Patterns of service use among persons with Schizophrenia and other psychotic disorders

Objective: This study assessed 12-month service use patterns among people with psychotic disorders and sought to identify determinants of service use. Methods: As part of a large two-phase Australian study of psychotic disorders, structured interviews were conducted with a stratified random sample of adults who screened positive for psychosis. Demographic characteristics, social functioning, symptoms, mental health diagnoses, and use of psychiatric and nonpsychiatric services were assessed. Data were analyzed for 858 persons who had an ICD-10 diagnosis of a psychotic disorder and who had been hospitalized for less than six months during the previous year. Results: People with psychotic disorders had high levels of use of health services, both in absolute terms and relative to people with nonpsychotic disorders. Those with psychotic disorders were estimated to have an average of one contact with health services per week. Use of psychiatric inpatient services was associated with parenthood, higher symptom levels, recent attempts at suicide or self-harm, personal disability, medication status, and frequency of alcohol consumption. Services provided by general practitioners (family physicians) were more likely to be obtained by older people, women, people with greater availability of friends, those with fewer negative symptoms, and those whose service needs were unmet by other sources. People who were high users of health services also reported having more contact with a range of non-health agencies. Conclusions: The predictors of service use accounted for small proportions of the variance in overall use of health services. The role of general practitioners in providing and monitoring treatment programs and other psychosocial interventions needs to be acknowledged and enhanced.

Burden attributable to child maltreatment in Australia

Child maltreatment is a complex phenomenon, with four main types (childhood sexual abuse, physical abuse, emotional abuse, and neglect) highly interrelated. All types of maltreatment have been linked to adverse health consequences and exposure to multiple forms of maltreatment increases risk. In Australia to date, only burden attributable to childhood sexual abuse has been estimated. This study synthesized the national evidence and quantified the burden attributable to the four main types of child maltreatment. Meta-analyses, based on quality-effects models, generated pooled prevalence estimates for each maltreatment type. Exposure to child maltreatment was examined as a risk factor for depressive disorders, anxiety disorders and intentional self-harm using counterfactual estimation and comparative risk assessment methods. Adjustments were made for co-occurrence of multiple forms of child maltreatment. Overall, an estimated 23.5% of self-harm, 20.9% of anxiety disorders and 15.7% of depressive disorders burden in males; and 33.0% of self-harm, 30.6% of anxiety disorders and 22.8% of depressive disorders burden in females was attributable to child maltreatment. Child maltreatment was estimated to cause 1.4% (95% uncertainty interval 0.4–2.3%) of all disability-adjusted life years (DALYs) in males, and 2.4% (0.7–4.1%) of all DALYs in females in Australia in 2010. Child maltreatment contributes to a substantial proportion of burden from depressive and anxiety disorders and intentional self-harm in Australia. This study demonstrates the importance of including all forms of child maltreatment as risk factors in future burden of disease studies.

The burden of child maltreatment in China: a systematic review

Objective To estimate the health and economic burdens of child maltreatment in China. Methods We did a systematic review for studies on child maltreatment in China using PubMed, Embase, PsycInfo, CINAHL-EBSCO, ERIC and the Chinese National Knowledge Infrastructure databases. We did meta-analyses of studies that met inclusion criteria to estimate the prevalence of child neglect and child physical, emotional and sexual abuse. We used data from the 2010 global burden of disease estimates to calculate disability-adjusted life-years (DALYs) lost as a result of child maltreatment. Findings From 68 studies we estimated that 26.6% of children under 18 years of age have suffered physical abuse, 19.6% emotional abuse, 8.7% sexual abuse and 26.0% neglect. We estimate that emotional abuse in childhood accounts for 26.3% of the DALYs lost because of mental disorders and 18.0% of those lost because of self-harm. Physical abuse in childhood accounts for 12.2% of DALYs lost because of depression, 17.0% of those lost to anxiety, 20.7% of those lost to problem drinking, 18.8% of those lost to illicit drug use and 18.3% of those lost to self-harm. The consequences of physical abuse of children costs China an estimated 0.84% of its gross domestic product – i.e. 50 billion United States dollars – in 2010. The corresponding losses attributable to emotional and sexual abuse in childhood were 0.47% and 0.39% of the gross domestic product, respectively. Conclusion In China, child maltreatment is common and associated with large economic losses because many maltreated children suffer substantial psychological distress and might adopt behaviours that increase their risk of chronic disease.

