IRIS Guidelines: Early Intervention in Psychosis IRIS Guidelines Update September 2012

Revision of the original 1998 IRIS Guidelines.

Narrative Matters: ‘The third space’ in Adolescent and Young Adult Fiction

In his article ‘Narrative Matters’, Gordon Bates (Bates, 2016) discusses the relevance of the humanities, and in particular that of fiction, in helping us to understand the experiences and problems of adolescents suffering men- tal health problems. Notably, the number of novels pub- lished for children and adolescents that focus on mental health problems has risen considerably since the begin- ning of this century. The ‘Goodreads’ (Goodreads, 2016) website lists more than 1000 fiction titles on matters pertaining to mental illness published for the UK and US markets since 2000.

Insight assessment in psychosis and psychopathological correlates: validation of the Spanish version of the Schedule for Assessment of Insight - Expanded Version

Background and Objectives: Lack of insight is a cardinal feature of psycho­sis. Insight has been found to be a multidimensional concept, including awareness of having a mental illness, ability to relabel psychotic phenomena as abnormal and compliance with treatment., which can be measured with the Schedule for Assessment of Insight (SAI-E). The aim of this study was to validate the Spanish version of SAI-E. Methods: The SAI-E was translated into Spanish and back-translated into English, which was deemed appropriate by the original scale author. Next, the Spanish version of the SAI-E was administered to 39 patients with schizophrenia or schizoaffective disorder (DSM-IV criteria) from a North Peruvian psychiatric hospital. The Positive and Negative Syndrome Scale for Schizophrenia (PANSS) and the Scale of Unawareness of Mental Disorder (SUMD) were also administered. Specifically, internal consistency and convergent validity were assessed. Results: Internal consistency between the 11 items of the SAI-E was found to be good to excellent (α = 0.942). Compliance items did not contribute to internal consistency (A = 0.417, B = 572). Inter-rater reliability was excellent (ICC = 0.99). Regarding concurrent validity, the SAI-E total score correlated negatively with the lack of insight and judgement item of the PANNS (r = -0.91, p <0.01) and positively with the SUMD total score (r = 0.92, p <0.001). Conclusions: The Spanish version of the SAI-E scale was demonstrated to have both excellent reliability and external validity in our sample of South American Spanish-speaking patients with schizophrenia spectrum disorders.

Humankindness: Illness, Animality, and the Limits of the Human in the Victorian Novel

This project posits a link between representations of animals or animality and representations of illness in the Victorian novel, and examines the narrative uses and ideological consequences of such representations. Figurations of animality and illness in Victorian fiction have been examined extensively as distinct phenomena, but examining their connection allows for a more complex view of the role of sympathy in the Victorian novel. The commonplace in novel criticism is that Victorian authors, whether effectively or not, constructed their novels with a view to the expansion of sympathy. This dissertation intervenes in the discussion of the Victorian novel as a vehicle for sympathy by positing that texts and scenes in which representations of illness and animality are conjoined reveal where the novel draws the boundaries of the human, and the often surprising limits it sets on sympathetic feeling. In such moments, textual cues train or direct readerly sympathies in ways that suggest a particular definition of the human, but that direction of sympathy is not always towards an enlarged sympathy, or an enlarged definition of the human. There is an equally (and increasingly) powerful antipathetic impulse in many of these texts, which estranges readerly sympathy from putatively deviant, degenerate, or dangerous groups. These two opposing impulses—the sympathetic and the antipathetic—often coexist in the same novel or even the same scene, creating an ideological and affective friction, and both draw on the same tropes of illness and animality. Examining the intersection of these different discourses—sympathy, illness, and animality-- in these novels reveals the way that major Victorian debates about human nature, evolution and degeneration, and moral responsibility shaped the novels of the era as vehicles for both antipathy and sympathy. Focusing on the novels of the Brontës and Thomas Hardy, this dissertation examines in depth the interconnected ways that representations of animals and animality and representations of illness function in the Victorian novel, as they allow authors to explore or redefine the boundary between the human and the non-human, the boundary between sympathy and antipathy, and the limits of sympathy itself.

