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Systematic Review abstact: Background: Emotion regulation (ER) impairments are a common feature of autism spectrum disorders (ASD). It is believed that by targeting ER difficulties directly, individuals with ASD might be better able to manage their difficult emotions and consequently improve their quality of life. Emerging research has begun to explore interventions aimed at treating ER difficulties in ASD, however, it remains unclear which approaches are most effective. Objectives: This review aimed to evaluate the effectiveness of various interventions targeting ER impairments in ASD. Method: Studies evaluating interventions targeting ER impairments in individuals under 18 years with ASD were included. 772 papers were identified across four databases: Ovid MEDLINE, PsycINFO, Embase, and Global Health. A systematic screening process led to the inclusion of nine papers in the review. Results: This review found promising evidence to suggest that behavioural and CBT-informed approaches, if appropriately adapted, can be effective at improving ER abilities in children with ASD. One study focused solely on mindfulness techniques with adolescents, demonstrating similarly encouraging findings for its application in ER treatment. Conclusions: Most studies comprised small sample sizes and thus, all results are interpreted with caution. Preliminary evidence indicates that ER impairments can be treated using a range of CBT, behavioural and mindfulness approaches. Larger randomised control trials are needed to determine confidently the efficacy of such treatments in this population. Empirical Paper abstract: Objective: Research shows that structured goal-setting enables goal progress and engenders well-being; however, it is not clear the extent to which this is true in executive dysfunction (EDF) populations. This study aimed to determine the effectiveness of a goal-setting intervention, supported by the Brain in Hand (BiH) app, on goal progress and well-being in individuals under 18 years with EDF. Methods: Using a multiple-baseline single-case experimental design, six participants (mean age = 14.8 years; SD = 1.94; male: female 2:1) underwent structured goal-setting sessions, during which goals were identified and broken down into achievable steps. Potential challenges to reaching these goals, along with suggested solutions were also considered. This information was uploaded to participants’ personalised BiH accounts on their smartphones, with scheduled prompts/reminders to encourage progress. Repeated measurements of “happiness” and goal satisfaction ratings were taken each weekday over a period of seven weeks. Outcome measures were administered pre- and post-intervention to determine if there were reliable changes in overall functioning and well-being. Results: Statistically significant improvements were found for goal progress, at a group level. No statistically significant changes were observed in participants’ “happiness” ratings. Two participants demonstrated reliable improvements in everyday functioning, with one showing reductions in negative affect. Conclusion: The findings suggest that structured goal-setting supported by the BiH app has the potential to aid young people with EDF progress towards their goals. Future recommendations are made, including extending the data collection period and investigating gender differences. Clinical implications are also described.

Systematic review: Background: Despite growing evidence showing links between Post Traumatic Stress Disorder (PTSD) and shame, and the protective role of self-compassion in relation to shame and self-criticism, there is no systematic review of the existing literature investigating whether Compassion Focused Interventions (CFI) reduce shame in people with PTSD. Objectives: This review addresses this gap and evaluates the research investigating the impact of CFIs on shame and negative cognitions of the self in adults with PTSD. Method: A systematic review, with no time restrictions, was completed using PsycINFO, Medline, Embase, Web of Science, Psychology & Behavioral Sciences Collection, PILOTS and PubMed. Additionally, relevant websites with articles by key authors in the field of interest were checked. References of included articles were screened to identify other relevant research studies. Results: In identifying only four articles, the review revealed research in this area is scarce. There is evidence that CFIs can lead to reductions in PTSD symptoms, shame and negative cognitions of the self (e.g., self-blame, guilt) in people with PTSD. However, due to a small number of studies included in this review, with mainly weak methodologies, it is impossible to reliably establish the effect of CFIs on people with PTSD. Conclusions: CFIs have a potential to reduce shame and negative cognitions of the self in adults with PTSD. However, due to limited research in this area and existing studies having weak methodologies, further research is needed with more studies incorporating stronger methodologies (e.g., Randomised Controlled Trials comparing CFIs with an active control group). Keywords: self-compassion, post-traumatic stress disorder, shame, negative cognitions, self-criticism Empirical paper: Despite emerging evidence indicating that self-compassion can have protective effects against shame and self-criticism, there is a lack of studies investigating direct effects of self-compassion on state shame and self-criticism when exposed to social stress. This study addressed this gap and investigated, in 62 healthy individuals, whether a brief Loving Kindness Meditation to self (LKM-S, n = 32), known to temporarily increase state self-compassion, can attenuate psychophysiological responses to a psychosocial stress test (Montreal Imaging Stress Task [MIST]) as compared to a neutral emotion induction (NEU, n = 30). An experimental design was used with self-report measures of shame, self-criticism and self-compassion as well as physiological measures of heart rate (HR), skin conductance level (SCL) and heart rate variability (HRV). It was investigated whether LKM-S has a protective effect in terms of reducing state shame and self-criticism when participants were exposed to MIST as compared to NEU. It was hypothesized that participants from LKM-S will have lower scores on state shame and self-criticism post MIST and higher self-compassion levels post MIST in LKM-S as compared to NEU. Additionally, the research used markers of sympathetic and parasympathetic variables to investigate whether LKM-S attenuated physiological responses to MIST. None of the described hypothesis were confirmed. The findings suggest that a brief one-off self-compassion intervention, although it temporarily increased self-reported self-compassion, is not sufficient to protect against shame and self-criticism in the context of a psychosocial stressor.

