudiced attitudes toward already-stigmatized groups (e.g., sexual orientation, gender, race and ethnicity) in which people living with HIV/AIDS may have membership. Previous research has suggested that, clinicians' attitudes and reactions toward HIV and sexual orientation may significantly impact their therapeutic impressions, yet questions remain with regard to how clients' HIV status and racial identity may operate in confluence to influence clinicians' therapeutic impressions. This question may be particularly significant with regard to mental health professionals, as research also suggests that racial/ethnic minority clients can be perceived by their clinicians as more disturbed as a result of clinicians' biased racial attitudes. In the present study, case vignettes featuring hypothetical Black or White men who are either HIV-positive or HIV-negative were presented to participants to explore the influence of a client's HIV status and race upon participants' therapeutic impressions. Results indicated that participants' expectations of therapeutic process and evaluations of the clients' symptomatology were influenced by the clients' race and HIV status. Participants expected slightly greater session depth for the Black clients than the White clients in the vignettes, and their initial impressions of symptomatology were also slightly more negative toward the White clients in the vignettes. With regard to the main effect of client HIV status, participants expected slightly greater session depth for the HIV-positive clients than the HIV-negative clients in the vignettes. However, participants expected slightly less session smoothness for the HIV-positive clients in the vignettes, and they also reported lower assessment of psychological, occupational, and social functioning toward the HIV-positive clients in the vignettes. The potential interaction of the hypothetical client's race and HIV status and its effect upon participants' clinical impressions was not found significant. Implications for research and practice are discussed.

In recent years, problem use of classified prescription drugs in the United States has become a critical public health concern garnering increased attention and resources. Although the focus has primarily been on problem use of prescription drugs with the highest abuse potential, evidence of the increasing prevalence and growing burden of problem benzodiazepine use in the United States is mounting. Most epidemiological research on problem prescription drug use, including benzodiazepines, has focused on use among individuals without a prescription. However, problem use also includes use with a prescription, but in ways, or for reasons, not recommended by a doctor. Of particular importance are individuals with a benzodiazepine prescription who experience clinically significant impairment or distress as a result of using their prescription in problematic ways. Several prescription-related risk factors could increase the risk of problem benzodiazepine use among individuals prescribed benzodiazepines. These include characteristics of the benzodiazepines prescribed (including dosage and abuse liability of the prescribed benzodiazepine), the amount of benzodiazepine prescribed over time (including medication possession ratio [i.e. whether the benzodiazepine recipient has more medication than is medically necessary] and days supply of medication) and prescription contextual variables (including whether the prescription recipient also receives other controlled substances and utilizes psychotherapeutic services). In addition, characteristics of the benzodiazepine prescription recipient (including alcohol disorders, drug disorders, anxiety disorders and mood disorders) could also predict problem benzodiazepine use. This dissertation aims to consider the independent and joint roles of these factors in the risk of problem benzodiazepine use among individuals with a prescription. To this end, the current dissertation consists of three parts: a systematic literature review and two analytic research papers investigating risk factors for the development of problem benzodiazepine use, using prospective individual-level medical and pharmacy claims information in the 2003-2004 Thompson Reuters MarketScan® Commercial Claims Databases. Modifiable variables including prescription characteristics, the amount of benzodiazepine prescribed over time and prescription contextual factors independently increased the risk of problem benzodiazepine use among individuals with a prescription. Psychiatric disorders, for which benzodiazepines are indicated (alcohol and anxiety disorders), or used off-label (drug and mood disorders), independently increased the risk of problem benzodiazepine use among individuals with a prescription. Further, psychotherapy and opioid prescriptions modified the increased risk of problem benzodiazepine use conferred by an anxiety disorder. This information can be used to develop specifically targeted prevention and treatment interventions, such as surveillance systems, to address the burden of problem benzodiazepine use in the U.S.