Global, regional, and national disability-adjusted life years (DALYs) for 306 diseases and injuries and healthy life expectancy (HALE) for 188 countries, 1990–2013: Quantifying the epidemiological transition

Background The Global Burden of Disease Study 2013 (GBD 2013) aims to bring together all available epidemiological data using a coherent measurement framework, standardised estimation methods, and transparent data sources to enable comparisons of health loss over time and across causes, age–sex groups, and countries. The GBD can be used to generate summary measures such as disability-adjusted life-years (DALYs) and healthy life expectancy (HALE) that make possible comparative assessments of broad epidemiological patterns across countries and time. These summary measures can also be used to quantify the component of variation in epidemiology that is related to sociodemographic development. Methods We used the published GBD 2013 data for age-specific mortality, years of life lost due to premature mortality (YLLs), and years lived with disability (YLDs) to calculate DALYs and HALE for 1990, 1995, 2000, 2005, 2010, and 2013 for 188 countries. We calculated HALE using the Sullivan method; 95% uncertainty intervals (UIs) represent uncertainty in age-specific death rates and YLDs per person for each country, age, sex, and year. We estimated DALYs for 306 causes for each country as the sum of YLLs and YLDs; 95% UIs represent uncertainty in YLL and YLD rates. We quantified patterns of the epidemiological transition with a composite indicator of sociodemographic status, which we constructed from income per person, average years of schooling after age 15 years, and the total fertility rate and mean age of the population. We applied hierarchical regression to DALY rates by cause across countries to decompose variance related to the sociodemographic status variable, country, and time. Findings Worldwide, from 1990 to 2013, life expectancy at birth rose by 6·2 years (95% UI 5·6–6·6), from 65·3 years (65·0–65·6) in 1990 to 71·5 years (71·0–71·9) in 2013, HALE at birth rose by 5·4 years (4·9–5·8), from 56·9 years (54·5–59·1) to 62·3 years (59·7–64·8), total DALYs fell by 3·6% (0·3–7·4), and age-standardised DALY rates per 100 000 people fell by 26·7% (24·6–29·1). For communicable, maternal, neonatal, and nutritional disorders, global DALY numbers, crude rates, and age-standardised rates have all declined between 1990 and 2013, whereas for non–communicable diseases, global DALYs have been increasing, DALY rates have remained nearly constant, and age-standardised DALY rates declined during the same period. From 2005 to 2013, the number of DALYs increased for most specific non-communicable diseases, including cardiovascular diseases and neoplasms, in addition to dengue, food-borne trematodes, and leishmaniasis; DALYs decreased for nearly all other causes. By 2013, the five leading causes of DALYs were ischaemic heart disease, lower respiratory infections, cerebrovascular disease, low back and neck pain, and road injuries. Sociodemographic status explained more than 50% of the variance between countries and over time for diarrhoea, lower respiratory infections, and other common infectious diseases; maternal disorders; neonatal disorders; nutritional deficiencies; other communicable, maternal, neonatal, and nutritional diseases; musculoskeletal disorders; and other non-communicable diseases. However, sociodemographic status explained less than 10% of the variance in DALY rates for cardiovascular diseases; chronic respiratory diseases; cirrhosis; diabetes, urogenital, blood, and endocrine diseases; unintentional injuries; and self-harm and interpersonal violence. Predictably, increased sociodemographic status was associated with a shift in burden from YLLs to YLDs, driven by declines in YLLs and increases in YLDs from musculoskeletal disorders, neurological disorders, and mental and substance use disorders. In most country-specific estimates, the increase in life expectancy was greater than that in HALE. Leading causes of DALYs are highly variable across countries. Interpretation Global health is improving. Population growth and ageing have driven up numbers of DALYs, but crude rates have remained relatively constant, showing that progress in health does not mean fewer demands on health systems. The notion of an epidemiological transition—in which increasing sociodemographic status brings structured change in disease burden—is useful, but there is tremendous variation in burden of disease that is not associated with sociodemographic status. This further underscores the need for country-specific assessments of DALYs and HALE to appropriately inform health policy decisions and attendant actions.