This paper is made up of three distinct parts: Part 1 presents an introduction to the concept of autism, an introduction to the research around girls with autism and their diagnosis in adolescence, a focus upon the theoretical understandings of self-concept and social identity, and the way that these are viewed through a relativist ontology. Next there is a turn towards the use of discursive and social constructionist paradigms and a focus upon the prominent discourses around autism. Finally, this focusses into a review of the literature into the self-concept and social identity of autistic adolescents and culminates with a focus upon the area of enquiry and the research questions that emerged. Part 2 presents an empirical paper that sets out the research rationale, methodology and results for the study. Findings are discussed, followed by consideration of strengths and limitations, and implications for further research. Part 3 is a reflective and reflexive critical appraisal of the research process and the role of the researcher. It starts with a narrative account of the way the research subject was selected, and how the ontological and epistemological positionality of the researcher impacted the aims, orientation, methodology and data analysis undertaken in this work. It ends with a focus upon the contribution to knowledge and practice that this research makes.

The predictors of postoperative seizure freedom are not clearly defined in the literature. The proposed predictive variables, e.g., age at seizure onset, duration of epilepsy and gender, have not been uniformly agreed upon as useful prognostic tools and there is a need for a large-scale study to identify suitable predictors. An understanding of such predictors would be useful in counselling patients in the preoperative work-up, with a view to create an economically efficient healthcare service in which patients have optimal post-operative outcomes. Many scientific papers reduce postoperative outcomes to seizure freedom exclusively, with limited papers evaluating the impact of epilepsy surgery on depression and anxiety, which can also have profound impacts on quality of life. Epilepsy surgery grants researchers an opportunity to assess how brain functions are affected in the absence of particular cerebral structures. Knowledge of how brain function is affected by a lobectomy is important when consenting patients before surgery and informing them of possible post-operative deficits. One brain region in particular, the mesial temporal lobe, is of particular interest given it houses several structures that are alleged to help in memory formation and spatial cognition. However, there is contrasting evidence about the role of the mesial temporal lobe and the extent to which the mesial temporal lobe is involved in representing the environmental layout, the objects within in, as well as binding to the former to the latter (known as feature binding). In particular, it is not clear whether impairments of visual working memory are specifically spatial or rather generalize across visual feature dimensions (e.g., location, colour and shape) following focal temporal lobe lesions. This thesis attempts to address aforementioned gaps in the literature. Firstly, I provide a comprehensive literature review of epilepsy, including the role of epilepsy surgery in its management. Thereafter, I provide a systematic review of the literature exploring postoperative psychiatric and neuropsychological outcomes in patients who undergo epilepsy surgery in the absence of any pre-operative lesion/s on structural magnetic resonance imaging. Subsequently, I present original data showing the factors that predict post-operative seizure freedom in patients who have undergone resective surgery for epilepsy. The following chapter looks at the predictors of post-operative anxiety and depression in patients who have undergone resective epilepsy surgery. The penultimate chapter explores the factors that predict post-operative changes in working, visual and verbal memory in patients who have undergone resective epilepsy surgery. Finally, in a bench-side study conducted in Saudi Arabia, I studied a cohort of patients who had undergone temporal lobectomies for medically resistant temporal lobe epilepsy to establish whether impairments of visual working memory binding are specifically spatial or generalise across visual feature dimensions following focal mesial temporal lobe lesions. With regards to seizure freedom, I found that pre-operative generalised seizures are less likely to exhibit seizure-freedom than patients without pre-operative generalised seizures. I also found that patients with temporal lobectomies were more likely to exhibit seizure-freedom than patients with extra-temporal. Patients with a unilateral local focus on electroencephalogram and those with a lower frequency of pre-operative seizures were more likely to be seizure free at two years. With regards to anxiety, I showed that postoperative anxiety is improved if patients were female, underwent right-sided cerebral resections or had lateral temporal lobe resections. With regards to depression, patients with pre-operative generalized seizures were less likely to exhibit depression than patients with other seizure types. Patients with left-sided hemisphere laterality were more likely to manifest postoperative depression than patients with right-sided hemisphere laterality. Finally, pre-operative non-generalised seizures were associated with an improved post-operative verbal memory whilst no pre-operative factors were independently associated with improved visual or working memory. With regards to the bench-side study, we showed that mesial temporal lobe pathology is associated with binding impairments that are spatially specific. Our results were in keeping with the idea that the left rather than right mesial temporal lobe structures were specifically involved in spatial binding.

