Centre for Youth Mental Health - Theses
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Item“It Was a Nice Place to Be.” A Phenomenological Exploration of Young People’s Experience of Moderated Online Social Therapy (MOST) For First-Episode Psychosis( 2021)First-episode psychosis (FEP) is a serious mental health condition that can effect a person’s thoughts, perception, mood, and behaviour (American Psychiatric Association, 2013) and is often characterised by a “loss of contact with reality (Bosnjak Kuharic, Kekin, Hew, Rojnic Kuzman, & Puljak, 2019).” As it typically emerges in late adolescence and early adulthood (Alvarez-Jimenez et al., 2019), psychosis can significantly disrupt a young person’s confidence and interrupt their social, emotional, and vocational life trajectories (Alvarez-Jimenez et al., 2013; Bucci et al., 2018). While the introduction of early intervention services has improved the short term outcomes for people experiencing psychosis (Cotton et al., 2016; A. Malla et al., 2017), overtime, psychotic disorders are still associated with poor long-term outcomes in regard to education, housing, physical health, employment, social inclusion, and poverty (Alvarez-Jimenez et al., 2012; Cotton et al., 2017). Evidence suggests that long-term maintenance care is required to prevent relapse and to preserve the clinical and functional gains achieved during early intervention (Alvarez-Jimenez et al., 2021; A. Malla et al., 2017). Digital mental health intervention has been identified as one possible way to provide long term maintenance support to young people with first episode psychosis. The use of digital mental health interventions in the treatment, management, and support of first-episode psychosis is a burgeoning area of interest in the mental health field as it presents an opportunity to provide lower intensity treatment over an extended period of time (Alvarez-Jimenez et al., 2019; Bell & AlvarezJimenez, 2019; Gumley et al., 2020). However, while digital mental health interventions have been trialled in first-episode psychosis populations, there is limited research exploring young people’s experiences of using digital technology and engagement with such interventions have tended to vary substantially. A better understanding of the subjective experience of the user is valuable in and of itself and can be used to improve interventions and identify facilitators and barriers to use. Thus, the knowledge gained via an in-depth exploration of young people’s experience could be harnessed to increase engagement levels of digital mental health interventions for first-episode psychosis. Aim: The primary aim of this thesis was to examine young people's experiences of the therapeutic and social network components of a long-term digital mental health intervention for first-episode psychosis. The secondary aim was to investigate young people's perspectives on the development of blended models of treatment for FEP. Two qualitative studies were conducted to achieve these aims. Study One: Study One used an interpretative phenomenological analysis approach to explore young people's subjective experiences of a long-term digital mental health platform, Horyzons, for FEP, with a particular focus on the experience of online therapy and the social network components. Twelve in-depth phenomenological interviews were conducted with young people who used the Horyzons platform to varying degrees. The data was split meaningfully into two sub-studies during the analysis process due to the breadth of information collected. Sub-study one became an exploration of young people's experience of social connection on the Horyzons platform. We found that the social network nurtured a sense of connection among community members. The platform became an embodied experience that gave young people a sense of self-recognition and belonging. This research also identified significant barriers to engagement, including social anxiety, paranoia, internalised stigma, lack of autonomy, and social protocol confusion. Sub-study two explored young people's experience of online therapy and found that the self-directed nature of the platform was beneficial and motivating to some and overwhelming for others. Moreover, the online therapy experience was idiosyncratic and took on different meanings for different young people. The online therapeutic content led to on-demand help-seeking, positive distraction, revision, generalisation and translation, and normalisation. On-demand help-seeking and positive distraction were identified as two ways in which online therapy was experienced differently from face-to-face therapy and spoke to the unique contribution that online therapy can make to a therapeutic intervention. Study Two: Study two used an end-user design approach combined with thematic analysis to explore young people's perspective of blended models of face-to-face and digital treatment in first-episode psychosis. The sample included ten participants. We found that young people strongly endorsed the use of blended models of care, in so far, as it enhances their treatment experience but does not replace the face-to-face care altogether. Increased accessibility to, and continuity of, care, a channel to access posttherapy support from peers, consolidation of psychoeducation and a way to strengthen the bond between a young person and clinician were identified as benefits of blended models of care. Conclusions: This thesis used two qualitative approaches to better understand young people's experience of digital mental health intervention for first-episode psychosis and young people's perspectives on blended models of mental health care for first-episode psychosis. By exploring experience and perspective, this research was able to shed light on different aspects of a digital mental health interventions for first-episode psychosis and identify facilitators and barriers to young people's engagement that has not been previously identified. This new knowledge constitutes a timely and relevant contribution to the field of digital mental health literature.