An imagery-based road map to tackle maladaptive motivation in clinical disorders

There is now a widespread recognition of the importance of mental imagery in a range of clinical disorders (1). This provides the potential for a transdiagnostic route to integrate some aspects of these disorders and their treatment within a common framework. This opinion piece argues that we need to understand why imagery is such a central and recurring feature, if we are to progress theories of the origin and maintenance of disorders. This will aid us in identifying therapeutic techniques that are not simply targeting imagery as a symptom, but as a manifestation of an underlying problem. As papers in this issue highlight, imagery is a central feature across many clinical disorders, but has been ascribed varying roles. For example, the involuntary occurrence of traumatic memories is a diagnostic criterion for PTSD (2), and it has been suggested that multisensory imagery of traumatic events normally serves a functional role in allowing the individual to reappraise the situation (3), but that this re-appraisal is disabled by extreme affective responses. In contrast to the disabling flashbacks associated with PTSD, depressed adults who experience suicidal ideation often report “flash forward” imagery related to suicidal acts (4), motivating them to self-harm. Socially anxious individuals who engage in visual imagery about giving a talk in public become more anxious and make more negative predictions about future performance than others who engage in more abstract, semantic processing of the past event (5). People with Obsessive Compulsive Disorder (OCD) frequently report imagery of past adverse events, and imagery seems to be associated with severity (6). The content of intrusive imagery has been related to psychotic symptoms (7), including visual images of the catastrophic fears associated with paranoia and persecution. Imagery has been argued (8) to play a role in the maintenance of psychosis through negative appraisals of imagined voices, misattribution of sensations to external sources, by the induction of negative mood states that trigger voices, and through maintenance of negative schemas. In addiction and substance dependence, Elaborated Intrusion (EI) Theory (9, 10) emphasizes the causal role that imagery plays in substance use, through its role in motivating an individual to pursue goals directed toward achieving the pleasurable outcomes associated with substance use...

The architecture of the psychiatric milieu

The last time a peer-reviewed volume on the future of mental health facilities was produced was in 1959, following a symposium organised by the American Psychological Association. The consensus was easy enough to follow and still resonates today: the best spaces to treat psychiatric illness will be in smaller, less restrictive units that offer more privacy and allow greater personalisation of space – possibly a converted hotel (Goshen, 1959). In some way, all those ideals have come to pass. An ideal typology was never established, but even so, units have shrunk from thousands of beds to units that typically house no more than 50 patients. Patients are generally more independent and are free to wander (within a unit) as they please. But the trend toward smaller and freer is reversing. This change is not driven by a desire to find the ideal building nor better models of care, but by growing concerns about budgets, self-harm and psychiatric violence. This issue of the Facilities comes at a time when the healthcare design is increasingly dominated by codes, statutes and guidelines. But the articles herein are a call to stop and think. We are not at the point where guidelines can be helpful, because they do not embody any depth of knowledge nor wisdom. These articles are intended to inject some new research on psychiatric/environmental interactions and also to remind planners and managers that guidelines might not tackle a core misunderstanding: fear-management about patient safety and the safety of society is not the purpose of the psychiatric facility. It is purpose is to create spaces that are suitable for improving the well-being of the mentally ill.

Young love: Romantic concerns and associated mental health issues among adolescent help-seekers

Over 50% of young people have dated by age 15. While romantic relationship concerns are a major reason for adolescent help-seeking from counselling services, we have a limited understanding of what types of relationship issues are most strongly related to mental health issues and suicide risk. This paper used records of 4019 counselling sessions with adolescents (10–18 years) seeking help from a national youth counselling service for a romantic relationship concern to: (i) explore what types and stage (pre, during, post) of romantic concerns adolescents seek help for; (ii) how they are associated with mental health problems, self-harm and suicide risk; and (iii) whether these associations differ by age and gender. In line with developmental-contextual theory, results suggest that concerns about the initiation of relationships are common in early adolescence, while concerns about maintaining and repairing relationships increase with age. Relationship breakups were the most common concern for both male and female adolescents and for all age groups (early, mid, late adolescence). Data relating to a range of mental health issues were available for approximately half of the sample. Post-relationship concerns (including breakups) were also more likely than pre- or during-relationship concerns to be associated with concurrent mental health issues (36.8%), self-harm (22.6%) and suicide (9.9%). Results draw on a staged developmental theory of adolescent romantic relationships to provide a comprehensive assessment of relationship stressors, highlighting post-relationship as a particularly vulnerable time for all stages of adolescence. These findings contribute to the development of targeted intervention and support programs.

