Section A reviews the clinical and risk implications of dual diagnosis along with the treatment context. The value of gathering firsthand accounts of service users to inform the planning and delivery of healthcare is touched on. The second part of the paper centres on theories of motivation and how they might be applied to help explain low rates of dual diagnosis treatment uptake and engagement. Finally, gaps in the literature are highlighted with recommendations for further research. Section B There is an emerging evidence base to support the use of integrated approaches that treat co-existing mental health and substance use disorders simultaneously. However, low rates of treatment uptake and engagement remain a concern. To address this, it would seem important to understand dual diagnosis treatment motivation and engagement, an area that has received little attention from the research community. The aim of this study was to explore service users’ and clinicians' understandings of how treatment motivation and its relationship with treatment engagement relate specifically to people with dual diagnosis. Transcripts from semi-structured interviews with four service users and four clinicians were analysed using narrative methodology. The study suggests that the factors underpinning treatment motivation and engagement among people viewed as having dual diagnosis are similar to those thought to be associated with addictions and mental health disorders generally although their relative influence and interaction effect might be different. It is suggested that negative perceptions of services, difficulties with trust, and therapeutic relationship are particularly important issues among dual diagnosis populations. Clinical and theoretical implications of the study are discussed in relation to the literature as well as recommendations for future research. Section C: Critical Appraisal. This paper provides a general overview of narrative research, including strengths and limitations as they relate to this study. With reference to the literature, clinical and theoretical implications are elaborated along with recommendations for future research. The author’s critical self-reflections regarding the process of initiating, carrying out and completing the study are highlighted. Following this, there is a section on the ethical considerations of the study. Finally, the measures taken to ensure the quality of the study and maximise internal consistency are presented.

A literature review in Section A reviews the conceptual and empirical literature with regard to the usefulness and challenges inherent in applying recovery approaches in secure services, with a particular focus on women with a diagnosis of personality disorder. Section B. Background: Some studies have suggested that recovery approaches could be facilitated in secure mental health services despite a number of inherent tensions. However, none have explored if this applies to women with a diagnosis of personality disorder in secure care. A group whose needs have historically been overlooked, and can present with complex care-seeking behaviours. Aims. To explore how staff working with these women understand and apply recovery approaches in secure units. Method. Eleven multidisciplinary staff members working in a medium-secure unit in the UK participated in in-depth interviews. The data was analysed using grounded theory. Results. A preliminary model was generated, which comprised of five categories: secure base, balancing tensions, therapeutic relationship, initiating recovery, and nurturing recovery. These appeared to interact and influence each other throughout the recovery process. Conclusions. Staff are required to continually balance a number of tensions and as such they need a secure base from which to explore the service-users’ unique recovery process through the medium of collaborative therapeutic relationships. Staff sharing a recovery ethos that is embedded in the culture of a conducive environment, and is supported by supervision and teamwork, fosters the actualisation of recovery principles of empowerment, identity formation, and hope. Section C provides a critical appraisal of the study as well as a personal reflection on what was learnt through the process of the conducting the study.

The thesis looks firstly at creativity and the creative process, approaching the subject from a whole range of different viewpoints, such as the psychological, philosophical, biographical and anthropological angles. Following from this there is an exploration of the ways in which creativity way be awakened and unfolded. Special attention is given to the conditions and situations that are likely to encourage creative development and to the blocks and difficulties that inhibit its expression. Particular reference is made, on the one hand, to art education and to the art, leisure, and teaching student, and on the other hand, to art therapy and the psychiatric patient. The themes of the individual and the community are explored in a complementary way in the final two chapters. The thesis emphasizes the viewpoint of the student and the patient, but since these people do not exist in a vacuum, this involves looking also at the teacher, the therapist and society. With reference to the psychiatric field, other specific questions arise, for example: How may creative opportunities assist the healing process? What are the reciprocal influences of art and mental illness? Throughout the thesis the term 'art' is used in the visual sense, but references are made to creativity in other fields where parallel conclusions apply. The emphasis has been placed on the adult, but the subject of 'Creativity and the Teaching Student' involves some references to child art and 'Creativity and the Community' involves all ages.