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ItemFoundations of Support: Interpersonal and personal processes associated with rural-based young people supporting a peer who experienced a traumatic event( 2021)There is limited research on how supporting a peer through a traumatic event is experienced by young people, and how this process occurs specifically within a rural setting. Furthermore, little is known about how this contextual environment can impact on individuals and interpersonal processes. The aim of this research was to understand the experiences of rural-based young people providing support to a peer who has experienced a traumatic event and the interpersonal processes associated with that support. A further aim was to understand how the contextual environment impacted on these individual and interpersonal processes. A qualitative study using a constructivist grounded theory was deemed an appropriate methodology to address the aims of the study and aid in the construction of a theory explaining the phenomenon. The study was based in Gippsland, a rural region which covers the south-eastern part of Victoria (Australia). Participants were recruited via convenience sampling, social media and snowballing techniques. The initial sample consisted of 18 participants, 5 males and 13 females, with a mean age of 16.38 (range 14-19 years). Participants completed an in-depth individual interview (semi-structured as well as broad open-ended interview questions developed based on the literature review). Theoretical sampling was required to obtain further information to better understand the impact of the contextual environment on the individual and interpersonal processes. The theoretical sample consisted of three previous participants and four new participants (n=7). This sample completed a refined interview protocol (based on topics identified by participants in the first interview, and the literature surrounding rural contextual issues). The final sample consisted of 22 participants, 6 male and 16 females, with a mean age of 16.54 (range 14-19). The grounded theory methodology supported the development of a substantive theory – ‘Foundations of Support’, which explained both the contextual influences and the personal and interpersonal processes associated with young people in Gippsland, Victoria, supporting a peer who experienced a traumatic event. Foundations of support highlighted that young people who shared responsibility for supporting their peer went back to life as normal, whereas young people who maintained sole responsibility, experienced mental health problems and felt woven into the mix. This theory implies that providing pathways to reconnecting with place and community, are essential in guiding young people back to their foundations of support, promoting self-regulation and social connection, whilst also reducing the burden of sole responsibility and the woven effect. In order to build a robust and broad theory which is meaningful across a range of contextual settings, future research should focus on testing the ‘Foundations of Support’ theory in populations such as urban youth, ethnic and minority groups, indigenous, Aboriginal or Torres Strait Islanders and other age brackets.
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ItemThe neural correlates of integrated self-other referential processing in social anxiety and major depressive disorders( 2020)Background: Social anxiety disorder (SAD) and major depressive disorder (MDD) are highly comorbid and share impairments in self-referential and social processing. Many naturalistic judgements activate these processes concurrently, which can be referred to as “self-other referential processing”. We sought to examine its neural correlates in young people with SAD and MDD using a novel experimental task. Methods: Fifty six young people aged 16 to 25 with diagnoses of SAD and/or MDD (15 with SAD [M=20.3 years, 60% female], 17 with MDD [M=19.8 years, 53% female], 24 with comorbid SAD and MDD [M=19.8 years, 67% female]) and 76 age and gender-matched healthy controls (HCs; M=20.7 years, 66% female) completed a novel self-other referential processing fMRI task that involved rating how much one related to emotional faces in active conditions, and judging how far apart each person’s eyes were in control conditions. Results: Participants with SAD had more and those with MDD had less activity in social cognitive areas than HCs when processing social information across all conditions and emotion types. Participants with comorbid SAD-MDD exhibited a distinct pattern of neural activity to patients with single diagnoses. Across the whole sample, the activation of reward system areas (the medial orbitofrontal cortex and caudate) in response to increasing relatedness correlated positively with a dimensional measure of social anxiety. Conclusions: Young people with SAD, MDD and comorbid SAD-MDD showed deficits in social processing, but they were not specifically related to self-other referential processing. Dimensional social anxiety symptoms were correlated with reward system activation, suggesting that such symptoms are associated with an overestimation of the hedonic value of social stimuli. These novel findings have implications for our understanding of the neural correlates of SAD and MDD, suggesting that alterations in social processing and reward functioning underlie the impairments in self and social processing that characterise both disorders.
