The contemporary mental health profession is facing a crisis of recruitment and retention. Services provided are complex, practically and conceptually. On one hand, assessments and treatments are provided, but on the other, staff become responsible for the administration of coercive security discourses and arrangements. This complex phenomenon can leave mental health personnel vulnerable to criticisms in exactly how best they should discharge their duties within an occupational remit of duality. Working in the correct or most appropriate way is a constant challenge for staff as they must meet with approval from both managers and colleagues negotiating a path between formal rules and informal norms. This exploratory study was undertaken within a mental health NHS Trust in the North of England. It interviewed twenty participants from a range of areas of work, namely hospital wards, occupational therapy departments and the community setting. A narrative interviewing technique has been used to collect occupational histories and stories which have been used in an attempt to illuminate the contemporary issues facing clinical staff. Findings suggest that their contemporary care delivery is much more complex than previously known and that there is a diverse range of background and conceptual challenges which workers face in addition to their organisationally prescribed practical mandates of work. Six normative orders of work have emerged from data that has been collected; bureaucracy, risk management, competence, morality, physical environment and care versus control. Participant reflections on professional autonomy and responsibility shed light on the perceived rationality of policies and procedures and 'governance at a distance' taking place in response to bureaucratic and risk reduction imperatives. Indeed, such work is demanding and the management of a professional 'performance', and the self regulating and adaption of emotion have been seen to be an important dimension in the observation of occupational competence and work-based socialisation processes. Furthermore, personnel are engaged in a complex and fluid role duality where they must personally reconcile their role as care provider whilst also maintaining levels of physical security in a contemporary and technologically advanced healthcare environment. In this thesis, it is argued that these normative aspects of work typify the social nature of mental health work and, in addition, take place under the auspices of Goffmanesque theorisations of the 'total institution', 'mortification of self and 'social contamination'. These findings draw particular attention to an under acknowledged aspect of mental health based inquiry where the formal and informal spheres of work are observed to co-mingle within the environment of psychiatry. In doing so, questions arise over the rationality of some systems of work which 'shop-floor' staff are engaged within, yet, at times, have very little opportunity to shape as individual practitioners.

Mental health concerns are presented in primary care settings regularly, yet a majority of these issues go undetected or are misdiagnosed by primary care physicians (PCPs). This may be due to a lack of mental health training for PCPs during their medical education. Over time, medical school curricula have evolved to include mental health training in order to bridge this gap in the healthcare system and to more readily identify patients in need of mental health services. The current study investigated AMA-accredited medical school curricula from universities across the US and US territories (N = 170) who train physicians in primary care, family medicine, or other generalist tracks. Data on mental health training were collected from the public websites of each school. Results showed that most universities indicated at least some type of required mental health training (85.3%), which were either didactic or experiential in nature. Although this result appears encouraging, further examination reveals that this training was most often limited to only one 4-week psychology-related course and a 6-week psychiatry rotation. Overall, many universities indicated at least one required course (N = 95), and most universities reported a required psychiatry rotation (N = 135). Moreover, only 12.9% of the sample reported having at least both didactic and experiential training required. The implications of this are varied. First, PCPs often have only a short amount of time with their patients, reducing their ability to fully assess both medical and mental health. A lack of exposure to mental health needs may lead to missed opportunities for intervention and improvement in patient health. Second, it is important for mental health professionals to work closely with PCPs in primary healthcare settings in order to improve rates for detection and treatment of mental health problems. In addition to improved patient outcomes, having mental health professionals integrate within primary healthcare can serve to decrease the stigma associated with seeking mental health treatment, as well as reduce long-term healthcare costs. This can also increase access to care for those individuals who are unable to see a mental healthcare provider, especially in rural areas. Finally, overall health may improve in relation to better mental healthcare, since medical and mental health have been consistently shown to significantly influence one another.

