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The overarching aim of the thesis was to enhance understanding of mental healthcare for migrants in Europe, from the perspectives of service users and providers. The thesis is presented as three papers: 1) a systematic review; 2) an empirical study; and 3) a critical appraisal. In Paper 1, a qualitative synthesis of professionals' experiences of and attitudes towards mental healthcare for migrants in Europe is presented. Thematic synthesis of twenty studies identified three themes: 1) the management of multifaceted and complex challenges associated with the migrant status; 2) professionals' emotional responses to working with migrants; and 3) delivering care in the context of cultural difference. Recommendations for professionals and services include increased organisational flexibility; collaboration with voluntary organisations in relation to addressing additional needs and specialist supervision for professionals; reflective practice and networking for professionals; building partnerships with migrant communities; and the adoption of a person-centred approach. Policymakers and commissioners should consider additional funding for services, increased provision of training to professionals, and extending universal access to care to include undocumented and uninsured migrants. Paper 2 is an empirical investigation of Central and Eastern European (CEE) migrants' experiences of mental health services in the UK. Thirteen CEE migrants living in the UK were interviewed. Three themes emerged from thematic analysis of the data: 1) attitudes towards help-seeking; 2) the experience of ethnic in/visibility; and 3) the role of communication in engagement with services. Clinical implications include the need to: provide education to CEE migrants relating to mental health and service availability; train professionals about the difficulties associated with migration and belonging to a minority group; strengthen inter-agency working with voluntary organisations, particularly those specialising in migrant and minority groups; increase collaboration with the CEE community; and adapt clinical practice. Finally, Paper 3 is a critical appraisal of the research process, including the researcher's personal reflections. This paper provides further detail regarding key decisions, the strengths and limitations of the project, and the wider clinical and research implications.

This thesis follows the paper-based format and papers one and two have been prepared for submission to Attachment and Human Development and the British Journal of Clinical Psychology, respectively. The relevant submission guidelines are included in the appendices (Appendix A and B).Attachment theory (Bowlby, 1977a) has prompted a wealth of empirical research in its contribution to adult attachment patterns and subsequent psychopathology in mental health (Holmes, 2001; Wallin, 2007). More recently, attachment theory has been proposed as a suitable framework by which to inform the organisation, design and delivery of mental health services (Goodwin, 2003; Seager et al., 2007) but it is unclear what this would look like in practice. Adopting an attachment-informed service model has key implications for individual and service outcomes and the two papers presented in this thesis aim to contribute to research in this area, followed by a critical review of the research, its relevance and future implications. Paper one is a narrative overview of the literature discussing the practice implications of services adopting an attachment-informed framework, and describes how this might be conceptualised in front-line service delivery. Articles reviewed described the influence of attachment theory in predominantly inpatient, secure forensic and/or psychiatric rehabilitation services, and its application within more generic community mental health services was explored. Paper two aimed to investigate the importance of individual attachment and service attachment to client psychopathology, quality of life, service utilisation and service costs in community-based mental health services. The final section, the Critical Review, critiqued the literature review and aimed to place the research within a wider context. This section considers the findings from the research and the limitations of the study, while also highlighting important issues for services, with implications for clinical practice and future research.

Hispanics are less likely than non-Hispanic whites to use mental health service, even after controlling for various social, environmental, and health factors. Mental health services disparities between Hispanics and non-Hispanic whites have been well-documented and consistent over time. However, very little is known about the impact mental health care organizations have on Hispanics’ access to mental health care, especially since the implementation of the Patient Protection and Affordable Care Act (ACA). The three papers in this dissertation utilize the 2010, 2014, and 2016 waves of the National Mental Services Survey (N-MHSS) to assess the impact of the ACA on Hispanics’ access to mental health care and mental health care organizations’ provision of integrated services. The N-MHSS is a national repository of data on the mental health organizations in the United States. This dataset was created to report the characteristics and client enrollment at mental health care organizations. Paper 1 uses the 2014 N-MHSS to describe the structural characteristics of mental health care organizations according to the proportion of Hispanics they serve and the organizations’ structural characteristics in Medicaid expansion and non-expansion states. Paper 2 uses the 2010, 2014, and 2016 N-MHSS waves to examines the impact of the ACA and the health safety net on Hispanic admissions at mental health care organizations. These three waves were merged together using a repeated cross-sectional design to assess whether Hispanic admissions increased after the implementation of the ACA. The final paper uses the 2014 and 2016 N-MHSS waves to assesses whether integrated care has increased at Hispanic-serving organizations compared with mainstream organizations two years after the implementation of the ACA. This paper also assessed whether the increased funding for integrated services under the ACA has disproportionately affected mainstream organizations compared with Hispanic-serving organizations.