Character in the workplace : self directedness mediates harm avoidance in the prediction of job performance

The purpose of this study was to test a model of the relationship between temperament, character and job performance, in order to better understand the cause of stable individual differences in job performance. Personality was conceptualized in terms of Cloninger, Svrakic and Przybeck’s (1993) theoretical framework of personality. It was expected that Self Directedness (character) would mediate Harm Avoidance and Persistence (temperament) in the prediction of job performance. In order to test the hypotheses, a sample of 94 employee/supervisor pairs was recruited from several organizations across Australia. Participants completed a number of questionnaires online, regarding their personality traits (completed by employees) and Job Performance (completed by Supervisors). Consistent with the hypothesis, Self Directedness was found to be a moderate, direct predictor of job performance. Also consistent with the hypothesis, Self Directedness mediated Harm Avoidance in the prediction of job performance. Results show that character (Self Directedness) is important in the prediction of job performance, and also suggests that fearful, avoidant individuals are less likely to perform well in the workplace, based on their low level of character development.

Brief opportunistic intervention : the role of psychologists in initiating self-change amongst problem drinkers

Excessive consumption of alcohol is a serious public health problem. While intensive treatments are suitable for those who are physically dependent on alcohol, they are not cost-effective options for the vast majority of problem drinkers who are not dependent. There is good evidence that brief interventions are effective in reducing overall alcohol consumption, alcohol-related problems, and health-care utilisation among nondependent problem drinkers. Psychologists are in an ideal position to opportunistically detect people who drink excessively and to offer them brief advice to reduce their drinking. In this paper we outline the process involved in providing brief opportunistic screening and intervention for problem drinkers. We also discuss methods that psychologists can employ if a client is not ready to reduce drinking, or is ambivalent about change. Depending on the client's level of motivation to change, psychologists can engage in either an education-clarification approach, a commitment-enhancement approach, or a skills-training approach. Routine engagement in opportunistic intervention is an important public-health approach to reducing alcohol-related harm in the community.

Under the carpet : the politics and trauma of patient harm

Few studies have investigated iatrogenic outcomes from the viewpoint of patient experience. To address this anomaly, the broad aim of this research is to explore the lived experience of patient harm. Patient harm is defined as major harm to the patient, either psychosocial or physical in nature, resulting from any aspect of health care. Utilising the method of Consensual Qualitative Research (CQR), in-depth interviews are conducted with twenty-four volunteer research participants who self-report having been severely harmed by an invasive medical procedure. A standardised measure of emotional distress, the Impact of Event Scale (IES), is additionally employed for purposes of triangulation. Thematic analysis of transcript data indicate numerous findings including: (i) difficulties regarding patients‘ prior understanding of risks involved with their medical procedure; (ii) the problematic response of the health system post-procedure; (iii) multiple adverse effects upon life functioning; (iv) limited recourse options for patients; and (v) the approach desired in terms of how patient harm should be systemically handled. In addition, IES results indicate a clinically significant level of distress in the sample as a whole. To discuss findings, a cross-disciplinary approach is adopted that draws upon sociology, medicine, medical anthropology, psychology, philosophy, history, ethics, law, and political theory. Furthermore, an overall explanatory framework is proposed in terms of the master themes of power and trauma. In terms of the theme of power, a postmodernist analysis explores the politics of patient harm, particularly the dynamics surrounding the politics of knowledge (e.g., notions of subjective versus objective knowledge, informed consent, and open disclosure). This analysis suggests that patient care is not the prime function of the health system, which appears more focussed upon serving the interests of those in the upper levels of its hierarchy. In terms of the master theme of trauma, current understandings of posttraumatic stress disorder (PTSD) are critiqued, and based on data from this research as well as the international literature, a new model of trauma is proposed. This model is based upon the principle of homeostasis observed in biology, whereby within every cell or organism a state of equilibrium is sought and maintained. The proposed model identifies several bio-psychosocial markers of trauma across its three main phases. These trauma markers include: (i) a profound sense of loss; (ii) a lack of perceived control; (iii) passive trauma processing responses; (iv) an identity crisis; (v) a quest to fully understand the trauma event; (vi) a need for social validation of the traumatic experience; and (vii) posttraumatic adaption with the possibility of positive change. To further explore the master themes of power and trauma, a natural group interview is carried out at a meeting of a patient support group for arachnoiditis. Observations at this meeting and members‘ stories in general support the homeostatic model of trauma, particularly the quest to find answers in the face of distressing experience, as well as the need for social recognition of that experience. In addition, the sociopolitical response to arachnoiditis highlights how public domains of knowledge are largely constructed and controlled by vested interests. Implications of the data overall are discussed in terms of a cultural revolution being needed in health care to position core values around a prime focus upon patients as human beings.