This portfolio thesis has three separate parts: a systematic literature review, an empirical paper, and corresponding appendices. Part One is a systematic literature review that aimed to identify the factors affecting the psychosocial experience of cancer for people with learning disabilities. Eight papers were identified by the database search, the findings of which are reviewed in a thematic synthesis. Four themes were derived from the data: Communication, Feeling Dismissed, Physical Impact of Cancer, and Finding Meaning. The quality of the presented findings is appraised, and implications of the findings and considerations for future research and clinical practice are discussed. Part Two is an empirical paper, which explores the perceptions of healthcare professionals towards cancer screening and BRCA gene testing for females with a learning disability. Six healthcare professionals were interviewed. Thematic analysis was undertaken to analyse the data. Four themes emerged from the date: Unpreparedness, Role of Others, Communication, and Professional Discomfort. Both the research and clinical implications are discussed. Part Three is comprised of the corresponding appendices to the systematic literature review and empirical paper. Also included in this is the first author's reflective statement and epistemological statement, which consider the experience of conducting the research and the researcher's values and philosophical position.

Every year, approximately 800,000 people die by suicide, with an estimated 20 times this figure making a suicide attempt. Developing an understanding of variables associated with suicide risk is important in improving clinical intervention and contributing to prevention. This thesis aims to enhance understanding of suicide by exploring psychological factors associated with suicide ideation and behaviour, including attachment and emotion regulation. Paper one is a systematic review of quantitative empirical research findings, exploring the relationship between emotion dysregulation and suicide ideation and behaviour in adults. Nineteen papers were identified through a systematic search. Results indicated that there was a positive association between emotion dysregulation and suicide ideation and behaviour. However, this was not always present when controlling for other psychological variables. Studies were critically evaluated and a narrative description of findings was presented. Clinical implications and recommendations for future research were discussed. Paper two is an empirical study exploring the relationship between attachment insecurity and suicide ideation and behaviour. Emotion regulation was considered as a potential mediator and betrayal trauma as part of a moderated mediation model. Sixty-seven participants completed self-report questionnaires measuring adult attachment, emotion regulation, suicide ideation, betrayal trauma, depression and hopelessness. Avoidant attachment was associated with suicide ideation. Emotion regulation did not mediate the relationship between attachment insecurity and suicide ideation and behaviour. Findings were considered in light of limitations. Clinical implications and directions for future research were discussed. Paper three is a critical appraisal of papers one and two. Reflections on the research process were provided, including further discussion regarding implications, as well as evaluation and justification of key decisions.

