This thesis forms part of the criteria for the qualification of the Doctorate in Forensic Psychology Practice (ForenPsyD). Its overall aim is to examine the prevalence of mental disorders and unmet needs among offenders managed by the Probation Service, because the understanding of this has very important implications for epidemiology, health service planning and future offending. The first chapter of this thesis presents a general introduction to the topic. Chapter two is a single case study, which describes work undertaken in relation to risk assessment and development of a care plan with a client managed by the Probation Service. A number of previously researched risk factors for offending have been identified in this case, these included: high numbers of previous convictions, presence of mental disorders, substance misuse, poor educational and vocational skills, poor cognitive and interpersonal skills, and limited social support. This study also demonstrated the practical utility of the Structured Assessment of Personality Abbreviated Scale (SAPAS; Moran et al., 2003), a brief screening measure for personality disorder case identification. The Structured Assessment of Personality Abbreviated Scale (SAPAS; Moran et al., 2003) is discussed and evaluated in chapter three. Presented evidence suggests that this measure can rapidly identify individuals at high risk of personality disorder with a good level of psychometric properties. Based on the above and developing evidence supporting its validity and reliability with forensic populations the SAPAS has been chosen to screen for case identification in the empirical study. Chapter four presents findings from the literature review on the prevalence of mental disorders in offenders on probation using a systematic approach. A total of 18 studies published between 1993 and 2013 were reviewed, suggesting significant lack of research in this area. The little research that exists demonstrates mixed findings as the prevalence of mental disorders reported varies making a comparison between the papers difficult. Despite the above, where possible weighted average prevalence rates were calculated. The estimated overall prevalence of PD was 19%, any current mental disorder 6%, alcohol misuse 62%, drug abuse 54, anxiety 13% and depression 10%. The findings from previous chapters were considered and informed more in depth, empirical research on the prevalence of mental disorders amongst offenders on probation presented in chapter five. The present study estimated that 61% of the probationers suffer from a current mental disorder according to Mini International Neuropsychiatric Interview (MINI; Sheehan et al., 1998), and found that a significant proportion experience difficulties with regards to social needs such as financial and housing difficulties, which have been previously identified as significant risk factors for reoffending. Finally, chapter six presents overall findings discusses its implications, explores limitations and provides direction for future research. Several wider implications can be drawn from this thesis, which shows that high numbers of probationers suffer from a variety of Axis I disorders, likely personality disorders, substance misuse and have a number of social needs. Based on these findings, it is possible to conclude that there is a need for the mental health substance misuse and social needs of offenders to be given a higher priority in terms of service delivery, education and research.

Background: Family carers are considered to be the most important resource available to support people with dementia. The number of older people who are carers is increasing in the United Kingdom, and little is known about how caregiving affects their quality of life (QoL). The World Health Organization has established the importance of measuring individuals’ QoL and of developing and using age-specific QoL tools. However, to date no dementia- and age-specific QoL scale has been developed for use with older family carers. Aim: This PhD study aimed to develop and evaluate the psychometric properties of the ‘Dementia Quality of Life Scale for Older Family Carers’ (DQoL-OC), a dementia- and age-specific scale for the evaluation of QoL of older family carers. This tool might provide more robust QoL outcomes than scales currently being used with this particular population, helping to improve the quality of the evidence that results from studies and interventions aimed at evaluating and enhancing the QoL of these individuals. Methods: This is a sequential exploratory mixed-methods research. The DQoL-OC items were identified in four focus groups with 19 older family carers in Nottinghamshire. Data were transcribed verbatim and analysed by two researchers independently, using Interpretative Phenomenological Analysis. Inter-coder reliability was established using the Cohen’s kappa coefficient. A set of 89 items assessed using a five-point rating scale was generated and evaluated for content and face validity by a panel of six experts. The modified version of the DQoL-OC containing 100 items was then tested with a non-probabilistic sample of 182 older family carers in the UK who were providing care at home for family members with dementia. A battery of additional scales was administered to establish convergent construct validity: the Satisfaction with Life Scale; the WHOQOL-AGE QoL Scale; Perceived Health Status Visual Analogue Scale; and Overall Perceived Health-Related Quality of Life Visual Analogue Scale. The QoL model was identified using Exploratory Factor Analysis. Eighteen participants took part in the test-retest reliability, and the two measurement sets were correlated using Intraclass Correlation. Cronbach’s alpha was used to measure internal consistency reliability. The Pearson coefficient was used to provide evidence of convergent construct validity and the Spearman’s rho coefficient was used to correlate the DQoL-OC with other sociodemographic and caregiving variables. Results: Thirty-three themes emerged from focus groups and were collated into three superordinate themes: aspects of care and caregiving; feelings and concerns; and satisfaction with life and with caregiving. Very good inter-coder reliability was established (r=0.839). The psychometric study demonstrated that a one-factor solution containing 22 items best represented the new QoL model. Excellent test retest reliability (lower bound r=0.835; < 0.0001) and internal consistency (α=0.936) scores were obtained. Convergent construct validity was established for all tested scales (< 0.0001). Significantly lower levels of QoL were found in female older carers, those who perceived their relatives with dementia as being at the earlier stages of the disease and with unstable dementia symptoms, those providing care more hours per day and more days per week, and those in younger-old age. Conclusion: This study allowed the exploration of a broad range of aspects that are of particular importance for the QoL of older family carers of people with dementia. The DQoL-OC was considered by participants to be a relevant and useful measure of QoL. DQoL-OC is a valid and reliable 22-item tool assessed using 1 to 5 rating scales, which may be useful in clinical practice and in research in order to improve the QoL of older family carers of people with dementia. These findings will inform future health and social care practice with regards to improving life quality for this overlooked sector of the population.