Saúde mental: o modelo clínico-comunitário numa unidade socio-ocupacional

Trabalho de projeto apresentado à Escola Superior de Educação de Paula Frassinetti, para obtenção do grau de mestre em Intervenção Comunitária

Adapting to change in contemporary Irish and Scottish culture: fiction to film

Abstract available: p. [ii]-[iii].

The interpersonal and mental health implications of the coherence of coming out narratives for a sample of gay men in committed romantic relationships

The coming out process has been conceptualized as a developmental imperative for those who will eventually accept their same-sex attractions. It is widely accepted that homophobia, heterosexism, and homonegativity are cultural realities that may complicate this developmental process for gay men. The current study views coming out as an extra-developmental life task that is at best a stressful event, and at worst traumatic when coming out results in the rupture of salient relationships with parents, siblings, and/or close friends. To date, the minority stress model (Meyer, 1995; 2003) has been utilized as an organizing framework for how to empirically examine external stressors and mental health disparities for lesbians, gay men, and bisexual individuals in the United States. The current study builds on this literature by focusing on the influence of how gay men make sense of and represent the coming out process in a semi-structured interview, more specifically, by examining the legacy of the coming out process on indicators of wellness. In a two-part process, this study first employs the framework well articulated in the adult attachment literature of coherence of narratives to explore both variation and implications of the coming out experience for a sample of gay men (n = 60) in romantic relationships (n = 30). In particular, this study employed constructs identified in the adult attachment literature, namely Preoccupied and Dismissing current state of mind, to code a Coming Out Interview (COI). In the present study current state of mind refers to the degree of coherent discourse produced about coming out experiences as relayed during the COI. Multilevel analyses tested the extent to which these COI dimensions, as revealed through an analysis of coming out narratives in the COI, were associated with relationship quality, including self-reported satisfaction and observed emotional tone in a standard laboratory interaction task and self-reported symptoms of psychopathology. In addition, multilevel analyses also assessed the Acceptance by primary relationship figures at the time of disclosure, as well as the degree of Outness at the time of the study. Results revealed that participant’s narratives on the COI varied with regard to Preoccupied and Dismissing current state of mind, suggesting that the AAI coding system provides a viable organizing framework for extracting meaning from coming out narratives as related to attachment relevant constructs. Multilevel modeling revealed construct validity of the attachment dimensions assessed via the COI; attachment (i.e., Preoccupied and Dismissing current state of mind) as assessed via the Adult Attachment Interview (AAI) was significantly correlated with the corresponding COI variables. These finding suggest both methodological and conceptual convergence between these two measures. However, with one exception, COI Preoccupied and Dismissing current state of mind did not predict relationship outcomes or self-reported internalizing and externalizing symptoms. However, further analyses revealed that the degree to which one is out to others moderated the relationship between COI Preoccupied and internalizing. Specifically, for those who were less out to others, there was a significant and positive relationship between Preoccupied current state of mind towards coming out and internalizing symptoms. In addition, the degree of perceived acceptance of sexual orientation by salient relationship figures at the time of disclosure emerged as a predictor of mental health. In particular, Acceptance was significantly negatively related to internalizing symptoms. Overall, the results offer preliminary support that gay men’s narratives do reflect variation as assessed by attachment dimensions and highlights the role of Acceptance by salient relationship figures at the time of disclosure. Still, for the most part, current state of mind towards coming out in this study was not associated with relationship quality and self-reported indicators of mental health. This finding may be a function of low statistical power given the modest sample size. However, the relationship between Preoccupied current state of mind and mental health (i.e., internalizing) appears to depend on degree of Outness. In addition, the response of primary relationships figures to coming out may be a relevant factor in shaping mental health outcomes for gay men. Limitations and suggestions for future research and clinical intervention are offered.