Eighty-five sponsors in a Veterans Administration family care program were interviewed for the purpose of ascertaining whether or not the social environment provided a viable alternative to institutional living for the chronic mentally ill. Also, the impact of various descriptive factors of the setting on the social characteristics in the home was estimated. A level of restrictiveness scale (areas in which the freedom of the residents is restricted) and a level of deviation from normative living scale (areas in which residents are excluded from family activities) were utilized to measure the social characteristics of the family care environment. A high degree of each of these factors has been linked with a custodial care type of arrangement and a low degree of these dimensions has been associated' with a rehabilitative type of dwelling. Fifteen per cent of the homes scored above 80% on the level of restrictiveness and only 5% of the residences fell into the same category on the level of deviation from normative living (maximum score 100%), indicating that only a small minority of homes could be placed in a custodial care type category in relation to each of these dimensions. Moreover, a sizeable proportion of homes, approximately 40% of the sample, scored under 50% on the level of deviation from normative living demonstrating that some opportunities are provided for residents to experience different facets of family living. The lack of association found between the level of restrictiveness and degree of deviation from normative living would seem to indicate that the pattern of care is less consistently structured than other dwellings dealing with a similar population. This inconsistency may be the result of a variety of "cross-pressures" on the sponsors related to the decentralized manner in which the program is administered. Sponsors who were previously employed in a custodial care setting scored significantly lower on the level of deviation from normative living scale than sponsors lacking such experience. Sixty-nine per cent of the "trained" sponsors as compared with 39% of the "untrained" sponsors scored below the median on the level of deviation from normative living (p < .01), indicating that the former group may be more involved in "rehabilitative" tasks than the latter group. Younger sponsors appeared to maintain more restrictive homes than older caretakers. Sixty-seven per cent of the caretakers under 40 years of age scored above the median on the level of restrictiveness whereas only 29% of caretakers over 60 years of age scored above the median on the same dimension (p < .12), indicating that there may be more restrictions in homes managed by younger sponsors than in those managed by older ones. Comments obtained from the sponsors seem to suggest that the motivation of the individual for participating in the family care program may play an important role in shaping the structure of the setting. Such individuals as the older person who joins the program for companionship and the former employee of a custodial care facility who desires to take on a broader, more active role with psychiatric patients, may tend to establish settings consistent with these needs. What is noteworthy is the lack of relationship between size of the home and the social dimensions in the environment. This negative finding brings into question a modification in family care programs which has been considered by some or already implemented by others, namely, limiting the number of ex-patients in a home. Based upon the findings different hypotheses were formulated to be tested in future research.

An increasing number of clients are seeking admission to state mental hospitals to satisfy non-psychiatric needs. The study describes this phenomenon, its possible causes and its consequences. The study draws profiles of these clients' characteristics, problems, needs, and level of functioning. Clients' expectations from the state hospital and differences between them and the hospital inpatient population are explored. The study was conducted on a time sample of 100 clients who sought admission to a New York State psychiatric center. The client sample were found not in need of inpatient treatment and were referred to an emergency housing program. Data were gathered through structured and unstructured questionnaires, interviews with clients, staff, center officials, and the center's statistical and patients' records. Chi-Square Test and Spearman Correlation were used to test relationships between variables. Study data indicated that: (1) The majority of clients were young, white, single, males, unemployed, educated below high school level, and were living with a relative or a friend at the time they appeared for admission. (2) Client's self assessment and staff assessment of clients' needs suggested that housing and financial aid were significant to more clients than psychiatric treatment. (3) Client's self assessment and staff assessments of individual client's level of functioning indicated that the majority of clients were able and willing to live independently in community settings. (4) The majority of clients sought admission to the psychiatric center expecting help with housing, financial and emotional problems in that order. (5) Client sample and patients admitted to the center during the same period did not differ significantly with regard to age, sex, race, religion and marital status. The two populations differed in admission status, educational level, employment status, and sources of referral to the Center. The study recommended a clear boundary distinction of psychiatric and non-psychiatric services and that psychiatric admission be based on psychiatric rather than social factors. The study also recommended several policy and planning options in dealing with the problem. A major option was the initiation of local personal social service centers to service clients with non-psychiatric problems.