Aims: Eating disorder recovery is often supported by caregivers and mental health professionals. This research portfolio focuses on the experiences of supporting someone with an eating disorder from the perspective of the caregivers and also mental health professionals. The aims of this research portfolio are: Firstly, to systematically review the published qualitative literature relating to the experiences of caregivers supporting someone during eating disorder treatment; and secondly, to investigate the factors which may contribute to burnout, the factors which may protect against burnout and ways of managing work related stress for healthcare professionals who work in an eating disorder service. Method: A systematic review and meta-synthesis of caregiver experiences with eating disorder treatment was conducted. Searches identified 1927 studies of which 12 met the inclusion criteria for the study. Quality assessment revealed a number of strengths and also some limitations of the studies. For the research study ten healthcare professionals were interviewed on their experiences of supporting people with an eating disorder and ways of managing work related stress/burnout in this role. Interpretative Phenomenological Analysis was used to analyse the data. Results: Five major themes were identified from the systematic review: “access to treatment”, “key features of treatment”, “support for the caregiver”, “encounters with health care professionals” and “the future – hopes and fears”. The research study identified seven super-ordinate themes: “Dealing with Client Physical Health Risks”, “Working to Different Goals from the Client”, “Awareness of own Eating Patterns”, “Personal Accomplishment”, “Working Together as a Team”, “Working with Caregivers” and “Ways of Managing Work Related Stress”. Conclusions: The systematic review highlighted a number of clinical implications including the importance to caregivers of early intervention, the provision of practical, tailored information, support for the caregiver, the need for caregivers and professionals to work collaboratively and the importance of instilling hope in caregivers. The research study highlights potential contributors to burnout in eating disorder services as well as positive or protective factors to burnout. It also highlights ways of managing burnout through ensuring a work-life balance, utilising self-care strategies, self-reflection and realising recovery is not 'all or nothing'.

Thesis advisor: Janet E. Helms / Historically, psychological theory and mental health researchers have viewed sex work as inherently harmful to sex workers and capable of producing negative mental and physical health effects (Sprankle et al., 2018). Moreover, research focused on clinicians’ expectations for sex workers in therapy has not specifically examined clinicians’ attitudes toward sex workers or sex work as separate concepts (Benoit et al., 2015; Koken, 2011; Ma et al., 2017). In addition, mental health professionals may not view sex work as legitimate work because of the virtual lack of evidence-based theoretical frameworks for guiding therapy for sex workers, and, therefore, may use prostitution stigma as a substitute for theory (Krumrei-Mancuso, 2017; Williamson & Cluse-Tolar, 2002). The present study investigated the extent to which mental health professionals’ expectations of sex work and sex workers were related to prostitution stigma and their perceptions of sex workers’ overall mental health and evaluations of sex work as decent work. In particular, the study investigated the extent to which mental health professionals stigmatized the work of sex workers. Mental health professionals (N = 201) read a clinical vignette and completed an online survey containing a demographic information sheet, the Attitudes Toward Prostitutes and Prostitution Scale (Levin & Peled, 2011); (c) the Decent Work Scale (Duffy et al., 2017), (d) the Hospital Anxiety and Depression Scale (Zigmond & Snaith, 1986), and (e) the PTSD-8 (Hansen et al., 2010). Results from multivariate multiple regression analyses supported that when mental health professionals held higher levels of stigma towards sex work and sex workers, they may diagnose the client with higher levels of PTSD symptoms. Further, the results supported that endorsement of a feminist orientation moderated the relationship between sex work stigma and diagnosis clients’ PTSD avoidance symptoms. The discussion included methodological limitations and implications for research and practice. / Thesis (PhD) — Boston College, 2020. / Submitted to: Boston College. Lynch School of Education. / Discipline: Counseling, Developmental and Educational Psychology.