Thesis (M.S.)--Boston University

Thesis (D.N.S.)--Boston University / PLEASE NOTE: Boston University Libraries did not receive an Authorization To Manage form for this thesis or dissertation. It is therefore not openly accessible, though it may be available by request. If you are the author or principal advisor of this work and would like to request open access for it, please contact us at open-help@bu.edu. Thank you. / 2031-01-01

Background: The cause of patient aggression is a very complex question, and it continues to be a challenging phenomenon in psychiatric inpatient services. This thesis provides a broad investigation into nursing staff attitudes towards inpatient aggression. Individual factors such as the history of violence are well studied. However, staff-level factors have received less attention. Aims and Objectives: The main purpose of this thesis was to explore and expand the knowledge base of nursing staff attitudes toward patient aggression in secure psychiatric hospitals. The four questions of this thesis were; 1. What does the literature suggest about the psychological and emotional effects of inpatient aggression on nurses working in psychiatric settings? (Chapter 2). 2. What are the factors associated with nurses’ attitudes towards patient aggression in UK secure psychiatric hospitals? (Chapter 4). 3. Is the Attitude Toward Aggression Scale (ATAS; Jansen et al., 2006a; 1997; 2005b) a suitable measure for assessing nurses’ attitudes towards patient aggression? (Chapter 3). 4. What are the benefits of using a direct staff-level intervention that utilises the positive behavioural support (PBS) philosophy when targeting attitudes towards patient aggression? (Chapter 5). Method: To answer the first research question a systematic review was completed to explore current literature focusing on the psychological and emotional effects of patient aggression (Chapter 2). A critical review was then conducted to explore the psychometric properties of the ATAS, a tool commonly used within psychiatric services to help monitor and evaluate attitudes towards patient aggression (Chapter 3). An empirical research study using quantitative measures was developed to explore nursing staff attitudes towards patient aggression in UK secure psychiatric hospitals (Chapter 4). Finally, a case study presents the effectiveness of a direct staff-level intervention on nurses’ attitudes and the management of patient aggression in a secure psychiatric hospital (Chapter 5). Overall Findings: 1. The systematic review (Chapter 2) identified several psychological and emotional effects when exposed to inpatient aggression. Psychiatric nurses were found to suffer from occupational stress, psychological strain and post-traumatic stress disorder symptoms. State anxiety was found to be the main emotional effect. 2. The psychometric review of the ATAS (Chapter 3) raised questions regarding the face validity, content validity, predictive validity, concurrent validity, and construct validity. The internal reliability was deemed satisfactory, whereas the test-retest reliability is yet to be explored. 3. The results from the primary study (Chapter 4) showed that the respondents viewed patient aggression as destructive. Verbal aggression was the most prevalent predictor for the communicative, protective, and intrusive attitude domains, whilst working with the female population was associated with having a destructive attitude. 4. This case study (Chapter 5) highlights the benefit of conducting a direct staff-level intervention when targeting attitudes towards patient aggression. There was a positive shift in how staff evaluated patient aggression following this intervention. The data also evidenced improvements in the patient’s ability to cope with anger-provoking situations, along with a reduction in the frequency and intensity of aggressive incidents. Conclusion: Nurses’ attitudes towards patient aggression have been found to influence the type of management strategies used. A better understanding of the sources of them may provide a useful guide when designing and developing cost-effective organisational interventions aimed to reduce the need for restrictive interventions in inpatient settings. This can help promote positive and proactive care and create a safer environment for both patients and staff.

