Introduction: This thesis explored the feasibility of conducting a randomised control trial (RCT) of Acceptance and Commitment Therapy (ACT) within patient’s Spinal Cord Stimulation (SCS) treatment pathway. Previous ACT literature has reported that this is an effective intervention with persons with chronic pain, even when in a self-help format. Whilst this growing body of ACT literature is promising, chronic pain is a broad term used for a number and varying levels of disability. Chronic neuropathic pain (CNP) is usually more complex and resistant to treatment. According to NICE guidelines SCS should be the last treatment option for CNP sufferers. However, there is currently a dearth of literature exploring the effectiveness of the addition of a psychological interventions with the SCS population. Objectives: The aim of this thesis was to explore the parameters of interest in ACT with SCS patient population including recruitment, acceptability of intervention and treatment signals. Design: A mixed between-within group design with repeated measures. There were three conditions in the study. Methods: Ethical and NHS trust approval was obtained. SCS participants were recruited from one Neuromodulation clinic during their routine appointment. Fourteen SCS patients that consented to the study were randomised to either SCS combined with an ACT self-help intervention (SCS-ACT) or SCS and treatment as usual (SCS-TAU). A third arm of the study was included to gain additional information on the ACT self-help intervention. This arm had been assessed for SCS surgery at the same neuromodulation clinic but deemed to be not suitable for the surgery. They were invited to the study via a letter from the clinic. All participants completed outcome measures pre and post-intervention. The participants in the two ACT arms (SCS-ACT and ACT-only) were given an ACT self-help manual and received telephone support sessions over six consecutive weeks. These participants also completed an interview at the end of the intervention. Results: Recruitment to the study was lower than expected and the majority of the participants in the ACT conditions (77%) did not complete the self-help manual. All the participants in the SCS-ACT condition had reliable improvement on at least two outcome domains, however, due to the small sample size it was not possible to assess whether these improvements were due to the SCS surgery or the ACT intervention. The interviews identified a number of barriers that prevented participants completing the manual. Discussion: The study demonstrated that a number of amendments need to be made to the study design and the self-help manual before a full-scale RCT is justified. Therefore it is recommended that a number of alterations are implemented in another feasibility study to assess whether this improves recruitment, retention and outcomes.

Background. This topic was proposed by the Service User and Carer Advisory Panel (SUCAP) which informs and supports Clinical Psychology training at The University of Nottingham. The project developed due to their concern about the ambiguity of crisis. They suggested that their understandings may be different from that of professionals. The reconfiguration of acute mental health services influenced the nationwide implementation of community treatment alternatives. However, crisis has remained a poorly operationalised concept, which can lead to problems in clinical practice. An increase in empirical efforts has aimed to establish clarity and increase the clinical utility of definitions. Despite these efforts, little is known about how service users and carers understand crisis. As suggested by the SUCAP, it is unclear if there is commonality within understandings of crisis. Due to the multiple stakeholders, exploring understandings of crisis from multiple perspectives could be useful in clinical practice. Aim. This study aimed to use Q-methodology to investigate multiple perspectives of crisis. By including service users, carers and professionals the research aimed to highlight consensus and discrepancy within these perspectives. Method. Twenty-six participants were recruited from a National Health Service crisis team, a third sector crisis service and an independent carer support group. In Phase One, clinical interviews with 16 participants (taken from each group) were conducted. Qualitative analysis aided the process of constructing a Q-set of 78 statements that represented the understandings of a crisis experience. In Phase Two, 13 participants (some of whom took part in Phases One and Two) completed the Q-sort procedure, in which they rated the extent to which each statement was characteristic of crisis. To support analysis and interpretation, demographic information was obtained, and pre/post questions elicited reflection on their completed Q-sorts. An inverted factor analytic method was used to analyse the Q-sort data. Results. The results of each Phase are discussed. The rotated two factor solution accounted for fifty percent of variance in people’s understandings of crisis. Factor one related to the understanding of crisis as an experience which can be defined by changes in awareness and perception of reality. Factor two related to the understanding of crisis as intense emotional pain, which is largely related to fear, anxiety and despair. Contrary to existing definitions of crisis, risk and mental illness were not highlighted as central characteristics of crisis. Different pairs of ‘groups’ (service user/professional; carer/professional; service user/carer) had little impact on the amount of shared understanding. However, understandings of crisis were highly variable between individuals. Furthermore, service users’ understandings were more variable than those of professionals or carers. Discussion. Although the findings offer some support to current theories of crisis, they contrast with the dominating characteristics of crisis represented in policy and empirical literature. This suggests that over deterministic definitions of crisis, that focus on risk and mental illness, are insufficient. These findings have implications for both clinical practice and future research.