Section A: Theorists have long suggested that the process of decentering may be linked to anxiety. This paper reviewed empirical studies to explore what, if any, relationship existed between decentering and anxiety. A systematic search yielded 16 papers that met inclusion criteria. Studies included were a range of cross-sectional design with simple and multi-variant associations; longitudinal design; causal-comparative design; and intervention designs. The review found good evidence from studies of sufficient quality to the conclusion that there is a negative association between decentering and anxiety. Evidence was not found for further comment on the nature of the relationship. Research that directly targets decentering as an independent variable while measuring anxiety as the dependent variable is one of the recommendations of this review. Section B: Anxiety presentations remain the most prevalent mental health condition and are associated with poor quality of life as well as an immense health care costs to the NHS. Transdiagnostic approaches that target the mechanisms of change in established therapies offer promise in developing briefer, more targeted interventions and have the potential to be applied across mental health presentations. The STAGE approach was developed as a two-step technique to directly target decentering and perspective broadening, hypothesised active ingredients of CBT and mindfulness therapies. This study sought to use a pilot and feasibility design to explore a new brief online self-help format of STAGE for those with self-reported anxiety. Overall, the STAGE programme was found to be mostly acceptable to participants. Additionally, trends and preliminary data were tentatively encouraging. However, attrition rates were considerable, and it was considered unfeasible to recruit and run a full-scale randomised control trial (RCT) without further adaptations to the STAGE format. Study limitations are discussed as are the implications for theory, research and clinical practice.

Research evidence shows that although Cognitive Behavioural Therapy (CBT) is a highly effective therapy and the gold standard in the treatment of Obsessive-Compulsive Disorder (OCD), a significant proportion of adults with OCD do not experience a clinically meaningful reduction in OCD symptoms post-treatment. As CBT for OCD is a challenging therapy, this may, at least in part, reflect poor patient engagement. The modest response rate also invites exploration of other psychological therapies that may enhance treatment outcomes. The first aim of the thesis was to examine patient engagement in CBT for OCD. This was achieved through a systematic review and meta-analysis of the magnitude, predictors and reasons for patient non-adherence, specifically refusal, dropout, session attendance and CBT task engagement, to CBT for OCD (paper 1), followed by a qualitative exploration, employing thematic analysis, of patients' perceptions of the barriers and facilitators to engagement in group CBT for OCD (paper 2). The second aim was to explore whether mindfulness-based interventions (MBIs) show potential for adults with OCD. Towards this aim, the thesis first examined the relationship of obsessive-compulsive symptoms with mindfulness and self-compassion in a large sample of treatment-seeking adults and tested whether mindfulness and self-compassion contributed to explaining obsessive-compulsive symptoms over and above depression severity, obsessive beliefs and distress tolerance (paper 3). This was followed by a qualitative analysis of patient experiences of MBIs, specifically mindfulness-based ERP (MB-ERP) and Mindfulness-based Cognitive Therapy adapted for OCD (MBCT-OCD) to elucidate whether these MBIs were perceived as acceptable and potentially efficacious treatments for OCD and to explore how they might achieve their positive effects (paper 4). After a general introduction, the four papers are presented, followed by a general discussion of results, a reflection on the strengths and limitations of the thesis and its clinical and research implications.

Background: Social feedback, i.e., receiving social rewards like approval, acceptance, interest, or praise or conversely, receiving social punishments like being excluded, rejected or criticised in social interactions, is a critical source of social information. There is abundant evidence suggesting that, compared to healthy controls, individuals with depression show more negative experience of social feedback, have a more negative expectation of social feedback, and potentially show dysregulation of negative emotions evoked by negative social feedback. The brain structural and functional alterations associated with changes in anticipation and response to social feedback in these groups is however unclear. The aims of this PhD thesis were to address multiple aspects of social feedback processing in depression: (1) Anticipating and consuming social feedbacks; (2) Processing the expectancy violation of social feedbacks. (3) Emotion regulation of social feedbacks. Methods: Multi-modal approaches, including fMRI, non-invasive brain stimulation, EEG, eye-tracker recording and cognitive testing were employed as research tools for my project. The large-scale MRI analysis of the existing neuroimaging data such as UK biobank were also used. Paper one. This study provides evidence that depression is characterized by distinct neural alteration in processing monetary and social incentives. Paper two. This study highlights an important role of expectancy violation in the brain dysfunction of social feedback perception and evaluation in depression. Paper three. This study suggests a causal role for rVLPFC in down-regulation of negative emotions produced by social exclusion. Paper four. This study highlights a more specific causal relationship between rVLPFC rTMS and reappraisal success of social pain compared to physical pain. Paper five. This study found that the tDCS-activated rVLPFC could improve emotion regulation capacity on social exclusion. However the findings do not suggest that individuals with high depressive mood benefit from a single-tDCS session on the emotion regulation of social exclusion. Paper six. This study demonstrates cultural differences in emotional reaction to and emotion regulation of social exclusion. Paper seven. This study provides evidence linking loneliness to grey matter volume changes in ACC and VLPFC in depression. Conclusions: Taken together these papers show neural deficits contributing to abnormal social feedback processing (anticipation, experience, expectancy violation, and emotion regulation) in individuals with depression. These results may have potential implications for clinical practice on how abnormal brain could be normalized in certain targeted interventions, and highlight the importance of protecting individuals with depression from specific social risk factors such as the negative social feedback.

