Offender characteristics are considered important in the prediction of future risk of re-offending and response to treatment. The psychiatric classification of offenders can therefore be an important variable influencing decision making. Although the relationship between personality disorder and offending is established in the literature, the relationship is complex. Recidivism of any type, particularly serious further offending that is violent or sexual in nature, has far reaching implications on the victims, the perpetrator, the criminal justice system and wider society. The identification and management of individuals with personality disorder is a priority for both mental health professionals and the criminal justice system. The overall aim of this thesis is to examine the relationship between personality disorder and further offending in adult forensic populations (prison and probation). Chapter one presents a general introduction to the topic. Chapter two presents a literature review following a systematic approach and poses the question: Is personality disorder associated with recidivism? The findings are generally supportive of the view that some personality disorders are associated with a greater likelihood of recidivism. The limited good quality research available indicates the need for further research. Chapter three presents a critique of a screening tool for personality disorder, the Standardised Assessment of Personality: Abbreviated Scale (SAPAS). It highlights that despite some shortcomings, the SAPAS is a simple, brief and useful first-stage screening tool for personality disorder that possesses adequate psychometric properties. It is proposed that a combined screening approach, using the SAPAS and Offender Assessment System Personality Disorder (OASys PD) screen, is necessary to improve the detection of antisocial cases, particularly in forensic populations. In Chapter four an exploratory cohort study examines personality disorder in a UK sample of offenders, that have committed a further serious sexual or violent offence, whilst under the active supervision of the London Probation Trust. The study investigated the prevalence and type of personality disorders using the SAPAS and OASys PD screen. Comparisons were made between serious further offence (SFO) offenders with and without personality disorder, and within the SFO group by type of SFO (violent or sexual). The SAPAS and OASys PD screen were also explored in relation to their ability to predict group membership (SFO vs. non-SFO). The study identified that personality disorder prevalence was higher in SFO offenders, particularly antisocial traits, and that the OASys PD and OASys risk of harm (RoH) classification are significant variables for predicting group membership. The study has added to the knowledge base and understanding of SFO offenders and has implications for the practice of Offender Managers/Supervisors in UK prisons and probation units. The findings support the efficacy of the screening approach used in the Offender Personality Disorder Pathway (DOH/NOMS, 2012), London Pathways Project. A single case study is presented in Chapter five which evaluates the utility of psychological therapy with a man on Licence, presenting with traits of antisocial personality disorder. The difficulties associated with working with this client group are considered. In Chapter six a discussion of the work presented concludes the thesis. Overall, the thesis identifies some interesting findings in relation to the prevalence of personality disorder in SFO offenders and the utility of some key tools used in the assessment of offenders in probation/prison, and how these could be used in relation to risk management.

The aims of this study were to explore the nature of comorbid Tourette syndrome and attention-deficit/hyperactivity disorder (TS+ADHD), in particular whether additive, independent or symptomatic phenocopy models of comorbidity can explain the co-occurrence of these two conditions, and to investigate the impact of comorbid ADHD symptoms on cognitive functions related to the control of tic symptoms in young people with TS. Electrophysiological activity and behavioural performance were measured during three cognitive tasks designed to assess goal-directed reinforcement learning, habit-based reinforcement learning, and cognitive control and were compared between young people with TS, ADHD, TS+ADHD and unaffected young people aged 9 to 17 years. The extent to which severity of tics, ADHD and comorbid oppositional-defiant disorder (ODD) symptoms predicted behavioural and electrophysiological correlates of reinforcement learning and cognitive control was also examined. The TS+ADHD and ADHD groups were impaired in goal-directed learning and modification of new behaviours using reinforcement feedback. ADHD symptoms were negatively associated with adaptive changes in the feedback-related negativity (FRN) ERP that were indicative of compensatory strategies employed to improve learning in the TS+ADHD group. In contrast, the TS+ADHD and ADHD groups showed intact habit-learning performance compared with unaffected controls. The TS+ADHD and ADHD groups were impaired in the ability to withhold inappropriate responses to Nogo stimuli during the Go/Nogo cognitive control task compared with TS and controls. Both ADHD groups also showed greater intra-individual variability than TS and controls. Concurrently, the TS+ADHD group were enhanced in the ability to withhold inappropriate Nogo responses and showed enhancement of the error-related negativity (ERN) ERP relative to the ADHD group. The TS group exhibited enhanced ERN ERPs and post-error slowing, a measure of the ability to adjust performance following errors. These findings are consistent with an additive, but interactive, model of comorbidity, and indicate that comorbid ADHD symptoms introduce impairments in young people with TS that will negatively impact upon the ability to control tics.