Threat appraisal for harm from falls: Insights for development of education-based intervention

Objective: This study aims to describe how patients perceive the threat of falls in hospitals, to identify patient characteristics that are associated with greater or lesser perceptions of the threat of falls, and to examine whether there is a discord between the risk that patients perceive in general and the risk that they perceive for themselves personally. Method: A cross-sectional survey amongst geriatric rehabilitation inpatients in Brisbane, Australia, was implemented. The first component of the survey dealt with the ‘general’ nature of in-hospital falls and falls related risks while the second component of the survey was directed at identifying whether the patient held the same belief for themselves. Results: A total of 21 out of 125 participants (17%) indicated that they felt that they were at risk of falling during their hospitalisation and 28 (22%) felt that they would injure themselves if they were to fall. Self-perceived risk of falls was associated with decreasing age and lower cognitive function (Functional Independence Measure Cognitive score). A majority of patients felt that falls most commonly occur in the bathroom [n=67 (54%)] and that if they were to fall, they would fall in the bathroom [n=56 (45%)]. Discussion: Patients generally do not think they are at risk of falling while in hospital and this may contribute to poor adherence to falls prevention strategies. It is possible that raising patient perception of the risk of falls and injury from falls in hospitals may help improve adherence to falls prevention strategies in this setting.

Do drivers respond emotionally and behaviourally differently to an intentionally anger provoking driving situation than to an ambiguous, but potentially provocative, one? Results of a self-report survey.

Aggressive driving is considered an important road-safety concern for drivers in highly motorised countries. However, understanding of the causes and maintenance factors fundamental to aggressive driving is limited. In keeping with theoretical advances from general aggression research such as the General Aggression Model (GAM), research has begun to examine the emotional and cognitive antecedents of aggressive driving in order to better understand the underlying processes motivating aggressive driving. Early findings in the driving area have suggested that greater levels of aggression are elicited in response to an intentionally aggressive on-road event. In contrast, general aggression research suggests that greater levels of aggression are elicited in response to an ambiguous event. The current study examined emotional and cognitive responses to two hypothetical driving scenarios with differing levels of aggressive intent (intentional versus ambiguous). There was also an interest in whether factors influencing responses were different for hostile aggression (that is, where the action is intended to harm the other) versus instrumental aggression (that is, where the action is motivated by an intention to remove an impediment or attain a goal). Results were that significantly stronger negative emotion and negative attributions, as well as greater levels of threat were reported in response to the scenario which was designed to appear intentional in nature. In addition, participants were more likely to endorse an aggressive behavioural response to a situation that appeared deliberately aggressive than to one where the intention was ambiguous. Analyses to determine if greater levels of negative emotions and cognitions are able to predict aggressive responses provided different patterns of results for instrumental aggression from those for hostile aggression. Specifically, for instrumental aggression, negative emotions and negative attributions were significant predictors for both the intentional and the ambiguous scenarios. In addition, perceived threat was also a significant predictor where the other driver’s intent was clearly aggressive. However, lower rather than higher, levels of perceived threat were associated with greater endorsement of an aggressive response. For hostile aggressive behavioural responses, trait aggression was the strongest predictor for both situations. Overall the results suggest that in the driving context, instrumental aggression is likely to be a much more common response than hostile aggression. Moreover, aggressive responses are more likely in situations where another driver’s behaviour is clearly intentional rather than ambiguous. The results also support the conclusion that there may be different underlying mechanisms motivating an instrumental aggressive response to those motivating a hostile one. In addition, understanding the emotions and cognitions underlying aggressive driving responses may be helpful in predicting and intervening to reduce driving aggression. The finding that drivers appear to regard tailgating as an instrumental response is of concern since this behaviour has the potential to result in crashes.

Comparison of self-reported driving behaviours and experiences of immediate-uptake and delayed-uptake licence holders

The objective of this paper was to explore experiences of ‘immediate-uptake’ (intermediate licensure at age 17-18 years, n = 928) and ‘delayed-uptake’ (intermediate licensure at age 19-20 years, n = 158) driver’s licence holders in the Australian state of Queensland. In Queensland, the graduated driver licence program applies to all novices irrespective of age. Drivers who obtained a Provisional 1 (intermediate) (P1) licence completed a survey exploring pre-Licence and Learner experiences, including the Behaviour of Young Novice Drivers Scale (BYNDS). Six months later, 351 drivers from this sample (n = 300 immediate-uptake) completed a survey exploring P1 driving. Delayed-uptake Learners reported significantly more difficulty gaining driving practice, which appeared to be associated with significantly greater engagement in unsupervised driving during the Learner period. Whilst a larger proportion of delayed-uptake novices, particularly males, reported the use of more active punishment avoidance strategies (avoiding Police, talking themselves out of a ticket) in the P1 phase, there was no significant difference in the BYNDS scores in the Learner and P1 phases according to licence-uptake category. Delayed-uptake novices report more difficulty meeting GDL requirements and place themselves at increased risk by driving unsupervised during the Learner licence phase. Additional efforts such as mentoring programs which can support the delayed-uptake Learner in meeting their GDL obligations merit further consideration to allow this novice group to gain the full benefits of the GDL program and to reduce their risk of harm in the short-term.