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ItemSuicide clusters in Australian youth: A nationwide study of risk factors and cluster prevention( 2020)Background: Young people have been shown to be two to three times more likely than adults to be involved in a suicide cluster. Yet, despite significant public health investment in the detection and prevention of suicide clusters, there is currently no gold-standard definition of what constitutes a suicide cluster, resulting in significant heterogeneity in way that suicide clusters are operationalised and detected. Further, few studies have examined how these differences influence our understanding of the characteristics, risk factors, and mechanisms underlying different suicide clusters. These gaps in evidence present a missed opportunity for the development of more precisely targeted interventions that aim to avert further suicides during an emerging suicide cluster. Aims and objectives: The broad aim of this thesis was to investigate the different definitions, risk factors, and mechanisms underlying suicide clusters to improve the precision with which communities respond to this public health burden. Specifically this thesis aimed to: 1) identify and compare the characteristics and definitions of suicide clusters using three common definitions of suicide clusters; 2) identify whether social links between cluster members can be identified using nationwide data; 3) quantify the association between exposure to suicide and exposure to suicide attempt on the independent outcomes of suicidal ideation, suicide attempt and suicide death; 4) identify the mechanisms underlying clusters that involve social links between cluster members based on two competing theories, namely the social transmission of suicidal behaviour and assortative relating. Methods: This thesis comprises three empirical studies that address each of the aims above. Study one (Chapter 2) involved a study of suicide clusters in 3027 Australians, aged 10-24, using data from the National Coronial Information System (NCIS). Suicide clusters were identified using: 1) the scan statistic; 2) a systematic search of coronial inquests into suicide clusters; and 3) descriptive network analysis. These techniques were chosen to operationalise three common definitions of suicide clusters, namely those which are greater than statistically expected, those which are perceived as significant, and those which involve social links between cluster members. Study two (Chapter 3) involved a systematic review and multi-level meta-analysis to examine the independent association between exposure to suicide and exposure to suicide attempt on outcomes relating to suicidal ideation, suicide attempt, and suicide. Study three (Chapter 4) examined the mechanisms underlying suicide clusters characterised by social links between cluster members. Individual-level risk factors were identified by examining the free text of police, coroner, autopsy and toxicology reports for the 3027 suicides included in Chapter 2. Evidence of the social transmission of suicidal behaviour (i.e., suicide contagion) and assortative relating were identified by examining the casewise concordance of the demographic, social, and clinical risk factors, as well as the circumstances of death among index and exposed cases involved in a suicide cluster. Lastly time-to-event analysis was conducted to identify the period of risk following exposure to suicide. Main results: Chapter 2 showed that the same data, when analysed in different ways identified markedly different point clusters. This was demonstrated by the significant differences in the location, size, duration of point clusters identified by the three common, yet methodologically different, cluster detection techniques. In doing so, the study showed that different methods for determining suicide clusters may have different implications regarding the scale of intervention that can be implemented. Chapter 3 showed that exposure to suicide is associated with subsequent suicide and suicide attempt, but exposure to suicide attempt is associated with suicide attempt only. From a suicide cluster perspective, results from the systematic review and meta-analysis suggest that exposure to suicide and suicide attempt do not incur uniform risk across the range of suicide, suicide attempt and suicidal ideation outcomes. The findings provide key insights into the potential risk factors associated with suicide clusters and pave the way for future studies involving the potential clustering of suicide attempt and/or self-harm behaviour. Chapter 4 showed young people who were exposed to suicide and were involved in a suicide cluster did not cluster on the basis of pre-existing clinical risk factors. However social factors such as residential remoteness and Aboriginal and Torres Strait Islander background were common risk factors among index and exposed cases. Additionally, young people who were exposed to the suicide of another were more likely to share similar circumstances of death, such as the method of suicide used. Results from the survival analysis shed light on the critical period of risk among young people who were exposed to the suicide of another and involved in a point cluster. These findings showed that the first three months (90 days) following exposure to the suicide of a friend or peer represents a period of heightened susceptibility to point clusters, which has important implications for preventative strategies. Discussion and conclusion: The findings reported in this thesis challenge the one-size-fits all approach to the detection and prevention of suicide clusters, and instead suggest that different suicide clusters may be associated with different characteristics, risk factors and mechanisms.