Impacto do plano individual de recovery no enriquecimento pessoal das pessoas com experiência de doença mental

Dissertação de Mestrado apresentada no Instituto Superior de Psicologia Aplicada para obtenção de grau de Mestre na especialidade de Psicologia Clínica

Influence des traits et troubles de personnalité sur l’intégration au travail de personnes aux prises avec un trouble mental grave

Bien que le travail soit bénéfique et souhaité par une majorité de personnes aux prises avec un trouble mental grave (TMG), les études réalisées auprès de cette clientèle montrent des taux d’emploi d’environ 10 à 20%. Parmi les services visant le retour au travail, les programmes de soutien à l’emploi (PSE) se sont montrés les plus efficaces avec des taux de placement en emploi standard oscillant entre 50 et 60%, sans toutefois garantir le maintien en emploi. Plusieurs études ont tenté de cerner les déterminants de l’obtention et du maintien en emploi chez cette population sans toutefois s’intéresser à la personnalité, et ce, bien qu’elle soit reconnue depuis toujours comme un déterminant important du fonctionnement des individus. De plus, peu de questionnaires d’évaluation de la personnalité selon le modèle de la personnalité en cinq facteurs (FFM) ont été utilisés auprès d’une clientèle avec un TMG et ceux-ci ont montré des propriétés psychométriques ne respectant pas des normes reconnues et acceptées. Cette thèse porte sur les liens entre la personnalité et l’intégration au travail chez les personnes avec un TMG. La première partie vise la validation d’un outil de mesure de la personnalité selon le FFM afin de répondre aux objectifs de la deuxième partie de la thèse. À cet effet, deux échantillons ont été recrutés, soit 259 étudiants universitaires et 141 personnes avec un TMG. Des analyses factorielles confirmatoires ont mené au développement d’un nouveau questionnaire à 15 items (NEO-15) dont les indices d’ajustement, de cohérence interne et de validité convergente respectent les normes établies, ce qui en fait un questionnaire bien adapté à la mesure de la personnalité normale dans des contextes où le temps d’évaluation est limité. La deuxième partie présente les résultats d’une étude réalisée auprès de 82 personnes aux prises avec un TMG inscrites dans un PSE et visant à identifier les facteurs d’obtention et de maintien en emploi chez cette clientèle, particulièrement en ce qui concerne la contribution des éléments normaux et pathologiques de la personnalité. Les résultats de régressions logistiques et de régressions de Cox (analyses de survie) ont démontré que l’historique d’emploi, les symptômes négatifs et le niveau de pathologie de la personnalité étaient prédictifs de l’obtention d’un emploi standard et du délai avant l’obtention d’un tel emploi. Une autre série de régressions de Cox a pour sa part démontré que l’esprit consciencieux était le seul prédicteur significatif du maintien en emploi. Malgré certaines limites, particulièrement des tailles d’échantillons restreintes, ces résultats démontrent la pertinence et l’importance de tenir compte des éléments normaux et pathologiques de la personnalité dans le cadre d’études portant sur l’intégration au travail de personnes avec un TMG. De plus, cette thèse a permis de démontrer l’adéquation d’un nouvel instrument de mesure de la personnalité auprès de cette clientèle. Des avenues futures concernant la réintégration professionnelle et le traitement des personnes avec un TMG sont discutées à la lumière de ces résultats.

The role of perceived housing quality and perceived choice to recovery: An ecological perspective on a housing first program in Lisbon

This study explores, from an ecological perspective, the relationship between perceived housing quality and the perception of choice, and between perceived choice and recovery of 45 Housing First Lisbon participants. For this purpose, we used a quantitative method and applied three instruments that report perceived housing quality, perceived choice and severe mental illness recovery. The findings reveal a significant and positive association between perceived housing quality and perceived choice, and between perceived choice and recovery, with choice being predicted by housing quality and recovery predicted by choice. These results reinforce the scientific evidence regarding the success of housing first models as a consumer choice-driven intervention, addressing pertinent environmental factors that contribute to housing stability. The study demonstrates that recovery processes can be maximized through services that empower their consumers by allowing them to choose and control the priority and order of the support services received.