Intimate partner violence (IPV), including physical, psychological, and sexual violence towards a partner, is a human rights violation that is associated with the development of a multitude of short- and long-term physical and mental health problems (WHO, 2013). IPV survivors are at greater risk of developing mood, anxiety, and trauma- and stressor-related disorders (García-Moreno et al., 2005). Public health guidelines recommend screening for IPV in mental health settings (WHO, 2013). However, most mental health practitioners do not routinely assess for IPV in their practice (Howard et al., 2010). Lack of training in how to assess for and respond to IPV has been identified as an important barrier for IPV assessment in mental health settings (Trevillion et al., 2016). IPV-related training has been linked to positive outcomes for clinicians, including higher ratings of perceived knowledge and confidence in addressing IPV (Forsdike et al., 2019). Yet, studies suggest that approximately one quarter to one half of mental health professionals have never received IPV-related training (Murray et al., 2016; Nyame et al., 2013). To address this gap, the WHO advanced a series of evidence-based training recommendations (WHO, 2013). At present, there is a dearth of research exploring the degree to which global mental health providers’ experiences of training resemble WHO guidelines. Furthermore, few studies have investigated factors that contribute to clinicians’ likelihood of participating in IPV-related training, and reasons for obtaining training are not well understood. There has also been no previous research into the relationship between mental health professionals’ experiences of training and their accuracy in correctly identifying IPV. The present thesis, consisting of two studies, sought to assess global mental health providers’ IPV-related training experiences, including factors that influence the probability of participating in training and the relationship between training and diagnostic accuracy. In study 1, mental health professionals’ IPV-related training experiences were surveyed, and factors that may contribute to the likelihood of participating in training were explored (e.g., IPV prevalence, norms, and legislation, and professional experience with IPV). The relationship between IPV-related training and knowledge and experience of relationship problems was also examined; 321 specialized mental health professionals (psychologists and psychiatrists) from 24 countries participated in an online survey. Participants responded to a series of questions regarding the content, duration, and frequency of their IPV-related training based on WHO recommendations, and rated their level of knowledge and experience with relationship problems. Descriptive analyses showed that nearly half of participants (46.9%) had never received IPV-related training. Approximately half of those who received training (49.4%) indicated that their training followed WHO recommendations. Logistic regressions revealed that participants who were from countries with relatively better implemented laws addressing IPV and participants who encountered IPV more often in clinical practice were more likely to have received training. Furthermore, participants who received training were more likely than those without training to report higher knowledge and experience of relationship problems. Findings highlight global challenges with regards to IPV-related training. They suggest that clinicians’ likelihood of participating in training is related to their clinical contact with IPV and the institutional context in which they practice. Study 2 investigated the relationship between IPV-related training and clinicians’ diagnostic accuracy in the context of relationship problems, using the same sample as study 1. Chi-square analyses evaluated relationships between IPV-related training and clinicians’ performance while assessing for clinically significant relationship problems (RPM) in case-controlled vignettes across two study conditions: RPM present (i.e., when the task was to correctly identify RPM) and RPM absent (i.e., when the task was to correctly identify that there was no RPM; normative relationship problems were presented). Results showed that participants who received IPV-related training were more likely to perform better than those without training in the RPM present condition, but not in the RPM absent condition. In the RPM present condition, participants were more likely to respond correctly when their training was more recent and more closely resembled WHO recommendations for training. In the RPM absent condition, a similar percentage of participants with training (60-78%) and without training (45-76%) misclassified normative relationship problems as clinically significant RPM. Overall, findings suggest that IPV-related training is related to improved diagnostic accuracy in the context of relationship problems. WHO recommendations for training are supported.

There are extensive amounts of psychological research that highlight the needs and experiences of racial ethnic minority populations in general and more specifically minority sexual identities and genders, also referred to as non-heteronormative populations (Alexeyeff & Besnier, 2014). However, there continues to be a lack of representation in the research of Polynesians and an even greater lack of representation of non-heteronormative Polynesians and their experiences (Allen et al., 2011). Māhū, a population of native Hawaiians who identify as non-heteronormative or third gender, are almost completely absent from scholarly work. This study examines the experience of self-identified māhū and how mental health professionals can support them. Qualitative interviews of six Native Hawaiians who identify as māhū were completed. Hermeneutic principles guided the interpretation and analysis of the interviews. Analysis of the interviews produced three main themes comprising seven subthemes. Primary themes included (a) the definition of māhū has changed over time and can be dependent on personal views through a cultural lens (b) the Hawaiian culture provides safety and protection for those who identify as māhū and (c) māhū have suggestions regarding the ways in which mental health practitioners (both Hawaiian and non-Hawaiian) can serve this population.