Thesis (M.S.)--Boston University

The main aims and objectives of this Ph.D. by publication are: • To analyse, explore and contextualise the psychiatric response to trauma and aetiological issues • To analyse and explore the management of Post-Traumatic Stress Disorder (PTSD) • To critically analyse the wider historical, legal and political management of mental disorder. Five peer-reviewed publications from recent years are presented on the theme of psychiatric responses to traumatic events. Two papers focus on the aetiology, (where the Oxford definition of aetiology is the ‘cause, set of causes, or manner of causation of a condition’), of PTSD and therefore consider the injuries that cause PTSD and also potential vulnerability factors (Green & Griffiths, 2013). These papers contain a mixture of quantitative and qualitative methods – examining characteristics such as psychological conceptions of risk in relation to illness duration within a case series for instance and a comparative statistical analysis of birth order in differing samples. Two papers consider modern aspects of the treatment of PTSD – including pharmacological and psychotherapeutic and difficulties and use a methodology of a structured review of the literature including analysis of the evidence base for trauma-focused Cognitive Behavioural Therapy (CBT) including Numbers Needed to Treat (NNT) (Green 2013, Green 2014). A final paper looks at admissions trends for PTSD and a range of other mental disorders and uses a statistical analysis of national data looking for emerging trends against a historical and political background of changes in the management of mental disorder (Green & Griffiths, 2014). These recent papers are set in context against older papers from a career which has spanned epidemiological research into risk factors for depression over six years, writings about psychopharmacology, and planned future research into birth order and domestic violence, and an editorial for the British Journal of General Practice (Green & Gowans, 2014) seeking to promote future epidemiological research into unmet mental health needs in the community. The papers can be viewed as being within the context of a continuum of research interests and publications (represented diagrammatically below in Figure One). In the narrative text I refer to this earlier work and also explain my plans for progress in terms of future research and publications, thus setting the work in this Ph.D. by publication in context within a continuing pattern of interests.

Background Alcohol-related deaths and hospital admissions have risen steeply in the United Kingdom and little is known about whether there are opportunities for preventive interventions or opportunities for the earlier detection of alcohol misuse. The purpose of this research was to investigate and describe patterns of healthcare utilisation in the pre-diagnosis period of alcoholic cirrhosis and alcoholic psychosis, two alcohol-related disorders which contribute significantly to alcohol related morbidity and mortality. This information is important as it could greatly facilitate a better understanding of opportunities for the earlier detection of alcohol misuse, and could also potentially encourage and assist practitioners in the timely identification of those who are at high risk of developing significant alcohol-related illnesses. Specific research objectives 1)To estimate rates of primary and secondary healthcare contacts before the diagnosis of alcoholic cirrhosis/psychosis and assess whether this differs from rates in the general population 2)To characterise the healthcare contacts and establish whether such consultations were for other conditions known to be related to alcohol. 3)As a secondary objective, to establish whether prior healthcare contacts led to recognition of alcohol problems and consequent interventions. Methods UK general practice and hospital admissions data were used for this research. A population of patients diagnosed with alcoholic cirrhosis and subsequently, a population of patients with alcoholic psychosis were identified. For each case, 10 patients without the disease who were of similar age and from the same general practice were selected as controls. For each disease group, a case-control study design was used to compare rates of primary care contacts and hospital admissions in cases to that of the control population. Further, the reasons for primary care visits and hospital admissions were assessed to describe the frequency of other alcohol-attributable morbidities in cases and controls, and to assess whether there were any morbidities which were strongly associated with the later development of alcoholic cirrhosis and psychosis. Finally, the proportions of patients who had a record of their alcohol use status or a record of an offer of brief alcohol intervention/referral were estimated. Results Alcoholic cirrhosis 2,479 patients with alcoholic cirrhosis and 24,790 controls matched on age and GP practice were available for analysis. Assessment of healthcare utilisation showed that people with alcoholic cirrhosis had 50% higher rate of GP visits and twice as many hospital admissions compared to the control population. This excess healthcare use was apparent as far as 10 years pre-diagnosis of alcoholic cirrhosis, but greater excesses were seen within 5 years of diagnosis. Cases of alcoholic cirrhosis did have a higher frequency of other conditions that are partly alcohol-attributable, especially diabetes, epileptic seizures, hypertensive diseases, injuries and digestive diseases. Of all these conditions, injuries, seizures and digestive diseases had the strongest association with the development of alcoholic cirrhosis. Overall, a high proportion of patients with alcoholic cirrhosis (84%) had their alcohol use documented on an average of 4 years before diagnosis and 58% of these records indicated harmful/hazardous drinking. However, only 1 in 5 patients (22%) had any record of a brief alcohol intervention or an alcohol referral. Alcoholic psychosis 1,731 patients with alcoholic psychosis and 17,310 matched controls were included in the study. As with alcoholic cirrhosis, there was a substantially higher rate of primary and secondary care use in cases which was apparent up to 10 years prior to disease diagnosis. Cases of alcoholic psychosis also had a higher frequency of partly alcohol attributable morbidities. However, the strongest associations were seen for intentional and unintentional injuries and seizures. 78% of cases of alcoholic psychosis did have their alcohol use recorded, 50% had a harmful/hazardous drinking record but only 1 in 5 (19%) had any intervention record. Conclusion and Implications: This research has shown that patients who misuse alcohol make frequent contacts with both primary and secondary care, suggesting that there are high number of opportunities within these healthcare settings to improve the early identification and treatment of alcohol use. Relatively few patients were identified to have received brief alcohol interventions/referral despite the large proportion of people with documented drinking problems, suggesting potential inadequacy in the treatment of alcohol problems. However, this may also partly be an artefact of recording biases. Considering that alcohol is one of the leading preventable causes of morbidity and mortality in the UK, these findings should encourage healthcare professionals to, at the very least, screen for alcohol misuse in patients presenting with any alcohol-attributable condition, and for policy makers to consider directing more effort towards integrating alcohol screening and brief intervention into routine clinical practice.