This is a study of military psychiatry in the Second World War. Focusing on the British Army, it recounts how the military came to employ psychiatrists to revise recruitment procedures and to treat psychiatric casualties. The research has shown that psychiatry was a valued specialty and that psychiatrists were given considerable power and independence. For example, psychiatrists reformed personnel selection and placed intelligence testing at the centre of the military selection of personnel. Psychiatrists argued that by eliminating the 'dull and backward' the tests would help improve efficiency, hygiene, discipline and morale, reduce psychiatric casualties and establish that the Army was run in a meritocratic way. However, it is probable that intelligence testing made it less likely that working-class men would receive commissions. Still, the Army had no consistent military doctrine about what the psychiatrists should be aiming for -to return as many psychiatric casualties to combatant duties as was possible or to discharge men who had found it impossible to adapt to military life. In the initial stages of the war, the majority of casualties were treated in civilian hospitals in Britain, where most were discharged. This was partly because the majority were regarded as constitutional neurotics. When psychiatrists treated soldiers near the front line most were retained in some capacity. The decision on whether to evacuate patients was influenced by multiple factors including the patients' military experience and the doctors' commitment to treatment or selection. Back in Britain, service patients were increasingly more likely to be treated in military hospitals such as Northfield -famous for the 'Northfield experiments'. These provided an alternative model of military psychiatry in which psychiatric intervention refocused away from individuals and their histories and onto social relationships, and where the psychiatrists' values were realigned with the military rather than with civilian general medicine.

Section A is a review of the literature on Community Treatment Orders (CTOs) in the context of their recent introduction in England and Wales. A critical review of the literature in relation to CTOs’ effectiveness is presented, followed by available evidence on service users’ perceptions of CTOs. Consideration of ethical issues that surround compulsory community treatment is also offered. The review highlights gaps in the literature regarding CTOs’ impact on service users’ interpersonal relationships and on how service users who are based in the UK perceive CTOs. Further qualitative research is recommended. Section B describes a qualitative study investigating male service users’ perceptions of their CTOs and the impact of this intervention on their interpersonal relationships. Grounded Theory was used to analyse interview data from 15 participants. Five higher-order categories and 15 categories were identified which contributed to a preliminary model of how service users develop their CTO perceptions. The factors that appeared to influence participants’ perceptions of their CTOs were: i) past and present social living conditions, ii) view of self in relation to mental health, iii) view of the CTO service, i.e. view of medication and mental health professionals. Finally, the model showed that CTOs had a limited or no impact on participants’ views of their relationships with their families, friends, partners and local communities. Results are discussed with reference to potentially relevant psychological theories. Clinical implications, including raising professionals’ awareness about the impact of coercion on the therapeutic relationship, and directions for future research are also presented. Section C is a critical appraisal of the study presented in Section B. It provides reflective responses to four questions in relation to the following areas: research skills acquired through conducting the study; what improvements could be made if repeating the study; clinical implications; and directions for future research.

Literature suggests that there are a growing number of ‘mental health professionals’ speaking out about their own experiences of using mental health services. Research suggests that these professionals face dilemmas when constructing their identity because they are drawing on two identities that are viewed as fundamentally different, i.e. ‘mental health professionals’ as powerful and ‘mental health service users’ as powerless. This study aimed to explore how ‘mental health professionals’ who are/have been ‘mental health service users’ construct their identity using a social constructionist epistemology, which views identity as fluid and continuously renegotiated in social contexts (Davies & Harré, 1990; Potter & Wetherell, 1987). Ten participants who self-identified as ‘mental health professionals’ who are/have been ‘mental health service users’ volunteered to take part. Interviews were transcribed and analysed using discourse analysis. Participants constructed their identity in a variety of ways, including as separate identities, i.e. a ‘professional identity’ and a ‘patient/mental health service user identity’ constructions, switching between the two in different contexts, therefore developing an ‘un-integrated identity’. Participants also developed an ‘integrated identity’ construction in some professional contexts. These results are discussed and implications for clinical practice and future research are explored.

Research shows that the integration of physical and mental healthcare in paediatric settings is beneficial in terms of clinical and cost effectiveness (Kahana, Drotar, & Frazier, 2008; Douglas & Benson 2008, Griffin & Christie, 2008). Due to the high rates of mental health problems within this population, several studies have shown that referral to paediatric psychology should be increased (e.g. Wagner & Smith, 2007). However, there are few studies investigating factors influencing healthcare professionals’ referral behaviour. The current study used theory of planned behaviour (Ajzen, 1988; 1991) to develop a questionnaire which explores factors influencing the referral of children and families to paediatric psychology. Psychometric properties of the questionnaire were examined. Findings indicate that the questionnaire holds good reliability and validity and that the main constructs of theory of planned behaviour are useful in predicting intention to refer to paediatric psychology. Specific beliefs about referral were also shown to influence intention to refer. Findings that individual referrer factors such as attitudes and beliefs can impact healthcare professionals’ referral behaviour indicates that multidisciplinary interventions and inter-professional education relating to the psychological aspects of illness are required. Recommendations for future research are discussed.