A literatura científica biomédica tem apontado que pessoas em intenso sofrimento psíquico encontram no consumo de drogas um modo de lidar com esse sofrimento. Assim, o consumo de drogas tem alta prevalência entre pessoas que apresentam algum quadro clínico psiquiátrico e este aparece muitas vezes como uma estratégia de lidar com os sintomas. Em contrapartida, este consumo aparece descrito como causador de pior prognóstico, colocando o usuário em situações de maior vulnerabilidade. Esta pesquisa teve como objetivo compreender a perspectiva de profissionais de um serviço de saúde mental sobre o consumo de drogas por pessoas em tratamento psiquiátrico. O estudo tem caráter qualitativo, descritivo e exploratório e foi aprovado por Comitê de Ética em Pesquisa. Foram realizadas entrevistas semi-estruturadas com 16 profissionais de um Centro de Atenção Psicossocial III (CAPS) do interior de São Paulo. Para a análise dos dados, considerou-se o papel da linguagem como construtora da realidade. Foi realizada análise de conteúdo temática, sendo construídas quatro categorias: Especificidades do contexto; O fenômeno da droga; O uso de drogas durante o tratamento psiquiátrico; e Fronteira entre a saúde mental e o uso de drogas. Os profissionais destacaram a presença do uso de drogas em pacientes do serviço, apesar da disposição da rede local em dividir o cuidado às duas demandas. Os participantes compreendiam que o sofrimento era o principal motivador para o uso de drogas nesta população. A identificação do consumo foi tema relevante para os profissionais não havendo, porém, protocolo específico para isto. O vínculo estabelecido com o paciente foi apontado como principal estratégia para identificação. O uso de drogas em pacientes do CAPS foi relatado como fomentando preconceito por parte de alguns profissionais, influenciados pelo discurso moral na construção de sentidos sobre os usuários de drogas. O tabaco não era descrito como uma droga, sendo algumas vezes compreendido inclusive como parte do tratamento no CAPS. Os discursos moral e biomédico construindo sentidos sobre o uso de drogas concorrem nas falas dos profissionais para explicar o fenômeno da droga. Da mesma forma, estratégias de cuidado dividem-se entre aquelas voltadas à redução de danos ou em busca da abstinência, sendo mais prevalentes as voltadas à abstinência. O papel central atribuído ao medicamento no tratamento suscitou questionamentos a respeito do lugar ocupado por este como droga ou como tratamento. Ações que proporcionem aos profissionais mais espaços para construção de sentidos a respeito do tema, seja de mais ajuda do que apenas uma divisão arbitrária (e aparentemente impossível de ser implementada na prática) entre as duas demandas. O momento das entrevistas foi uma oportunidade para a construção destes sentidos. / Biomedical scientific literature has showed that people under severe mental suffering conditions usually consume drugs as a coping strategy. Therefore, the drug consumption has high prevalence in psychiatric patients and is frequently described as a coping strategy to deal with theirs symptoms. On the other hand, this drug consumption is described as causing poorer prognosis, including putting the users in vulnerable situations. This research aimed to understand the perspective of professionals from a mental health service about the patients drug use during psychiatric treatment. This study is qualitative, descriptive and exploratory and was approved by the Research Ethics Committee. Sixteen semi-structured interviews were conducted with professionals of a Psychosocial Care Center (CAPS- 3) in a medium city in the countryside of São Paulo state. For data analysis, we consider the role of language as a constructor of reality. A thematic content analysis was performed, resulting in four categories: Particularities of the context; the drug phenomena; drug use during psychiatric treatment; and the boundaries between mental health and drug use. The professionals highlighted a perceived presence of drug use in patients, despite of the local network willingness in offering care for both demands. Participants understood that suffering was the main motivator for the use of drugs in this population. Identifying the drug consumption was a relevant issue for professionals, however, there was no specific protocol to address this issue. Establishing bonding with the patient was pointed out as the main strategy for drug use identification. The drug use in CAPS patients was reported as contributing to the stigma by some professionals, mostly influenced by the moral discourse on meaning making attributed to drug users. Tobacco was not described as a drug, and sometimes was even understood as part of treatment in CAPS. Both moral and biomedical discourses constructed meanings about the use of drugs compete in the professionals´ speeches to explain the drug phenomena. Similarly, care strategies were divided between those aiming to reduce damage or seeking withdrawal, and the most prevalent ones were those focused on drug abstinence. The central role assigned to medication in the treatment raised questions about the place occupied by the medication as drug or as a treatment tool. Actions providing professionals more opportunities for meaning making about this subject can be more helpful than the currently arbitrary division (and seemingly impossible to implement in practice) for addressing both demands. The interviews offered the professionals an opportunity for the construction of these meanings and senses.