The role of pharmacists in caring for young people with chronic illness

Purpose - To explore the perceived and potential roles of pharmacists in the care of young people aged 10-24 years with chronic illness, through the exemplar of juvenile arthritis, from the perspectives of UK community and hospital pharmacists, health service commissioners, rheumatology health professionals and lay advocates. Methods - A sequential mixed methods study design comprising: focus groups with community and hospital pharmacists; telephone interviews with pharmacy and rheumatology stakeholders and commissioners, and multidisciplinary group discussions to prioritize roles generated by the first two qualitative phases. Results - The high priority roles for pharmacists, identified by pharmacists and rheumatology staff, were: developing generic healthcare skills among young people; transferring information effectively across care interfaces; building trusting relationships with young people; helping young people to find credible online health information, and the need to develop specialist expertise. Participants identified associated challenges for pharmacists in supporting young people with chronic illness. These challenges included parents collecting prescription refills alone, thus reducing opportunities to engage, and pharmacist isolation from the wider healthcare team. Conclusions - This study has led to the identification of specific enhancements to pharmacy services for young people which have received the endorsement of a wide range of stakeholders. These suggestions could inform the next steps in developing the contribution of community and hospital pharmacy to support young people with chronic illness in the optimal use of their medication.

Partner relationship in couples living with atrial fibrillation

The aim of this thesis was to describe and explore how the partner relationship of patient–partner dyads isaffected following cardiac disease and, in particular, atrial fibrillation (AF) in one of the spouses. The thesis is based on four individual studies with different designs: descriptive (I), explorative (II, IV), and cross-sectional (III). Applied methods comprised a systematic review (I) and qualitative (II, IV) and quantitative methods (III). Participants in the studies were couples in which one of the spouses was afflicted with AF. Coherent with a systemic perspective, the research focused on the dyad as the unit of analysis. To identify and describe the current research position and knowledge base, the data for the systematic review were analyzed using an integrative approach. To explore couples’ main concern, interview data (n=12 couples) in study II were analyzed using classical grounded theory. Associations between patients and partners (n=91 couples) where analyzed through the Actor–Partner Interdependence Model using structural equation modelling (III). To explore couples’ illness beliefs, interview data (n=9 couples) in study IV were analyzed using Gadamerian hermeneutics. Study I revealed five themes of how the partner relationship is affected following cardiac disease: overprotection, communication deficiency, sexual concerns, changes in domestic roles, and adjustment to illness. Study II showed that couples living with AF experienced uncertainty as the common main concern, rooted in causation of AF and apprehension about AF episodes. The theory of Managing Uncertainty revealed the strategies of explicit sharing (mutual collaboration and finding resemblance) and implicit sharing (keeping distance and tacit understanding). Patients and spouses showed significant differences in terms of self-reported physical and mental health where patients rated themselves lower than spouses did (III). Several actor effects were identified, suggesting that emotional distress affects and is associated with perceived health. Patient partner effects and spouse partner effects were observed for vitality, indicating that higher levels of symptoms of depression in patients and spouses were associated with lower vitality in their partners. In study IV, couples’ core and secondary illness beliefs were revealed. From the core illness belief that “the heart is a representation of life,” two secondary illness beliefs were derived: AF is a threat to life, and AF can and must be explained. From the core illness belief that “change is an integral part of life,” two secondary illness beliefs were derived: AF is a disruption in our lives, and AF will not interfere with our lives. Finally, from the core illness belief that “adaptation is fundamental in life,” two secondary illness beliefs were derived: AF entails adjustment in daily life, and AF entails confidence in and adherence to professional care. In conclusion, the thesis result suggests that illness, in terms of cardiac disease and AF, affected and influenced the couple on aspects such as making sense of AF, responding to AF, and mutually incorporating and dealing with AF in their daily lives. In the light of this, the thesis results suggest that clinicians working with persons with AF and their partners should employ a systemic view with consideration of couple’s reciprocity and interdependence, but also have knowledge regarding AF, in terms of pathophysiology, the nature of AF (i.e., cause, consequences, and trajectory), and treatments. A possible approach to achieve this is a clinical utilization of an FSN based framework, such as the FamHC. Even if a formalized FSN framework is not utilized, partners should not be neglected but, rather, be considered a resource and be a part of clinical caring activities. This could be met by inviting partners to take part in rounds, treatment decisions, discharge calls or follow-up visits or other clinical caring activities. Likewise, interventional studies should include the couple as a unit of analysis as well as the target of interventions.