<p> Problem Statement: Military members and their family members who are part of the Global War on Terrorism have experienced deployments and war for over sixteen years and with the resulting toll on both the veteran and their intimate partner. As a result, higher levels of pathology, such as PTSD, Anxiety, and Depression have been experienced by this population. While research has studied the effect of combat on military members, very little research has addressed the effects on family members. Further, no research that has been found by this researcher, has addressed the concept of resonating of pathology between the combat veteran and their intimate partner. Resonating of Pathology, or resonating pathology, for the purposes of this study, is the combat veteran and the intimate partner demonstrating the same pathology at similar levels. </p><p> The Veteran&rsquo;s Healthcare Services have begun to treat couples together and may have also witnessed this phenomenon. Understanding the relationship between combat, veteran pathology, and intimate partner pathology will have implications for practitioners and researchers. Understanding the factors that related to this phenomenon will have implications for both clinicians and researchers. </p><p> Methods: Veterans and their intimate partners from across the United States, (<i>N</i> = 398), were asked to complete a survey through the internet. The couples were asked to complete the survey separately, however, within the same session so that their results could be tied together. The veterans were asked to complete the Combat Exposure Scale (CES), the PTSD Check List for the DSM 5 (PCL&ndash;5), the Patient Health Questionnaire 9 (PHQ&ndash;9), and the Generalized Anxiety Disorder 7 (GAD&ndash;7). The intimate partners were asked to complete the PCL&ndash;5, the PHQ&ndash;9, and the GAD&ndash;7. </p><p> Results: Results suggest that there was a moderate relationship between combat experience and pathology for combat veterans. While other factors were examined to determine what was included to predict pathology within the veteran, combat experience seemed to be the primary factor for predicting PTSD, Anxiety, and Depression in the combat veteran. </p><p> Results also suggested that there was a relationship between the pathology of combat veterans and the pathology their intimate partners, as measured in this research. Not only was there resonating, or resonating of pathology, within the couples, but this tended to occur within categories of pathology such as moderate and severe levels of Anxiety and Depression. While multiple factors such as frequency of communications, number of children, and types of communication were examined, combat experiences tended to be the primary factor for predicting pathology in both the veteran and the intimate partner. </p><p> Conclusion: Combat veterans and their intimate partners appear to be experiencing the phenomenon of resonating, or resonating, of pathology. Couple-analysis demonstrates that this phenomenon is being experienced as a couple and suggests that could have implications for future research and clinical practice. Demographic factors did not seem to influence the pathology for either the veteran or their partner. Combat experience does, however, seem to be a predictor for pathology in not only the veteran but also for the intimate partner as well. </p><p>

Following a rise in people 'speaking out' about their recovery and thus challenging traditional psychiatric ideas of chronicity, the recovery approach has become a central guiding vision within mental health services. This thesis comprises two parts. The first part applies a genealogical method to conduct a genealogical analysis of the recovery approach through exploration of UK policy within the last decade. This explores the conditions of possibility for its emergence in UK policy and mental health services and its growth. In the second part, a Foucauldian discourse analysis is used to analyse stories of recovery. Recovery stories are collected from organisational websites in the third sector and public sector. Subject positioning and power/knowledge implications are discussed in light of eleven discursive constructions: personal interpretation, person al responsibility, socioeconomic opportunity, self - management, an ongoing process, expertise and sharing stories, professional embodiment, fulfilment through work, living well without work, acceptance of illness and acceptance by others. These 'personal' testimonies might reflect wider discourses in the mental health system. The research shows the powerful interests at play under the discourse of recovery, and the promotion of particular 'truths' that this brings with it. Counter to this are smaller sites of resistance. Implications are discussed for clinical practice and further research.

Dementia and caregiving have received increasing research, clinical and political attention over the past forty years. However, such attention has been particularly focused on understanding the biomedical markers and interventions for dementia within majority populations. Little attention has been afforded to understanding alternative conceptualisations of dementia particularly from varying cultural and religious lens’. Existing research which has attempted to explore cultural understandings of dementia has done so in a homogenising manner and masked potential nuances between different cultures and religions. Research has also tended to shy away from exploring the impact of dementia upon spousal relationships. Given spouses (predominately wives) have been shown to deliver much of dementia caregiving this is an important area to illuminate, both for its clinical and moral implications. Taking in to account these two distinct gaps in knowledge, the present study aimed to explore the experiences and meanings of Punjabi Sikh wives in living with husbands who have a label of dementia. This study adopts a grounded theory methodology to explore the experiences of Punjabi Sikh wives living with husbands who have been given a diagnosis of dementia. Based on the accounts of eleven wives, a model was generated which revolved around the various processes associated with living with a husband with dementia. The emergent model consisted of three distinct, yet interacting theoretical processes, the wives’ responses, systemic responses and resistive responses. The wives’ responses centred around how they acknowledged, understood and ultimately lived with changes they experienced in their husbands and themselves. The systemic responses outlined the ways in which participants perceived their wider system to negate their responses through, ignoring, misunderstanding and denying the changes in their husbands. Finally, participants recounted their resistive responses against such systemic pressures. Based on the accounts of the participants, implications for clinical practice and future research are discussed.

