PhDs...

Assessment of functional improvement in the hemiparetic arm following focal rehabilitation intervention

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The complex nature of upper limb function presents a challenge for rehabilitation following neurological injury. Some patients, with relatively mild injury, have potential to recover useful function such as the ability to use the hand to hold and manipulate objects (active function). Others with more severe injury will continue to have a non-functional upper limb, and may require assistance from another person (or their own non-affected arm) to care for the affected limb (passive function). The aim of this thesis was to develop and evaluate a self-report upper limb measure of active and passive function – the Arm Activity measure (ArmA).

A systematic review demonstrated that no suitable measure was available, but provided possible items for inclusion in the ArmA. Patient-selected items were also included from goal setting for spasticity intervention. A modified Delphi consultation was undertaken to reduce the number of items, followed by item confirmation with a larger group of clinicians and pilot testing with patients and carers. The resulting twenty-item measure has two sub-scales of ‘active’ and ‘passive’ function.

Two inter-linked studies were undertaken, firstly to evaluate the psychometric properties of the ArmA, and secondly to undertake a hypothesis-generating cohort investigation of the course of functional changes following spasticity intervention.

Internal consistency evaluated by Cronbach’s alpha was >0.85 for both sub-scales. Kappa coefficients for test-retest reliability were >0.90. Mokken analysis demonstrated unidimensionality for both subscales (Item H >0.5 for all items). Expected convergent and divergent relationships were seen with comparison measures (rho 0.5-0.63). The passive function sub-scale was responsive to change following spasticity intervention. In the cohort study, spasticity initially reduced following intervention and then increased again. Passive function improved and was maintained despite the increase in spasticity.

Adequate psychometric properties were demonstrated for the passive function sub-scale although further evaluation is indicated, particularly for the active function sub-scale.

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Supporting the recovery of black individuals who use adult community mental health services

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Aims and Objectives
The project aims to address the above gap in the existing literature by developing and testing a framework of recovery support for black individuals who use adult community mental health services. The project is being conducted as part of the REFOCUS programme and is structured around the MRC Framework for designing and evaluating complex interventions.

Methods
The study is using an experimental mixed methods design composed of three phases:

Phase 1:  Data from three sub-studies is being used to develop a framework of recovery support.
Sub-study 1: A systematic review and narrative synthesis of existing models of recovery for black individuals.
Sub-study 2: 13 semi-structured interviews which focused on the meaning of recovery. 
Sub-study 3: 5 focus groups assessing the barriers and facilitators of recovery from mental health problems.

Phase 2: The preliminary framework developed in Phase 1 has been used to inform a component of a complex intervention to support recovery: the REFOCUS intervention. 

Phase 3: The effectiveness of the REFOCUS intervention for black individuals will be assessed in a cluster RCT.  The RCT evaluation includes both a quantitative pre-planned subgroup analysis and a qualitative process evaluation both including individuals from black communities. Data from the RCT evaluation will be used to further refine and develop the model of recovery support for black individuals who use community mental health services.

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Improving occupational performance for people with a diagnosed psychotic disorder post discharge from hospital

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The purpose of this study is to develop and pilot an intervention to improve occupational performance for people with a psychotic condition. An admission to hospital and deterioration of mental health are disruptions in life that can result in skill loss and decrease in daily routine and habits.  The intervention aims to address specific problems with occupational performance following discharge for hospital.

The first phase of the study uses qualitative methods to develop an intervention using best available evidence. Focus groups with staff and service users, a literature review of theories and models of occupational performance and a systematic review are carried out to gather the evidence.  A manualised intervention and fidelity scale will be developed, and appropriate outcome measurement tools identified prior to phase two commencing.

 The second phase of the study uses quantitative methods. A case control design is used to evaluate preliminary evidence of effectiveness of  the intervention.  A process evaluation will also be carried out to illuminate the acceptability and feasibility of the intervention.

The Recommendations of this study aim to outline trial parameters to enable this study to be followed by a randomised control trial of the intervention developed.

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Disclosure of a mental health problem in the employment context: Measurement of stigma and discrimination and development of a decision aid tool’

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Introduction
This thesis expands knowledge about an important barrier to finding and keeping work for individuals with a mental health problem: the perception of and response to stigma and discrimination. Disclosure decisions are identified as a key point in which stigma and discrimination become personally relevant to the individual.

