Chiara Causier - A thesis submitted in partial fulfilment of the requirements of the degree of Doctor of Clinical Psychology 

Systematic Review of the Literature: Structural barriers to help-seeking in first-episode psychosis: a systematic review and thematic synthesis
Aim: Access to timely treatment is key to early intervention in psychosis. Despite this, significant barriers to treatment remain. In this review we aimed to identify the structural barriers that patients and caregivers face in help-seeking for first-episode psychosis, and the recommendations provided to address these.
Methods: We conducted a systematic review (PROSPERO: CRD42021274609) of qualitative studies reporting structural barriers to help-seeking from the patient or caregiver perspective. Searches were performed in March 2023, restricted to studies published from 2001. Study quality was appraised using Critical Appraisal Skills Programme. Data were analysed using thematic synthesis.
Results: Nineteen papers from 11 countries were included. Across all papers, participants reported experiencing structural barriers to receiving healthcare. For many patients and caregivers, the process of accessing healthcare is complex. Access requires knowledge and resources from parents, caregivers, and healthcare providers, yet too often there is a misalignment between patients’ needs and service resources. Expertise amongst healthcare providers vary, and some patients and caregivers experience negative encounters in healthcare.
Participants highlighted earlier caregiver involvement and greater peer support are potential routes for improvement.
Conclusion: Patients and caregivers face multiple structural barriers, with legislative practices that discourage family involvement, and healthcare and transport costs found to be particularly problematic. Understanding these barriers can facilitate the design of more accessible services for first-episode psychosis. Further research is needed focusing not only on the perspectives of patients and caregivers who have accessed professional help, but crucially on those who have not.
Service Improvement Project: Improving access to secondary mental health services for young Pakistani women: a qualitative study
Background: Almost three quarters of mental health problems start by the age of 25, yet youth are often underrepresented in UK services. This is particularly true for those of ethnic minorities. In this service improvement project, we aimed to understand how young Pakistani women and their parents make decisions to seek help for mental health problems, and the barriers and facilitators that may exist to them accessing professional help.
Methods: Young Pakistani women with experience of severe mental health problems and their parents were recruited from a community sample. Semi-structured interviews were conducted with six young people and two parents. Data were analysed using reflexive thematic analysis.
Results: Pakistani culture and its interplay with British culture strongly influenced the decisions and ability of young Pakistani women and their parents to help-seek, largely through the role of stigma. External stigma, low mental health literacy, and lack of culturally informed services were identified as the most common barriers to accessing care. These barriers fed into the internalised stigma these young women experienced which, through fear of damaged reputation and personal prejudices, posed further barriers to seeking help. Participants highlighted recommendations for both individual-level (e.g., increased education and awareness) and service-level change (e.g., greater choice over care) to facilitate accessibility of professional help.
Conclusions: Young Pakistani women face multiple challenges to accessing care for mental health difficulties, largely surrounding the cultural tensions and stigma they face. Addressing both individual and service-level challenges may facilitate the development of services that are more inclusive and accessible.
Theory Driven Research Project: Fighting OCD together: an experimental study of the effectiveness and acceptability of seeking and receiving emotional support for OCD
Excessive reassurance-seeking in OCD has been linked to the maintenance of OCD, functioning as a type of checking ritual. Current treatments recommend the imposition of the extinction of seeking and providing reassurance; however, this is not well tolerated. Although it has been suggested that the provision of support may provide a more helpful alternative, there is no empirical evidence for this. In the present study, 36 participants with OCD engaged with two personalised semi-idiographic scenarios in which they imagined seeking and receiving reassurance and seeking and receiving emotional support in counterbalanced order. The primary outcome measure was urge to seek reassurance, which was found to significantly decrease in the support condition relative to the reassurance condition regardless of order of presentation. Emotional support was perceived as significantly more acceptable when compared to imagining reassurance in terms of higher ratings of perceived helpfulness in managing emotions, feelings of calmness and closeness, and the sense that they were fighting OCD together. These findings provide preliminary evidence for the value of encouraging the seeking and giving of emotional support as an alternative to reassurance. Implications for clinical work and further research are discussed.

Keywords: access
excessive reassurance seeking
obsessive compulsive disorder
schizophrenia
help-seeking behaviours
ethnic minority
cognitive behavioural therapy
emotional support
diversity
caregivers
systematic review
youth mental health
Advisor: Waite, F
Knight, M