Purpose: The aim of this research was to investigate perceptions of child sexual abuse (CSA), particularly the perceptions held by CSA perpetrators and the public. Given the influence perceptions can have on a CSA victim’s wellbeing and disclosure behaviour, and a CSA perpetrator’s sexual recidivism risk, gaining insight into these perceptions was considered important. Method: To facilitate this investigation, a multifaceted approach was adopted. This commenced with chapter one, a systematic literature review, which aimed to identify which factors influence English and Welsh perceptions of CSA victims. The second chapter comprised an empirical research project which aimed to investigate the influence of a victim’s abuse history, victim-perpetrator relationship and a perpetrator’s gender on British perceptions of CSA. These three factors were selected due to their hypothesised influence on perceptions and lack of investigation. Following this, chapter three was completed which involved a critique of the Gudjonsson Blame Attribution Inventory-Revised (GBAI-R). This was to assess the inventory’s suitability for chapter four and to inform practitioners of its utility. Finally, chapter four entailed a case study which aimed to investigate whether a CSA perpetrator’s offence-specific minimisation could be reduced. This was facilitated by completing a six-session intervention on an individual basis. Results: This thesis revealed various findings. Specifically, chapter one revealed respondent gender influences public perceptions of CSA victims as males perceived CSA victims more negatively than females. Regarding chapter two, a victim’s abuse history, victim-perpetrator relationship and a perpetrator’s gender were not found to influence British perceptions of CSA. However, similar to chapter one, females were significantly more pro-victim compared to males. In chapter three, the critique identified some evidence of the GBAI-R being psychometrically sound and utilising an efficient administration methodology. Despite this, some concerns were raised regarding the representativeness of its normative data and the inventory’s susceptibility to extreme scores. Finally, chapter four revealed some evidence of the intervention reducing the perpetrator’s offence-specific minimisation although it was not possible to firmly conclude this. Conclusion: The findings highlight the need for further research into perceptions of CSA. This should include investigations into why males are less pro-victim compared to females and the impact this might have on CSA. Research should also continue to investigate the influence of a victim’s abuse history, victim-perpetrator relationship and a perpetrator’s gender on perceptions of CSA. As part of this research a more representative sample should be recruited to enable the generalisation of findings. A more comprehensive critique of the GBAI-R should also be facilitated as well as further investigations into minimisation.

Whilst the positive relationship between neuroticism and burnout is well-established within the extant literature, it is also acknowledged that neurotic individuals may differ in the extent to which they experience such detriments in well-being. In concordance with dual-processing theories of behaviour, it was suggested in this thesis that executive functions may enable one to enact in a ‘goal-orientated’ manner, and thus overcome one’s instinctive neurotic tendencies towards burnout. Through the four studies of this thesis, a research model was constructed and examined in which the core executive functions of working memory, active inhibition and task switching were proposed to reduce the extent to which neuroticism positively predicted burnout (which in studies 2 and 3 was suggested to occur via negative affect). Although the overall neuroticism-burnout relationship was not found to be conditional upon any of the three executive functions, there was some evidence that the constituent paths of an indirect neuroticism-burnout model (via negative affect) were moderated by executive functions. Specifically, active inhibition significantly decreased the negative affect-burnout relationship in study 2, and this relationship was found to be conditional on task-switching in study 3, to the extent that lower task-switching reduced the moderating effect of active inhibition on the relationship between negative affect and burnout. In study 3 it was also found that higher levels of working memory capacity were associated with a reduction in the neuroticism-negative affect relationship. The findings of this research did not support an overall moderating effect of executive functions, whilst only partly supporting the broader suggestion that executive functions may regulate the negative outcomes that occur when vulnerable individuals experience stressors. In light of the results of this thesis, limitations of the research were discussed (including methodological differences across studies and the use of unitary executive function measures) and suggestions made for future research (e.g. longitudinal study designs).