Previous research into communication between care workers and care home residents with dementia has not utilised the experience of healthcare professionals who work with people with dementia on a daily basis. Previous research mostly consists of observational studies and the assessment of care worker training programmes. No study has yet attempted to establish the efficacy of isolated communication strategies, recommended by healthcare professionals, and administered by care workers within a residential care setting. This thesis first presents the thematic analysis of 16 semi-structured interviews with healthcare professionals who have experience of working with people with dementia. The participants discuss the personal characteristics required in a healthcare professional to facilitate communication, the verbal and non-verbal strategies they use and the organisational factors which can impact the delivery of communication as desired. Two of the recommended strategies, alpha commands and pacing an interaction, were then analysed experimentally. Three care worker-resident dyads were videoed during morning care routines in an ABAC design. Resident communicative behaviour was measured using an amended version of the Positive Response Schedule (PRS) (Perrin, 1997), the Resistiveness to Care Scale (RTC-DAT) (Mahoney et al., 1999) and compliance. It was found that the conditions containing a significantly higher percentage of alpha commands produced significantly higher PRS scores. This was shown within each dyad and across the dyads (r=+0.65, p<0.05). The results for the pacing condition were inconclusive as the residents responded quickly after instructions were given. This exploratory study found a significant effect of alpha commands on the communicative behaviour of care home residents with dementia. The implications for future research and care worker training are discussed.

This thesis explored service-users' experience of developing self-compassion using Compassionate Mind Training (CMT). A systematic review of the existing literature on compassion and compassion-based interventions identified the primarily focused of research has been on symptom outcome measures utilizing quantitative approaches. No study that explored the experiences and processes of developing self-compassion was identified. The aims and epistemological stance of the researcher led to a qualitative methodology being used. Once ethical approval was gained, six participants were recruited from two CMT programmes, being run by the same facilitators. All service-users who completed the programme reported a development of self-compassion. Participants were interviewed face-to-face using a semi-structured interview schedule. Interpretative Phenomenological Analysis was selected to analyse the transcribed data. The analysis of the data identified four super-ordinate themes: essential components of self-compassion; process of self-compassion development over time; group experiences; and negotiating change. The first two themes focused on the development and experience of self-compassion. The second two themes included the experience of developing self-compassion in a group and the general change process. Each theme is discussed and presented with supporting quotes. The study found that service-users are able to develop components of self-compassion using CMT. However, continued practice of compassionate behaviours needs to follow the end of the programme for self-compassion to become habitual. The study also identified a number of group factors and processes that prevented or promoted therapeutic change. The results are discussed with reference to the current literature on self-compassion, compassion-based interventions, group processes, mechanisms of change, and further investigation. A model of self-compassion development is proposed. Finally, the researcher's critical reflections of the research process are presented.

Medical referrals are requests, typically from generalist to specialist physician, to see a patient in order to offer an opinion or further care and increasingly are conducted through information technology as electronic referrals (e-referrals). This study set out to determine an appropriate e-referral to psychiatry. A field study was conducted. The criteria and supporting information requirements for an appropriate e-referral to psychiatry were determined. These results were used in turn to conduct a gap analysis on current e-referral standards. It was possible to conclude that current standards would not meet the needs for an e-referral to psychiatry. The results were also used as a case study to address gaps in the knowledge of e-referrals. There was a recurrent theme that the development of e-referrals must account for a number of contexts and as such e-referrals should be developed conceptually before technical deployment. Next steps in research were then discussed. / Graduate / 0723 / sbp@uvic.ca