Aims: The aim of this thesis portfolio was to examine the psychological impact of experiencing a traumatic event in young children and parents. Factors that may predict an individual’s psychological response following a traumatic event were also explored. Design: This portfolio contains two main papers and supporting chapters. The first paper, a meta-analysis, reviewed the prevalence of post-traumatic stress disorder (PTSD) in preschool-aged children. The second paper, an empirical study, examined the impact of a child’s admission to a Paediatric Intensive Care Unit (PICU) on parents. In both papers, factors contributing to higher emotional distress were explored. The additional chapters include further information and an overall discussion and critical review. Results: The meta-analysis revealed that a significant minority of preschool-aged children met the diagnostic threshold for PTSD following direct exposure to trauma. The empirical paper indicated a high prevalence of parents who were vulnerable to future psychological distress (PTSD and depression) following their child’s PICU admission. Pre-trauma factors, including pre-existing mental health difficulties, and peri-trauma appraisals strongly predicted parent vulnerability to psychological distress. These factors predicted parental vulnerability over and above medical severity markers. Conclusions: Children under six years old can develop PTSD, with similar prevalence trends to older children following different trauma types. It is therefore important for clinicians to be aware of symptoms in young children, and for appropriate interventions to be developed. A high proportion of parents of are at risk of developing longer-term psychological distress following their child’s PICU admission. Importantly, pre-trauma psychological factors, and peri-trauma appraisals, predict parental psychological vulnerability. The importance of applying appropriate diagnostic criteria, and using screening measures to identify individuals are discussed. Early identification can trigger support that will likely benefit both the individual and their family.

Aims: This portfolio aims to aid understanding of processes of mental health stigma relating to “Borderline Personality Disorder” (BPD), and how developments in the nosology of Personality Disorder may affect the perceptions of laypeople in legal settings. It contains a review of the evidence concerning clinician attitudes and reactions toward BPD, and an empirical investigation of the effect of International Classification of Diseases-11 (ICD-11) terminology upon jury decision-making and perceptions. Design: This portfolio consists of an general introduction to the topic, a systematic review of clinician attitudes and responses to BPD, an empirical paper outlining a quasi-experimental study of the effect of the “Severe Personality Disorder, Borderline Pattern” ICD-11 classification upon jury decision-making, an extended methodology, and an overall discussion and evaluation section. Findings: The systematic review confirms that negative attitudes toward BPD remain a problem in clinical groups and are likely to relate to both unhelpful stereotypes and challenging therapeutic interactions, implicating a need for well-evidenced training programmes. Various methodological limitations of this literature are discussed. The empirical paper identified significant differences relating to increased perceptions of dangerousness and the need for segregation and coercion when a defendant’s mental health problems were described as a “Severe Personality Disorder, Borderline Pattern”, although differences in jury-decision making were not observed. Value of work: This work indicates that BPD remains a particularly stigmatised diagnosis among clinicians, and this is likely to remain the case until well-evidenced training programmes are made a crucial component of ongoing professional development. This work makes a novel contribution to the study of jury perceptions and decision-making and is possibly the first to assess the effect of the new ICD-11 classification upon processes of stigma toward Personality Disorder. It has important implications for the way in which clinicians communicate clinical information in legal settings.