Methods
A mixed methods approach was used. After a systematic review, in-depth interviews were conducted with mental health service users. These themes identified were further explored using data collected in three employment contexts: 1) employed; 2) volunteering; and 3) unemployed. These themes and the systematic review were then used to develop a decision aid tool (DAT) to assist mental health service users in reaching disclosure decisions. The initial feasibility and acceptability of this DAT were assessed. In a complementary strand of work a narrative review on measures of mental illness stigma was conducted. A new measure of experienced discrimination (DISCv12) was then developed and psychometrically tested, as the review identified no suitable measure.

Results
Four super-ordinate themes were drawn from the analysis of the in-depth interviews (n=15): 1) public understanding of mental health problems; 2) the employment context; 3) personal impact of labelling; and 4) disclosure needs. These super-ordinate themes and their constituent sub-themes were reflective of the additional interviews (n=30). The finalised DAT demonstrated feasibility and acceptability (n=15). Mean decisional conflict regarding disclosure reduced from 52.0 to 35.5 after completing the DAT. The final DISCv12 demonstrated good psychometric properties (n=86) including inter-rater reliability (weighted kappa range: 0.62-0.95), internal consistency (α=0.78) and test-retest reliability (n=46) (weighted kappa range: 0.56-0.89).

Conclusions
This thesis advances knowledge by developing an empirically based model of disclosure beliefs and behaviours related to stigma and discrimination, by developing and piloting a decision aid tool relating to disclosure decisions, and by providing a new measurement tool to investigate experienced discrimination.

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Thesis passed at viva in March 2011 (decision ratified by KCL May 2011)

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Staff experiences of implementing recovery: a grounded theory study

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Developing a recovery orientation in mental health services is a policy goal in the UK and internationally. Recovery from severe mental illness involves, in addition to treating symptoms and deficiencies, a focus on developing a fulfilling and personally meaningful life. This implies an increased emphasis on personal strengths, positive identity development and the promotion of well-being. Personal well-being is not only a central component of recovery, empirical research also shows its association with improved functioning and resilience and suggests its protective value against the onset or re-occurrence of mental illness.

The promotion of well-being has been a focus of the academic discipline of positive psychology. In this tradition the attention of psychotherapy was shifted away from only repairing the negatives towards an approach directly building positive emotions, character strengths and meaning. One specific method is “Positive Psychotherapy”, which has proved effective in promoting well-being and ameliorating depression in people with common mental disorders.  “Positive Psychotherapy” seems to be a promising approach to also increase well-being in people with severe mental illness, such as psychosis, and hence support their recovery. However, to date neither a theoretical model nor empirical evidence exists for the application for “Positive Psychotherapy” in this client group.

The proposed project aims to test Positive Psychotherapy in a group format with people with a diagnosis of psychosis. The objectives are:
(a) To develop a theory-based and testable model of Positive Psychotherapy for psychosis
(b) To manualise Positive Psychotherapy for psychosis by developing and evaluating an intervention manual
(c) To establish trial parameters through a pilot study.

A phased approach according to the established MRC Framework for Evaluating Complex Health Interventions, including theory development, model building and validation, and an exploratory trial, will be employed to reach the above aims.

This project will adapt and evaluate a promising intervention to improve well-being for the first time for people with psychosis. It will provide the basis for both practical service improvement and empirical evaluation of the intervention in a definitive RCT.

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Measuring how mental health staff support recovery from the service user perspective.

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Background
Recovery has become enshrined in the mental health policy of many countries. This provides a challenge to the way mental health workers have traditionally worked. If staff are to work in a different way to support recovery, there is a need to evaluate this. Some measures have been developed to assess the recovery orientation of staff and services from a service user perspective. None of these existing measures were developed in the UK and none have undergone extensive psychometric evaluation. Both of these facts make it difficult to recommend their use in the UK. This research involves the design, validation and use of a new measure –the INSPIRE-that assesses how service users experience support for their recovery from mental health workers.

Method
This research uses existing measurement design and evaluation methods and is composed of three phases.

Phase One: INSPIRE development

Phase Two: psychometric evaluation of INSPIRE

Phase Three: use of INSPIRE to evaluate the REFOCUS RCT

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