There is a growing research interest into investigating why NICE (National Institute for Health and Care Excellence) guidelines are not consistently followed in UK mental health services. The current study utilised grounded theory methodology to investigate clinical psychologists’ use of NICE guidelines. Eleven clinical psychologists working in routine practice in the NHS were interviewed. A theoretical framework was produced conceptualising the participants’ beliefs, decision making processes and clinical practices. The overall emerging theme was “considering NICE guidelines to have benefits but to be fraught with dangers”. Participants were concerned that guidelines can create an unhelpful illusion of neatness. They managed the tension between the helpful and unhelpful aspects of guidelines by relating to them in a flexible manner. The participants reported drawing on specialist skills such as idiosyncratic formulation and integration. However, as a result of pressure, and also the rewards that follow from being seen to comply with NICE guidelines, they tended to practice in ways that prevent these skills from being recognised. This led to fears that their professional identity was threatened, which impacted upon perceptions of the guidelines. This is the first theoretical framework that attempts to explain why NICE guidelines are not consistently utilised in UK mental health services. Attention is drawn to the proposed benefits and limitations of guidelines and how these are managed. This study highlights the importance of clinical psychologists articulating and advertising their specialist skills. The findings are integrated with existing theory and research, and clinical and research implications are presented.

This study used Interpretative Phenomenological Analysis (IPA) to investigate the experiences of African immigrant mothers living in the UK with a child diagnosed with an Autism Spectrum Disorder (ASD). Six mothers took part in one-off semi-structured interviews. The results indicated five themes: caring for a child we didn’t expect, the pain of stigma and rejection, making sense of our child’s difficulties and diagnosis, negotiating conflicting belief systems and faith as “key”. Many aspects of the mothers’ experiences appear related to their position as immigrants from cultures with very different belief systems regarding child development and disability. Stigma, blame and social isolation appeared to compound the difficulties they experienced. Conflicts between African cultural beliefs and a western, medical understanding of ASD, appeared to create a feeling of cognitive dissonance for the mothers. The strategies they used to negotiate this appear to map onto Berry’s (2005) acculturation strategies, suggesting the experience of having a child with ASD impacts upon the acculturation process. Implications for clinical practice and policy are discussed, including the importance of raising awareness of ASD among immigrant communities, supporting parents to integrate conflicting belief systems and facilitating the development of peer-support groups within minority communities.

The transition to parenthood involves psychological and social adjustments for men and women, with evidence of possible declines in mental health and close relationships. This thesis examined the relationship between parents' mental health (depression, anxiety, PTSD), the parent-infant relationship, couple's relationship and infant development. The five articles in this thesis were part of a prospective multi-method investigation of first-time parents. Parents completed questionnaires in late pregnancy, 3 months and 15 months postpartum (Article 3 & 4), detailed observations of parent-infant interactions 3 months postpartum (CARE-index; Article 4), in-depth interviews (Birmingham Interview of Maternal Mental Health) 5 months postpartum (Article 1 and 2), and infant development (Bayley Scales III) was examined at 17 months postpartum (Article 5). Results showed that a proportion of men and women suffered from poor mental health. Mental health problems were more common in pregnancy than postpartum. Women experienced worse mental health than men, but few other gender or within couple differences were found (Articles 2 & 3). A relatively high rate of poor parent-infant interactions was found (Article 4) and many parents reported feelings of anger towards their infant (Articles 1 & 2). Parents' perceptions of their infant's characteristics were important for the parent-infant relationship (Article 3) and infant's cognitive, language and motor development (Article 5). Additionally, women's postpartum PTSD and prenatal depression were associated with poor infant development (Article 5). Men's mental health was associated with poor interaction with their infants (Article 4), negative perceptions of the father-infant and couple's relationship (Article 3). These findings suggest that both men and women should be included in early mental health and family relationship interventions. However, the small low-risk sample limits generalizability of results. Future research would benefit from exploring the links between parental, infant and family relationship variables further, over time in larger more representative samples.