Studies of sexual murder are abundant, but an empirically supported understanding of this type of crime and its perpetrators is limited in important ways. The overall aim of this thesis was to work towards a theoretical model recognising that sexual murder is a heterogeneous concept. Also, the thesis aimed to understand sexual murder in the wider context of sexual aggression against adult women. First, a systematic review was conducted to clarify the existing typologies of sexual murder. Three consistently observed subtypes were found. These were labelled sexualised murder, grievance murder, and rape murder. A behaviour that could be used to differentiate groups was post mortem sexual interference (PMSI), indicative of sexualised murder. Subsequently, a study was conducted comparing subgroups of sexual murderers (those who had engaged in PMSI, and those who had not), and rapists, on developmental factors, adult lifestyle, and criminal career. The main finding was that the groups responded differently to early adversity. Difficulties with social and sexual relationships leading to the development of sadistic interests, as opposed to pervasive antisociality, distinguished PMSI sexual murderers from rapists, while non-PMSI sexual murderers were largely similar to rapists. However, although the role of psychopathy in sexual aggression is debated, no group was strongly characterised by psychopathy in the present study. A secondary study was conducted to verify that this finding was not associated with limitations in the assessment tool used (the Psychopathy Checklist: Screening Version [PCL: SV]; Hart, Cox, & Hare, 1995). Good psychometric properties were found. Next, a case study demonstrated the functional heterogeneity of the act of killing under the broadly defined term ‘sexual murder’, and highlighted the importance of this in forensic case formulation and intervention. Finally, drawing on the findings of the present research, a new model of sexual murder is proposed to address some of the issues discussed in this thesis.

No description available.

The present study was conducted to evaluate perceptions of the importance of various factors that may determine the wage or salary level in jobs. Items describing various job characteristics reflecting the factors of Skill, Effort, Responsibility, Working Conditions, and Organizational characteristics were rated by 510 subjects from a variety of organizations. Results indicated that the items did not cluster into the five categories noted above. Instead, three factors were identified and labeled Job Complexity, Accountability, and Work Context. There were few gender or occupational differences in the ratings of the items. The implications of the results for the development of equitable wage and salary systems are discussed.