Eating disorders have the highest mortality rate of any mental health diagnosis in the United Kingdom. They are also highly co-morbid with anxiety and depression. It is possible that some of the maintaining factors of anxiety and depression are also present in eating disorders - particularly safety behaviours. One safety behaviour that has received little attention in eating disorders is reassurance-seeking. To enhance understanding of this safety behaviour, specifically in eating disorders, this research set out to: 1. understand the relationship between reassurance-seeking and clinical anxiety and depression; and 2. develop and validate a reassurance-seeking measure specific to eating disorders. A systematic review identified 19 papers that examined the relationship between reassurance-seeking and clinical depression or anxiety. The findings of this review suggest that the more a person seeks reassurance, the worse their symptoms of anxiety and depression are. Moreover, the pattern of reassurance-seeking across the two diagnoses had several differences (e.g., those with depression seek reassurance about social threats, while those with anxiety seek reassurance about general threats). However, the findings were based on a limited number of papers and thus should be treated cautiously. Limitations and implications for clinical practice are also discussed. Recommendations for future research include the need to investigate reassurance-seeking in other disorders (e.g., eating disorders). Subsequently, the development and validation of a reassurance-seeking measure specific to eating disorders was undertaken. One hundred and sixty-seven participants completed the Reassurance-Seeking in Eating Disorders Questionnaire (RSED-Q), which was developed for this research. Additional measures completed by participants addressed anxiety, depression, eating pathology, social anxiety, and general reassurance-seeking. Factor analysis was undertaken on the responses of the RSED-Q. Six factors emerged, which were meaningful both statistically and psychologically. The six factors showed strong internal consistency, good test-retest reliability, acceptable concurrent validity, and strong clinical validation. The RSED-Q predicted eating pathology more strongly than did the more generic measure of reassurance-seeking. Thus, the RSED-Q was more useful in explaining eating pathology than existing measures of reassurance-seeking. Limitations are discussed, and recommendations are made for addressing reassurance-seeking in clinical practice in eating disorders. Recommendations for future research include using a specific rather than generic measure of reassurance-seeking, and to extend this work into experimental designs to determine causality.

Close to 800,000 people die by suicide every year. There are various risk factors which increase suicidal risk, including having a mental health condition, physical illness, debt and unemployment. It is a global trend that men are at a greater risk of death by suicide. However, risk factors alone do not help us to understand why people die by suicide. Psychological models have attempted to conceptualise these risk factors into theories which help us to understand suicidal behaviour. However, they do not account for men’s elevated risk of death by suicide. It appears that the factors associated with male suicide are complex and warrants further research attention. This Large-Scale Research Project (LSRP) adds to the limited literature in this area. It is made up of two qualitative papers which aim to provide an in-depth exploration of the factors associated with male suicide. A prior suicide attempt is the biggest risk factor for a future death by suicide. Therefore, both papers present the findings of research using samples of men with lived experience of having attempted suicide. Paper one reports a systematic review of the qualitative literature which aimed to better understand the factors associated with men’s suicide attempts and to integrate these findings into a theoretical understanding of male suicide. Eleven studies were included in the review which were assessed for their quality and contribution to the literature. The findings from these studies were synthesised using a meta-ethnography approach. The synthesis identified that the men’s suicide attempts were experienced in the context of feeling disconnected from themselves, others and the world. Many interconnecting factors accounted for this disconnection, including feelings of loneliness, early adversities, substance use, psychological pain, feeling different, experiencing rejection and factors related to masculine gender norms. Feeling disconnected led to experiences of hopelessness. It was from this position that the men viewed suicide to be a solution to their distress. The synthesis identified how reconnection with the self and others provided turning points towards a more hopeful future. Paper two reports a grounded theory analysis examining the role of self-directed disgust in male suicide. Self-disgust, whereby aspects of the self are perceived as “revolting” or “contaminated”, has been associated with some mental health difficulties. To date, qualitative research has not examined self-disgust in males, nor in suicidality. This was the aim of paper two. Nine men who had attempted suicide took part in an interview which explored self-disgust and their suicidality. The interview data was analysed using constructivist grounded theory. This approach acknowledges the role of the researcher in the analysis process and fits with the researcher’s position on the social construction of knowledge and understanding. What emerged out of the analysis, was that self-disgust did not explain the participant’s suicide attempts in their entirety; instead, self-disgust interacted with other endured emotional experiences and feelings of worthlessness. The combination of this endured distress provided a context for the participants to perceive themselves as unable to cope and experience feelings of disconnection and hopelessness. It was from this position that suicide was seen as a solution to their psychological pain. During this process, many disgust-related properties (such as seeing oneself as repellent or fearing exposure of one’s “disgustingness”) increased the men’s suicide risk. Self-disgust appeared more pervasive in the lives, and suicidality, of men with a history of multiple traumas. The findings of this LSRP support current theoretical accounts of suicide (e.g. hopelessness, suicide as a solution to psychological pain), whilst also providing novel insights into male suicidality. What emerged out of both analyses was how the experience of being disconnected worsened men’s distress and exacerbated suicide risk. Paper two builds on our understanding of suicidal men’s disconnection and psychological pain by highlighting the prominence of self-disgust within these factors, particularly in those with a history of childhood abuse. The analyses provide some support for the theory that masculine gender rules and norms may increase men’s suicide risk (for example, leading men to conceal distress). However, it should be noted that men who conceal their distress may be unlikely to participate in research. Additional limitations are discussed in each paper. Despite this, there are methodological strengths to this LSRP, including methods to increased trustworthiness and quality. Furthermore, both papers used analytic methods which are grounded in their respective data sources. This LSRP has implications for clinical psychology and the wider healthcare context. This includes risk assessment and the benefits of exploring disconnection and fostering reconnection. Future research could explore the current findings and the effectiveness of intervening with high levels of self-disgust. Evaluating these interventions will further advance our understanding of working clinically with men at risk of suicide. By disseminating this LSRP, it is hopeful that the findings (and the voices and bravery of the research participants) will prompt further clinical and research exploration of male suicide.