Background: Iraqi people have been experiencing traumatic events continually for several decades. Consequently, high prevalence rates of trauma-related symptoms have been documented. In contrast, there is a clear lack in mental health services available for traumatised people. This study aimed to screen for PTSD, depression, and anxiety, assess related variables (e.g. coping strategies, posttraumatic cognitions, and social support), and develop a self-help guide (SHG) for traumatised university students. Methods: Self-report scales were validated via two studies. The first study validated three scales, including Baghdad Trauma History Screen (BTHS), Brief Cope, and Social Support in a sample of 360 (140 males, 220 females) university students. In the second study, the psychometric properties of the scales of Posttraumatic Stress Symptoms (SPTSS), Posttraumatic Cognitions Inventory (PCTI), and the Hospital Anxiety and Depression Scale (HADS) were gained in a sample of 505 (199 males, 306 females) university students. The SHG was developed. Its effectiveness was examined in a sample of participants who reported symptoms that fully met PTSD criteria. The sample included 125 participants: 65 in the experimental group (used the guide for six weeks) and 60 in the control group (did not use the guide). Baseline tests were conducted in both groups before conducting the experiment and post tests afterward. In addition, focus groups were conducted with experts and university students to evaluate the SHG. Results: The scales were reliable and valid. Eighty four percent (424/505) of participants reported at least one traumatic event. Thirty five percent of 424 traumatised students fully met the DSM-IV criteria for PTSD with high levels of Depression and anxiety. Only 11% of participants reported no symptoms at all. Females reported more symptoms than males. The results also revealed that active coping, seeking support, and perceived social support from family was associated with low levels of PTSD, while high levels of PTSD related to the number of traumatic events either experienced by participants themselves or their family members or friends, non problem focused coping, negative posttraumatic cognitions about self and the total posttraumatic negative cognitions. After using the SHG, there were significant increases in the tendency to use active and seeking support coping and significant decreases in non problem-focused coping, negative cognitions about self and the total negative cognitions. There was a significant reduction in levels of PTSD. This reduction related to re-experiencing and avoidance symptoms but not hyperarousal. The level of depression was also reduced. Anxiety was not reduced. However, the experiment was not double blind due to practical reasons and this may influence the results. Conclusion: using the SHG enhanced coping strategies and reduced negative cognitions about self. This led to a reduction in PTSD and depression. Several implications were presented. In addition, self-report scales that validated in this study can be used in future research in the field of traumatic stress in Arabic-speaking populations.