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Item“It levels you out again but you're not dealing with the trauma”: An exploration into how people with a history of interpersonal childhood trauma and psychosis subjectively experience antipsychotic medications( 2020)Among people diagnosed with psychotic disorders, those with a history of interpersonal childhood trauma (ICT) present with a more complex clinical profile. In addition to experiencing hallucinations/delusions, these individuals can experience a range of post-traumatic stress/trauma-related symptoms and, more specifically, the distress associated with remembering/re-experiencing traumatic events. There is also a high likelihood that people with trauma and psychosis will experience dissociation, depression, anxiety, suicidality, substance use and cognitive impairment. Irrespective of their symptomatic profile, these individuals are often prescribed an antipsychotic medication. Little is known about how these individuals experience the emotional, cognitive and physical effects of antipsychotics or how antipsychotics influence their trauma-related and other non-psychotic symptoms. Thus, this study aimed to explore how people with psychosis and a history of ICT subjectively experience the wide-ranging psychological and physical effects of antipsychotic medications. An embedded mixed-methods research design with a qualitative phenomenological priority was implemented. Nineteen people who were diagnosed with psychosis and had experienced ICT participated in semi-structured interviews. Participants were specifically asked about how antipsychotics influenced their 1) general emotional, cognitive and physical states, 2) trauma-related thoughts, emotions and physical responses and 3) dissociative symptoms (depersonalisation and derealisation). Participants’ interview transcripts were analysed using interpretative phenomenological analysis. The results demonstrated that, for most participants, antipsychotic medications altered the way they experienced their memories of childhood trauma. There were differences between participants in how antipsychotics altered their trauma memories. Some participants indicated that their medication alleviated the frequency and/or intensity of distressing trauma-related thoughts, emotions and/or physical symptoms, while others mentioned that their flashbacks and thoughts of past traumatic events intensified. Participants also reported that, by supressing trauma-related thoughts and emotions, antipsychotics prevented them from confronting or processing their childhood trauma. While participants considered this beneficial in the short term, they recognised that they would need to confront their trauma to heal. As such, having trauma memories supressed by the emotional and cognitive effects of antipsychotics was not considered beneficial in the long term by these participants. There was also a mixed response from participants about whether antipsychotic medications altered their dissociative symptoms. Many participants reported that antipsychotics supressed their emotions and/or impaired their cognitive functioning, while a few mentioned that they were able to think more clearly and concentrate for longer. Many participants also described varying adverse physical effects of antipsychotic medications. The most common were weight gain and movement difficulties. Participants reported that they had tried many different antipsychotics before finding a medication that was somewhat effective in alleviating their psychotic symptoms. This study’s findings suggest that the cognitive, emotional and physiological effects of antipsychotic medications can be experienced as beneficial or detrimental depending, in part, on how they influence trauma-related thoughts/emotions/physical responses and dissociative symptoms. These findings highlight the need for intervention studies that evaluate the effect of antipsychotic medication on the trauma-related/post-traumatic stress and dissociative symptoms of people with a history of childhood trauma and psychosis.