This thesis aims to increase clinical understanding of depression and anxiety in people living with Chronic Fatigue Syndrome/Myalgic Encephalomyelitis (CFS/ME), a disabling longterm condition for which there is currently no known cure. Two clinical papers are presented. Each examines potentially relevant psychological mechanisms. Due to the lack of effective medical treatments for CFS/ME, clinical focus is presently the management of physical symptoms, primarily with a view to reducing levels of fatigue (White et al., 2011). At a research level, there has been greater examination of factors associated with fatigue, with associated depression and anxiety being under-researched. This is despite the high levels of reported co-morbidity (Larkin & Martin, 2017), and evidence for the dynamic interplay between mental and physical health (Kiecolt-Glaser et al., 2002) The role of psychology in supporting people with CFS/ME is mired in controversy. Examination of co-morbid mental health difficulties in CFS/ME has been hampered by symptomatic overlap with depression (Griffith & Zarrouf, 2008), methodological concerns regarding previous psychological research and treatment (Laws, 2017; Vink & Vink-Niese, 2019) and concerns raised by patient activist groups (Kelland, 2019). On the one hand, critics caution of the 'psychologisation of physical illness' (Gaudsmit & Gadd, 1991; Richman & Jason, 2001); on the other, the rejection of psychology as a relevant discipline risks neglecting the research and treatment of co-morbid mental health difficulties. Greater understanding of associated psychological factors could inform the development of evidence based, CFS/ME specific therapeutic interventions, aimed at reducing co-morbid depression and anxiety. Such targeted interventions would complement a multi-disciplinary approach to CFS/ME and would not seek to refute potentially underlying organic pathology. Potentially predisposing personality traits has been one controversial area of research into CFS/ME. Perfectionism has attracted attention (Kempke et al., 2015), driven in part by clinical observations (Surawy et al., 1995) and arguably stereotyping (Deary & Chalder, 2008). However, this may remain a valid area of research with regards to co-morbid depression and anxiety; perfectionism has been found to be a trans-diagnostic risk factor for a range of both physical and mental health conditions (Egan, Wade, Shafran, 2011), and higher levels of perfectionism have been evidenced in people living with CFS/ME (White & Schweitzer, 2000). It is therefore clinically important to consider the potential relationship between perfectionism and emotional distress in physical health populations, including CFS/ME. However, research to date has focussed on the relationship between perfectionism and fatigue, as well as perfectionism as a predisposing risk factor for CFS/ME. Within the CFS/ME population, the association between perfectionism and depression and/or anxiety is under-researched, hence the selection of the question addressed in Chapter 1: What is the relationship between perfectionism and co-morbid depression and anxiety in people living with CFS/ME? Chapter 1 systematically reviews the existing evidence of a relationship between perfectionism and either depression or anxiety, in this patient group. This process identified 7 relevant studies reported in 8 papers. Several factors of perfectionism were explored. Consistent with the wider literature and psychological theory, narrative synthesis indicated maladaptive perfectionism was consistently associated with depression. However, evidence for associations with other aspects of perfectionism was inconsistent. The relationship between perfectionism and anxiety in CFS/ME was identified as an under-researched area. The review was prepared for submission to the Journal of Psychosomatic Research and formatted accordingly (see Appendix A). The journal was chosen because of its focus upon the relevance of psychological processes in physical health. Findings of the review are intended to guide directions for future research, in addition to therapeutic interventions which seek to reduce depression in this patient group. Chapter 2 examines the potential applicability of the Self-Regulatory Executive Function (S-REF) model of emotional distress (Wells & Matthews 1994) to understanding depression and anxiety experienced alongside CFS/ME. This model predicts that prolonged distress arises not from symptom-related appraisals or thought content per se, but rather metacognitive beliefs about worry and/or rumination, which drive unhelpful thought processes and responses; this is termed the cognitive-attentional syndrome (CAS; Wells & Matthews 1994). Two types of metacognitive belief are theorised to be of particular importance in activating and maintaining the CAS: positive metacognitive beliefs about the usefulness of worry, e.g. 'Worrying helps me cope', and negative metacognitive beliefs about the uncontrollability and danger of worry, e.g. 'When I start worrying, I cannot stop'. The study found metacognitive beliefs accounted for a significant proportion of the variance in both depression and anxiety, when controlling for demographic and clinical variables including level of fatigue. Negative metacognitive beliefs, lack of cognitive confidence and cognitive self-consciousness and the CAS emerged as significant independent statistical predictors of depression. Positive metacognitive beliefs, negative metacognitive beliefs and the CAS emerged as significant independent statistical predictors of anxiety. Overall, results provided support for the S-REF model. The relationship between positive metacognitive beliefs and depression was fully mediated by the CAS. Relationships between negative metacognitive beliefs and both depression and anxiety, and positive metacognitive beliefs and anxiety were partially mediated by the CAS. The paper is intended for submission to the British Journal of Health Psychology (Appendix B), selected due to the focus on all aspects of psychology related to health, including the management of chronic illness. Findings are intended to have implications for clinical interventions, specifically aiming to reduce co-morbid anxiety and/or depression in people living with CFS/ME.