<p> Conventional studies of veterans&rsquo; longitudinal mental health approach the topic through the post-traumatic stress disorder (PTSD) lens. This qualitative study shifts the focus from a PTSD psychosomatic-centric approach to a psycho-spiritual examination of the sequela of war in the veteran psyche: this approach has been named in recent literature, <i>moral injury</i>. Utilizing a methodological approach situated in the philological region of hermeneutics, a Reductionist dialectic was selected. This study illustrates that the quotidian war poetry read by this researcher exhibits psycho-spiritual moral injury. The relevant emergent themes of the study include: (a) the function of memory, of not-forgetting, (b) the psychological torment of psychic dismemberment, (c) the acknowledgment of suffering in archetypal salt, and (d) the not-forgetting component of psychic re-memberment necessary for resolving moral injury. Reorienting the focus from PTSD to moral injury, this study finds critical implications to helping war veterans with their sequela of war. For instance, conventional treatments for PTSD such as prolonged exposure (PE) or cognitive behavior therapy (CBT), while effective for treating the co-morbid symptoms of PTSD, do not address the profound insights which can be gleaned from re-examination of the phenomena in terms of moral injury. Most importantly, moral injury as a psycho-spiritual dilemma is something for which the veteran must embrace primacy in seeking resolution, working outside of the typical evidenced-based therapies. This comports with the alchemists who cautioned: Only by working with intense focus on self-transformation can the lapis philosophorum be achieved. </p><p>

The research is a qualitative exploration of perceptions of adolescent mental health and collaborative working concerning this. There are rising numbers of young people with difficulties relating to mental health and a need to develop closer links between services and schools has been identified (Department for Education, 2015b). However, there is not enough known about how agencies work together, despite their differences, in order to effectively support adolescent mental health. Part one utilised semi structured interviews to explore, in depth, how, educational psychologists (EPs), Children and Adolescent Mental Health Service (CAMHS) professionals and secondary school staff view adolescent mental health with regards to issues, practices, collaboration and how they view their own and other’s roles in supporting young people with mental health difficulties. Part two consisted of discussion groups guided by the use of vignettes, in order to explore the ways in which, EPs, CAMHS professionals and secondary school staff problem solve both in their own professional group and in a multi-agency group to explore the commonalities and differences in this. Findings from part one indicate that there are differences in perceptions of adolescent mental health across these three groups, with particular regards to their own and each other’s roles. Further to this findings indicate a lack of a shared understanding, characterised by a level of departmentalism. Findings from part two indicate that there are significant differences between the way in which schools, EPs and CAMHS professionals make sense of cases and in the way in which they work in their own professional group compared to how they work in multiagency groups. There were also indications that the differences that were found between groups in both part one and two, actually worked to increase the effectiveness of the approach in the multiagency groups, creating an enhanced and richer understanding of the problem given. Overall findings indicate that although on the surface thinking appears similar there are significant differences in thinking across EPs, CAMHS and schools in this area. Implications and recommendations for practice include; developing clarity and transparency regarding roles and fostering closer links by developing a shared understanding through opportunities for joint training.

ABSTRACT Introduction In Southern Botswana, an expected advantage of the decentralisation and integration of mental health services into general health services was the potential to allow for the district hospitals to manage a larger number of mentally ill patients thus decreasing the patient load of Lobatse Mental Hospital. However, the number of admissions to the referral hospital for the south of Botswana is increasing. The objective of the study was to describe the capacity of district hospitals to care for mentally ill patients in terms of the provision of relevant inpatient, outpatient and outreach mental health services as well as the availability of trained workers who agree with the principles of decentralisation of mental health services. Materials and methods This was a descriptive cross sectional study involving a self-administered questionnaire survey of key informants and health care providers conducted in five district hospitals in the south of Botswana. There were a total of 5 Chief Medical Officers, and 75 ward staff (12 doctors and 63 nurses) in the study. The quantitative data was entered using the Statistical Package for Social Scientists (SPSS version 13) and analyzed by this software. The qualitative data was coded and thematically analysed and reported. Results In all five hospitals, all the doctors and nurses had undergraduate training in psychiatry and were expected to manage mentally ill patients. There were eighteen health workers (1 doctor and 17 nurses) with postgraduate training in psychiatry/mental health.