Do cyberbullies suffer too? Cyberbullies' perceptions of the harm they cause to others and to their own mental health

While it is recognised that there are serious correlates for students who are victims of cyberbullying including depression, anxiety, lower self-esteem and social difficulties, there has been little research attention paid to the mental health of students who cyberbully. It is known that students who traditionally bully report they feel indifferent to their victims, showing a lack of empathy and that they themselves are at increased risk for psychosocial adjustment. However, there is scant research on the mental health associations of students who cyberbully or their awareness of their impact on others. The current study sought to ascertain from Australian students who reported cyberbullying others in years 6 to 12 (10-19 years of age), their perceptions of their mental health and the harm they caused to and the impact their actions had, on their victims. Most students who cyberbullied did not think that their bullying was harsh or had an impact on their victims. They reported more social difficulties and higher scores on stress, depression and anxiety scales than those students who were not involved in any bullying. The implications of these findings for the mental health of the cyberbullies and for psychologists in schools who assist them, are dis-cussed.

The role for police in addressing alcohol-related harm inside and outside licensed premises

Alcohol consumption is enmeshed with Australian culture (Palk, 2008) and the use and misuse of alcohol contributes to considerable health and social harms (Barbor et al., 2010; English et al., 1995; Gutjahr, Gmel, & Rehm, 2001; Palk, 2008; Steenkamp, Harrison, & Allsop, 2002). Despite shifts in the way that alcohol is consumed and how it is used, it has been reported that one-third of all alcohol consumed is done so within licensed premises (Lang, Stockwell, Rydon, & Gamble, 1992). Consequently, licensed premises are over-represented as settings in which alcohol-related harms occur. These harms, particularly those related to violence, are associated with particular licensed premises operating in the night-time economy (Briscoe & Donnelly, 2001b; Chikritzhs, Stockwell, & Masters, 1997; Homel, Tomsen, & Thommeny, 1991; Stockwell, 1997). Police have a role in not only responding to the manifestation of harms, such as crime, injuries, assaults, domestic violence, stealing and sexual offences, but they also have a role in preventing problems, and thereby reducing alcohol and other drug-related harms (Doherty & Roche, 2003). Given the extent of alcohol consumption within licensed premises and the nature and extent of the harms, as well as the lack of opportunity to influence outcomes in other settings (e.g. the home), licensed premises offer police and other stakeholders a significant opportunity to influence positively the reduction of alcoholrelated harm. This research focuses specifically on the police role in policing licensed premises. Primarily, this research aims to investigate the factors which are relevant to why and how police officers respond to alcohol-related incidents inside and outside licensed premises. It examines the attitudes and beliefs of police and assesses their knowledge, capacity and ability to effectively police licensed premises. The research methodology uses three distinct surveys. Each contributes to understanding the motivations and practice of police officers in this important area of harm reduction. Study One involved a survey of police officers within a police district (Brisbane Central District) in Queensland, Australia and used a comprehensive questionnaire involving both quantitative and qualitative techniques. A key research outcome of Study One was the finding that officers had low levels of knowledge of the strategies that are effective in addressing alcohol-related harm both inside and outside licensed premises. Paradoxically, these officers also reported extensive recent experience in dealing with alcohol issues in these locations. In addition, these officers reported that alcohol was a significant contextual factor in the majority of matters to which they responded. Officers surveyed reported that alcohol increased the difficulty of responding to situations and that licensed premises (e.g. nightclubs, licensed clubs and hotels) were the most difficult contexts to police. Those surveyed were asked to self-assess their knowledge of the Liquor Act (Qld), which is the primary legislative authority in Queensland for regulating licensed premises. Surprisingly, well over half of the officers (65%) reported ‘no’ to ‘fair’ knowledge of the Act, despite officers believing that their skill level to police such premises was in the ‘good to very good range’. In an important finding, officers reported greater skill level to police outside licensed premises than inside such premises, indicating that officers felt less capable, from a skill perspective, to operate within the confines of a licensed premise than in the environment immediately outside such premises. Another key finding was that officers reported greater levels of training in responding to situations outside and around licensed premises than to situations inside licensed premises. Officers were also asked to identify the frequency with which they employed specified regulatory enforcement and community-based strategies. Irrespective of the type of response, ‘taking no action’ or passive policing interventions were not favoured by officers. The findings identified that officers favoured taking a range of strategies (sending home, releasing into the custody of friends, etc.) in preference to arrest. In another key finding, officers generally reported their support for operational stakeholder partnership approaches to policing licensed premises. This was evidenced by the high number