Arts and health are international fields of practice with stakeholders from various disciplines. It is known that the UK has an established practice of collaboration in the form of interdisciplinary partnerships in arts and health (Clift et al., 2009, White, 2009), whereas in Denmark initiatives exist ad-hoc and there is no such established field (Jensen and Wille, 2015). This thesis is a qualitative study investigating the interdisciplinary relationships between stakeholders engaged in arts and health practice in the UK and in Denmark. The identified stakeholders in the study are: health professionals, museum educators and mental health service users. Semi-structured interviews were conducted with 36 participants including health professionals, museum educators and service users. Data were collected in Denmark and in the UK. A thematic approach was used to analyse the data and theoretical lenses of sociological theories of professions and institutional logics were employed to explore the findings. There were two stages to the data collection in Denmark; the first was a small-scale pilot study where the findings identified that arts engagement have health and wellbeing benefits for mental health service users. These benefits are perceived to include empowerment and meaning in life, which are two of the core principles of recovery; arts engagement can therefore be a useful tool in recovery and although this was a small-scale pilot study, the findings are not dissimilar to findings from other studies examining this issue. However, the pilot study also highlighted some further issues with the interaction between museum educators and service users that had unintended negative effects. The larger scale study was then conducted in Denmark to explore the interaction between service users and museum educators. The findings illustrate, similarly to the pilot study, that arts engagement is perceived to be beneficial for service users. The findings also show that the experience of visiting a museum was not always positive and depended upon the interaction with the museum educators. The service users identified points about the museum educators as a professional group which gave the idea that if museums in Denmark want to engage positively with people with mental health problems, then the training of staff and the improvement of institutional approaches to support working with vulnerable people are essential. In order to further understand and explore the professionals in arts and health practice and what contributes to an effective partnership, the next part of the study took place in the more established arts and health field in the UK. In this way, this part of the study was conducted in the UK and was chosen in order to explore a setting with health professionals and museum educators working together in an interdisciplinary collaboration. This stage of the study reveals that interdisciplinary work in arts and health is complex, given the different disciplines and institutions involved. However, findings throughout the study (in Denmark and in the UK) illustrate that competing institutional logics play a vital and ambiguous part in the work of the professions involved in arts and health practice and that this presents a challenge for interdisciplinary working in the field. The UK part of the study also illustrates that aspects of practice, such as risk management, are approached from different perspectives depending on the profession involved and are interpreted in various ways according to the disciplinary background. Working in unfamiliar settings creates professional vulnerability and ambiguity and the interdisciplinary setting illustrates that professionals have territories that they want to uphold. However, the study also shows that there is an agreement among the professionals that an interdisciplinary approach to the field is necessary. The conclusion of the study has, from the perspectives of the participants, served to highlight some benefits and challenges in the interdisciplinary field of arts and health practice. The study suggests that an awareness of the existing complexities of logics, a pragmatic framework in which multiple and competing logics can co-exist and that recognising the differences between disciplines and institutions could benefit practice in the field. In addition, offering various arts activities in diverse health settings and for different health issues, including health promotion, treatments and recovery, can strengthen a patient-centred approach of healthcare that both the UK and Denmark strive to achieve. Furthermore, the study makes recommendations for the field of practice.

The following academic thesis explores the links between offender motivation and violence reduction treatment for adult male offenders, with a focus on those with a mental illness. The thesis begins with a systematic review of the literature regarding the impact of motivation on interventions aimed at reducing violence and aggression. The majority of reviewed studies provided tentative support for the theory that individuals with higher levels of motivation stay in treatment longer and have better treatment gains regarding violence reduction. The following chapter includes an empirical study investigating the impact of Stage of Change, as measured by the Transtheoretical Model (Prochaska & DiClemente, 1982), on the outcome of treatment. The focus of this study was the Violent Offender Treatment Programme (VOTP), designed for mentally disordered offenders, and its application within a High Security and a Medium Security hospital. The programme itself was found to be effective in reducing violence outcomes, however there was little support for the Stages of Change model as a form of categorising those who were more likely to improve. Chapter 4 then presents a Case Study of an adult male offender, with a diagnosis of Delusional Disorder, in order to ascertain whether the VOTP could be adapted for individual use. Case study results were not clinically significant but are discussed in light of current research and forensic practice. A critical appraisal of the Violence Risk Scale (Wong & Gordon, 1998-2003) is then presented in Chapter 5, due to this being a primary risk assessment tool referred to throughout the doctoral works. The thesis concludes with a chapter summarising the key points and involving a reflective element by the author.

This thesis will aim to identify the role of protective factors in clinical risk prediction and management of inpatients in secure services. Chapter one provides an introduction to the field of forensic risk assessment, and a justification for the importance of including protective factors to create a more balanced assessment of patient risk. Chapter two presents a systematic review exploring the role of protective factors in various risk assessment tools. The aims of this review is to identify risk assessment tools that incorporate a measure of protective strengths, and the predictive validity of these tools for the outcome of inpatient aggression or violence. Chapter three provides a critical review of the START, specifically focused on its strengths and weaknesses as a risk prediction tool, demonstrating good validity, reliability, in addition to excellent inter-rater reliability. Findings will be reported in terms of the clinical utility of this tool. Chapter four presents the findings from a research project that aimed to identify the predictive validity of the START in female forensic inpatients, highlighting the efficacy of the specific risk estimates. Chapter five utilises a case study to identify how promoting protective factors in the form of coping skills can reduce self-harming behaviours. This case study aims to demonstrate that focusing treatment on promoting patient strengths can be effective in reducing adverse outcomes. Finally, chapter six discusses the overall findings and clinical implications from the present thesis. Future research directions will also be discussed.