Mental health professionals are at high risk of experiencing work-related stress and burnout due to the challenging and highly emotive environments in which they work. This may lead to a range of physical and psychological symptomology which may affect them and also the quality of care provided to patients. This thesis presents a systematic review of the literature regarding the effectiveness of workplace interventions designed to reduce or prevent work-related stress and burnout when compared to no intervention or alternative interventions for mental health professionals working in adult mental health settings. The thesis then presents an empirical study, using the Job Demands-Resources model of burnout. Personal resources (styles of coping, self-compassion, cognitive fusion and valued living) were tested as (a) moderators of the relationship between job demands and exhaustion and (b) mediators of the relationship between job resources and disengagement within a sample of mental health nurses. Methods: A systematic review and meta-analysis of randomised controlled trials (RCTs), non-randomised controlled trials (N-RCTs), controlled before and after (CBA) and interrupted time series workplace (ITS) interventions were conducted. Primary outcomes were occupational stress and burnout. An assessment of strength of evidence was made using GRADE criteria. A quantitative cross-sectional survey of 214 mental health nurses was used to examine the role of: self-compassion, cognitive fusion, engaged living and coping in the development of burnout. Results Thirteen eligible studies were identified comprising 11 RCTs and 2 CBA’s. Overall, there was no beneficial effect of organisational and relaxations intervention was found for reducing burnout or work-related stress. There are some promising findings for the effectiveness of staff training and psychosocial interventions in the short and medium-term. Overall, the quality of studies was low due to risk of bias and a lack of precision due to low number of participants in each study. In the empirical paper, the moderating role of personal resources in the development of exhaustion was not supported. By contrast the mediating role of personal resource between job resources and disengagement was supported. Discussion At present, there is limited evidence for the effectiveness of workplace interventions. This is influenced by the low number of intervention studies and the quality of interventions to date for mental health professionals. There is preliminary evidence for the potential for third-wave cognitive behavioural interventions such as acceptance commitment therapy in reducing disengagement in mental health nurses. Interventions to reduce exhaustion need to include strategies to reduce job demands.

The purpose of this study was to explore the ways mental health providers continue developing and strengthening their skills to have a great impact and overall beneficial effect on the families they are supporting. An interview questionnaire was created to explore participants’ experiences working with families and their children to generate an understanding of their current experiences in the mental health field. Through this study we have learned that the mental health providers are aware of the traits that they have to possess in order to provide the best care for the clients and their families. The participants in the study stay motivated by seeing the positive client outcomes and receiving feedback from their clients and families. They apply new research, go to workshops, are change agents, seek supervision, and network with other professionals for support. The qualitative design was used in order to collect the data from the participants. The study sample consisted of twelve Mental Health Providers. One‑on‑one interviews were conducted, a consent was obtained per participant, and transcribed for thematic analysis. Based on participant narratives, a key finding in this study found that there are barriers to the mental health professionals, due to cost, time restraints, lack of peer support, and supervision. A key finding was the motivation of the Mental Health Professionals to continue providing services to the families was high due to the feedback and positive client outcomes. Future research is needed to explore additional ways to better support the Mental Health Provider in the mental health field.

Difficulties experienced at work can cause feelings of burnout that become prolonged and intensified without acts of self-care. The intense nature of mental health workers' jobs may make them, more vulnerable to burnout than other professionals. Because mental health professionals' mental and emotional wellness can significantly affect their work, adequate self-care is critical to both their well-being and that of their clients. Previous researchers have investigated the self-care behaviors of mental health professionals, but little was known about how gender affected the use of these behaviors in burnout prevention among mental health professionals. The purpose of this quantitative study was to examine the relationship between self-care behaviors and burnout among a sample of 325 mental health professionals working in New York. Differences in the ways male and female mental health professionals practiced self-care behaviors were also investigated. Burnout and gender role theories were used as the theoretical framework. Study instruments included the MBI-HSS and the Brief COPE. Multiple regression analysis and independent sample t tests were employed to analyze survey data. Analysis revealed levels of self-care behaviors were significantly predictive of depersonalization, emotional exhaustion, and reduced personal accomplishment. Gender differences in self-care behaviors were indicated for substance use, self-blame, depersonalization, emotional exhaustion, and reduced personal accomplishment. Since burnout is a significant problem for many mental health professionals, understanding how self-care affects burnout is critical to promoting behavioral changes among these professionals. Self-care among mental health professionals may improve their professional and personal lives.