of officers (over 90%) reporting that there should be shared responsibility for enforcing the provisions of the Liquor Act. Importantly, those surveyed also identified the factors which constrain or prevent them from policing licensed premises. Study Two involved interviewing a small but comprehensive group (n=11) of senior managers from within the Queensland Police Service (QPS) who have responsibility for setting operational and strategic policy. The aim of this study was to examine the attitudes, perceptions and influence that senior officers (at the strategy and policy-setting level) had on the officers at the operational level. This qualitative study was carried out using a purposive sampling (Denzin & Lincoln, 2005; Guba & Lincoln, 1989), focused interview and thematic analytic approach. The interview participants were drawn from three tiers of management at district, regional as well as the whole-of-organisational level. The first key theme emerging from the study related to role, in terms of both the QPS broader organisational role, and the individual officer role with respect to the policing of licensed premises. For the QPS organisational role, participants at all three strategic levels had a high degree of congruity as to the organisations service role; that is, to enhance public safety. With respect to participants’ beliefs as to whether police officers have knowledge and understanding of their individual roles concerning licensed premises (as opposed to the QPS role), participants reported most commonly that officers had a reasonable to clear understanding of their role. Participant comments also were supportive of the view that officers operating in the research area, Brisbane Central District (BCD), had a clearer understanding of their role than police operating in other locations. The second key theme to emerge identified a disparity between the knowledge and capability of specialist police, compared with general duties police, to police licensed premises. In fact, a number of the responses to a variety of questions differentiated specialist and general police in a range of domains. One such example related to the clarity of understanding of officer role. Participants agreed that specialist police (Liquor Enforcement & Proactive Strategies [LEAPS] officers) had more clarity of understanding in terms of their role than generalist police. Participants also were strongly of the opinion that specialist police had higher skill levels to deal with issues both inside and outside licensed premises. Some participants expressed the view that general duty police undertook purely response-related activities, or alternatively, dealt with lower order matters. Conversely, it was viewed that specialist police undertook more complex tasks because of their higher levels of knowledge and skill. The third key theme to emerge concerned the identification of barriers that serve to restrict or prevent police officers from policing licensed premises. Participant responses strongly indicated that there was a diversity of resourcing barriers that restrict police from undertaking their roles in licensed premises. Examples of such barriers were the lack of police and the low ratio of police to patrons, available officer time, and lack of organisational investment in skills and knowledge acquisition. However, some participants indicated that police resourcing in the BCD was appropriate and officers were equipped with sufficient powers (policy and legislation). Again, the issue of specialist police was raised by one participant who argued that increasing the numbers of specialist police would ameliorate the difficulties for police officers policing licensed premises. The fourth and last key theme to emerge from Study Two related to the perception of senior officers regarding the opportunity and capability of officers to leverage off external partnerships to reduce harms inside and outside licensed premises. Police working in partnership in BCD was seen as an effective harm reduction strategy and strongly supported by the participants. All participants demonstrated a high degree of knowledge as to who these partners were and could identify those government, non-government and community groups precisely. Furthermore, the majority of participants also held strong views that the partnerships were reasonably effective and worked to varying degrees depending on the nature of the partnership and issues such as resourcing. These senior officers identified better communication and coordination as factors that could potentially strengthen these partnerships. This research finding is particularly important for senior officers who have the capacity to shape the policy and strategic direction of the police service, not only in Queensland but throughout Australasia. Study Three examined the perceptions of those with links to the broader liquor industry (government, non-government and community but exclusive of police) concerning their understanding of the police role and the capacity of police to reduce alcohol-related harm inside and outside licensed premises, and their attitudes towards police. Participants (n=26) surveyed represented a range of areas including the liquor industry, business represenatives and government representatives from Queensland Fire and Rescue Service, Queensland Ambulance Service, Brisbane City Council and Queensland Health. The first key theme to emerge from Study Three related to participant understanding of the QPS organisational role, and importantly, individual officer role in policing licensed premises. In terms of participant understanding of the QPS role there was a clear understanding by the majority of participants that the police role was to act in ways consistent with the law and to otherwise engage in a range of enforcement-related activities. Participants saw such activities falling into two categories. The