Background: There has been relatively little research on the prevalence and use of tobacco products in developing countries, where the majority of morbidity and mortality from tobacco use in this century is expected to occur. This is particularly true of countries in Africa. I conducted this study in the Ashanti region of Ghana, primarily to measure prevalence and risk factors for smoking, and secondarily to develop a template for national surveys in similar settings in developing countries. I also investigated the history of tobacco use in Ghana and looked into current implementation of tobacco control policy, in particular the Framework Convention on Tobacco Control (FCTC). The FCTC Is the World Health Organization's first public health treaty, established to counter the tobacco pandemic internationally. Methods: First, using electronic literature searches of the tobacco document archives and local library, I searched for all documents with information on the tobacco industry in Ghana and all studies of the prevalence of smoking in Ghana. Secondly, using a two-stage cluster randomized sampling design, I collected data from adults aged 14 and over in a representative household sample of approximately 720 households in the Ashanti Region of Ghana. Finally, I conducted interviews with 20 key policy makers involved with Ghana's implementation of the Framework Convention on Tobacco Control (FCTC) and other tobacco control policies to assess Ghana's progress of implementation. Results: Searches of the literature and tobacco document archives established that British American Tobacco (BAT), and latterly the International Tobacco Company Ghana (ITG) and its successor, the Meridian Tobacco Company (MTC), have been manufacturing cigarettes In Ghana since 1954. After an initial sales booming the two decades after independence in 1957, further increases in consumption typical of the tobacco epidemic in most countries did not occur. Possible key reasons include the taking of tobacco companies into state ownership, and a lack of foreign exchange to fund tobacco leaf importation in the 1970s, both of which may have inhibited growth at a key stage of development; and the introduction of an advertising ban in 1982. BAT ceased manufacturing cigarettes in Ghana in 2006. My survey involved 7096 eligible individuals resident in the sampled households, of whom 6258 (88%; median age 31 (range 14-105) years; 64% female) participated. The prevalence of self-reported current smoking (weighted for gender differences in response) was 3.8% (males 8.9%, females 0.3%), and of ever smoking 9.7% (males 22.0%, females 1.2%). Smoking prevalence was strongly related to increasing age, being highest in the 60-69 age-group (Odds Ratio relative to 14-19 year olds 6.36 (95% Confidence Interval 3.26 to 12.38, Ptrend<0.001), and varied significantly in relation to religion (overall p<0.001), being particularly high in those of Traditionalist belief relative to the Christian majority (adjusted OR 7.50, 95% CI 4.43-12.69);in relation to education level (overall p=0.03, adjusted OR for those with no or only primary education compared with those of tertiary education OR 1.49, 95% CI 0.81-2.73); and in relation to occupation (overall p=0.003, adjusted OR for skilled workers relative to the unemployed 0.66, 95% CI 0.41-1.06). Smokers were more likely to drink alcohol (adjusted OR 7.70, 95% CI 4.63-12.93, p<0.001) and to have friends who smoke (adjusted OR 4.24, 95% CI 3.52-5.11 p<0.001), and significantly less likely to take exercise (adjusted OR 0.82, 95% CI 0.72-0.93, p<0.05). Among smokers, over three quarters (76%) had attempted to quit in the last six months, with the main sources of advice being friends and spouses. Use of smoking cessation medications, such as nicotine replacement therapy, was very rare. About 10% of cigarettes smoked were smuggled brands. About a third (38%) of smokers were highly or very highly dependent. Overall the proportion of ever-smokers who had quit smoking was high (61%) in all age groups. The median number and Interquartile range of cigarettes smoked per day by male and female current smokers on weekdays were respectively 6(1- 40) and 5 (4-10), and at weekends 19 (2-70) and 11 (8-20) respectively. The commonest brands smoked were London Brown (42%) and King Size (22%), both manufactured by BAT. Smokeless tobacco had been used ever by 3.2% of men and had been used more by older than younger people (adjusted OR for over 50's relative to 14-19 year olds 2.09 (95% 1.38-3.18, p<0.05, Ptrend =0.006). Knowledge of the health risks of smoking, including passive smoking and its impact on children and non-smokers, was high; radio (74%) and television (28%) were the main sources of such information and advice. Levels of health awareness were typically but not invariably higher in older people, in men, among the more highly educated and in those living in rural areas. There were few restrictions on smoking in public, and most people (38%) therefore worked and/or spent time in places where smoking was permitted. There was very strong support (97%) for comprehensive smoke-free legislation, mainly among Christians and Muslims. Despite the advertising ban, around a third of respondents (35%), particularly in urban areas, had noticed advertising of tobacco or tobacco products. Again radio was the main source of exposure (72%) but some had also noticed advertising on television (28%). The interviews with policy makers showed that they had good knowledge of the content of the FCTC, and reported that although Ghana had no explicit written policy strategy on tobacco control, the Ministry of Health had issued several tobacco control directives both before and after ratification of the FCTC. A national tobacco control bill had been drafted but had not yet been implemented, something which the policy makers needed to happen urgently. Challenges identified included the absence of a legal framework for implementing the FCTC, and a lack of adequate resources and prioritization of tobacco control efforts. Conclusions: Despite rapid economic growth and a sustained tobacco industry presence, smoking prevalence In Ghana was low, particularly among younger people. This suggests that In contrast to many other developing countries, progression of an epidemic increase in smoking has been avoided. Awareness of health risks and support for smoke-free policies were high in Ghana. Exposure to tobacco advertising or promotion was limited, and most smokers reported having tried to quit. Whether these findings are cause or effect of the current low smoking prevalence is uncertain. The likely reasons that I have identified for the low smoking prevalence include an early advertising ban, substantial state intervention in the tobacco industry at a crucial point of growth, socio-cultural factors (particularly religion), the harsh economic environment at a time when the industry was experiencing growth and other public health interventions such as health education by stakeholders involved in tobacco control. Although policy makers were aware of the FCTC, implementation of the World Health Organization (WHO) treaty has been slow, requiring an urgent need for the passage of the national tobacco control bill into law to enable the country to sustain its tobacco control efforts.

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