Introduction: The construct of mindfulness, a non-judgemental awareness of present moment experience, has been increasingly recognised in recent years as being positively associated with psychological wellbeing. In light of accumulating evidence pointing to an inverse relationship between mindfulness and a wide range of psychological distress outcomes, including depression, mindfulness has been increasingly incorporated into modern psychotherapies and healthcare services, and the importance of psychometrically quantifying the construct of mindfulness has become paramount. One of the most reliable and valid instruments developed for the assessment of different aspects of dispositional mindfulness is the Five Facets Mindfulness Questionnaire (FFMQ; Baer et al., 2006), which measures the dimensions of ‘Nonreact’, ‘Observe’, ‘Actaware’, ‘Describe’ and ‘Nonjudge’. However, the psychometric properties of the FFMQ are yet to be tested in clinically depressed individuals with substantial levels of persistent depression. Moreover, there has been no attempt to date to qualitatively explore the experience of mindfulness in those naïve to mindfulness training in order to further determine its role in the management of depressive symptomatology. Methods: Using a convergent parallel mixed methods design, the present study investigated the psychometric properties of the FFMQ in a sample of 187 adults with moderate to severe, persistent depression recruited from a large National Institute for Health Research funded randomised controlled trial (Morriss et al., 2010). Internal consistency and test retest reliability (at six months) were assessed and construct validity was examined with confirmatory factor analyses (CFA) and by statistically correlating the FFMQ to measures of depression, and mindfulness-related constructs; self-compassion, rumination and experiential avoidance. In addition, using semi-structured interviews, a subset of 20 participants were interviewed to explore their experience of depression and perceived associated changes in dispositional mindfulness. Interview data were analysed using qualitative thematic analysis. Results: Results of psychometric testing supported the internal consistency and test-retest reliability of the FFMQ. CFA indicated that both a correlated and hierarchical model fit the data acceptably, with results slightly favouring the correlated model. Contrary to predictions however, CFA showed that the facet ‘Nonjudge’ did not load onto an overarching factor of mindfulness. ‘Nonjudge’ was further found to show a non-significant correlation with depression and only a weak correlation with experiential avoidance and rumination. Thematic analysis of the qualitative data indicated that participants’ ability to retain a non-judgmental awareness of present moment experience deteriorates with the onset of depressed mood. This seemed to occur automatically and deliberately as a strategy to avoid contact with painful internal and external experiences, hence indicating a self-inflicted process of awareness restriction that appears to be a contributing factor to the maintenance of depression. Conclusions: Contrary to what has been previously understood, albeit with different populations, the factor structure of the FFMQ alters in the face of moderate to severe, persistent depression, with the facet ‘Nonjudge’ no longer forming a component of this construct. Therefore, a four factor model (excluding Nonjudge) is proposed for use in this population. The qualitative data has provided possible explanations for the idiosyncratic behaviour of the facet Nonjudge in people experiencing moderate to severe, persistent depression. Both data sets converge to confirm an inverse relationship between mindfulness and depression. Moreover, the qualitative data suggests that deliberate efforts to restrict facets of mindfulness represents a conscious attempt to manage negative experiences that paradoxically maintains and aggravates depression. Future research following-up participants with substantial levels of depression into remission may shed further light on the role of mindfulness in moderate to severe, persistent depression.

Childhood secondhand smoke (SHS) exposure causes substantial ill health and mortality, and poses a significant economic and social burden. This thesis aimed to explore the prevalence and determinants of smoking in the home after childbirth, and to understand the experience and attitudes of mothers who stop smoking during pregnancy but relapse soon after delivery. In study one, the factors associated with child SHS exposure in the home were systematically reviewed. Parental smoking, low socioeconomic status and being less educated were all frequently and consistently independently associated with children’s SHS exposure in the home. Children whose parents held more negative attitudes towards SHS were less likely to be exposed. In study two, cohort data were analysed to estimate maternal self-reported prevalence of SHS exposure among young infants (≤3 months) of women who smoked just before or during pregnancy, and identify its associated factors. In 471 households, the prevalence of smoking in the home was 16.3% (95% CI 13.2-19.8%), and after multiple imputation controlling for non-response 18.2% (95% CI 14.0-22.5%). Mothers’ smoking ≥11 cigarettes per day were 8.2 times (95% CI 3.4-19.6) more likely to report smoking in the home. Significant associations were also observed for younger age, being of non-White ethnicity, increased deprivation and less negative attitudes towards SHS. In study three, semi-structured interviews with women who quit smoking during pregnancy, but relapsed ≤3 months postpartum were conducted. Central to mothers’ accounts of their smoking behaviours during pregnancy and postpartum was their desire to be a ‘responsible mother’. Mothers described using strategies to protect their infant from SHS exposure, and held strong negative attitudes towards other smoking parents. After relapsing, mothers repositioned themselves as ‘social/occasional’ smokers rather than ‘regular’ smokers. Taken together, these findings can be used to inform the development of future, targeted interventions to prevent or reduce infant and child SHS exposure.