first category related to reactive policing, which included actions around responding to trouble in licensed premises, monitoring crowd controllers and removing trouble-makers. In the second category, proactive approaches, participants identified the following activities as consistent with that approach: early intervention with offenders, support of licensed premises operators and high visibility policing. When participants were asked about their understanding of individual officer roles in the policing of licensed premises, a range of responses were received but the consistent message that emerged was that there is a different role to be played by general duty (uniformed) police compared to specialist (LEAPS Unit) police, which reflects differences in knowledge, skill and capability. The second key theme that emerged from the data related to the external participants’ views of the knowledge and capability of specialist police, compared with general duty police, to police licensed premises. As noted in the first key theme, participants were universally of the view that the knowledge, skill and capability of police in specialist units (LEAPS Unit) was at a higher level than that of general duty police. Participants observed that these specialist officers were better trained than their colleagues in generalist areas and were therefore better able to intervene knowledgeably and authoritatively to deal with problems and issues as they emerged. Participants also reported that officers working within BCD generally had a positive attitude to their duties and had important local knowledge that they could use in the resolution of alcohol-related issues. Participants also commented on the importance of sound and effective QPS leadership, as well as the quality of the leadership in BCD. On both these measures, there was general consensus from participants, who reported positively on the importance and effectiveness of such leadership in BCD. The third key theme to emerge from Study Three concerned the identification of barriers that serve to restrict or prevent police officers from policing licensed premises. Overwhelmingly, external participants reported the lack of human resources (i.e. police officers) as the key barrier. Other resourcing limitations, such as available officer time, police computer systems, and the time taken to charge offenders, were identified as barriers. Some participants identified barriers in the liquor industry such as ‘dodgy operators’ and negative media attention as limitations. Other constraints to emerge related to government and policy barriers. These were reflected in comments about the collection by government of fees from licensees and better ‘powers’ for police to deal with offenders. The fourth and final key theme that emerged from Study Three related to the opportunities for and capability of police to leverage off external partnerships to reduce harms inside and outside licensed premises. Not surprisingly, participants had a comprehensive knowledge of a broad range of stakeholders, from a diversity of contexts, influential in addressing issues in licensed premises. Many participants reported their relationships with the police and other stakeholders as effective, productive and consistent with the objectives of partnering to reduce alcohol-related harm. On the other hand, there were those who were concerned with their relationship with other stakeholders, particularly those with a compliance function (e.g. Office of Liquor & Gaming Regulation [OLGR]). The resourcing limitations of partners and stakeholders were also raised as an important constraining factor in fulfilling the optimum relationship. Again, political issues were mentioned in terms of the impact on partnerships, with participants stating that there is at times political interference and that politicians complicate the relationships of stakeholders. There are some significant strengths with respect to the methodology of this research. The research is distinguished from previous work in that it examines these critical issues from three distinct perspectives (i.e. police officer, senior manager and external stakeholder). Other strengths relate to the strong theoretical framework that guides and informs the research. There are also some identified limitations, including the subjective nature of self-report data as well as the potential for bias by the author, which was controlled for using a range of initiatives. A further limitation concerns the potential for transferability and generalisability of the findings to other locations given the distinctive nature of the BCD. These limitations and issues of transferability are dealt with at length in the thesis. Despite a growing body of literature about contextual harms associated with alcohol, and specific research concerning police intervention in such contextual harms, there is still much to learn. While research on the subject of police engaging in alcohol-related incidents has focused on police behaviours and strategies in response to such issues, there is a paucity of research that focuses on the knowledge and understanding of officers engaged in such behaviours and practices. Given the scarcity of research dealing with the knowledge, skills and attitudes of police officers responding to harms inside and outside licensed premises, this research contributes significantly to what is a recent and growing body of research and literature in the field. The research makes a practical contribution to police agencies’ understanding of officer knowledge and police practice in ways that have the potential to shape education and training agendas, policy approaches around generalist versus specialist policing, strategic and operational strategy, as well as partnership engagements. The research also makes a theoretical contribution given that the research design is informed by the Three Circle