Changes in the prevalence of breast feeding in preterm infants discharged from neonatal units : a register study over 10 years

Objective: There are indications that the prevalence of exclusively breastfed preterm infants is decreasing in Sweden. The objective was to investigate trends in exclusive breast feeding at discharge from Swedish neonatal units and associated factors in preterm infants. Design, setting and participants: This is a register study with data from the Swedish Neonatal Quality Register. Data from 29 445 preterm infants (gestational age (GA) <37 weeks) who were born during the period 2004–2013 were retrieved. Data included maternal, perinatal and neonatal characteristics. Data were analysed for the whole population as well as for 3 GA groups. Results: From 2004 to 2013, the prevalence of exclusive breast feeding decreased, in extremely preterm (GA 22–27 weeks) from 55% to 16%, in very preterm (GA 28–31 weeks) from 41% to 34% and in moderately preterm infants (GA 32–36 weeks) from 64% to 49%. The decline was statistically significant (p<0.001) in all 3 GA groups. This decline remained significant when adjustments were made for factors negatively associated with exclusive breast feeding and which became more prevalent during the study period, that is, small for GA (all groups) and maternal mental illness (very preterm and moderately preterm infants). Conclusions: In the past 10 years, Sweden has experienced a lower rate of exclusive breast feeding in preterm infants, especially in extremely preterm infants. The factors analysed in this study explain only a small proportion of this decline. The decline in exclusive breast feeding at discharge from neonatal units raises concern and present challenges to the units to support and promote breast feeding.

Film policy in practice: a case study of Scottish Screen’s funding schemes

This thesis examines cultural policy for film in Scotland, from 1997 to 2010. It explores the extent to which the industry is shaped by film policy strategies and through the agency of public funding bodies. It reflects on how Scottish Screen, Scotland’s former screen agency, articulated its role as a national institution concerned with both commercial and cultural remits, with the conflicting interests of different industry groups. The study examines how the agency developed funding schemes to fulfil policy directives during a tumultuous period in Scottish cultural policy history, following the establishment of the Scottish Parliament with the Scotland Act 1998 and preceding the Independence Referendum Act 2013. In order to investigate how policy has shaped the development of a national film industry, a further two case studies are explored. These are Tartan Shorts, Scotland’s former flagship short film scheme, and the Audience Development Fund, Scotland’s first project based film exhibition scheme. The first study explores the planning, implementation and evaluation of the scheme as part of the agency’s talent development strategy. The outcomes of this study show the potential impact of funding methods aimed at developing and retaining Scottish filmmaking talent. Thereafter, the Scottish exhibition sector is discussed; a formerly unexplored field within film policy discussions and academic debate. It outlines Scottish Screen’s legacy to current film exhibition funding practices and the practical mechanisms the agency utilised to foster Scottish audiences. By mapping the historical and political terrain, the research analyses the specificity of Scotland within the UK context and explores areas in which short-term, context-driven policies become problematic. The work concludes by presenting the advantages and issues caused by film funding practices, advocating what is needed for the film industry in Scotland today with suggestions for long-term and cohesive policy development.