Initially, researchers proposed that Fragile X syndrome (FXS) should be called AFRAX syndrome because it was thought to be caused by an autism gene (Gillberg, Persson, & Wahlström, 1986). However, as research into FXS has progressed and an exploration of the behavioural phenotype has taken place important differences have emerged. The systematic review (Paper 1) aims to delineate a behavioural phenotype for Fragile X Syndrome (FXS). Ten papers were included in the review. All papers were of a standard to demonstrate a behavioural phenotype for FXS. There are attributes of the FXS behavioural phenotype that meet the criteria for both Attention Deficit Hyperactive Disorder (ADHD) and/or Autism Spectrum Condition (ASC). However, there is robust evidence to support a broad FXS behavioural phenotype comprising: 1) social behavioural and communication difficulties, 2) emotional regulation difficulties, 3) repetitive and restrictive behaviour and speech. Several recommendations for research and clinical practice are discussed. The aim of the empirical study (paper 2) was to examine if there are differences between the behaviour phenotype profiles of those with FXS who have a diagnosis of ASC and those that do not. Parents were asked to complete an online questionnaire that included the Social Responsiveness Scale (SRS), the Wessex Questionnaire, and standard demographic information. The findings of the 38 parents who completed the questionnaire are discussed below. Finally, the research review (Paper3) will explore the author’s research process. This includes a discussion about the decisions to undertake the research, as well as a review of the methodological limitations, implications for policy direction, further research and clinical implications.

Broadly speaking the dissertation is concerned with the repetition compulsion (RC) and the question of why we repeat; the motivation and form of agency behind repetition. A review of existing literature indicates that there is little consensus concerning these points and that interpretations of the concept vary widely, resulting in a loss of construct validity and utility. In the aim of remedying this state of affairs, I return to Freud's Beyond the pleasure principle; his most comprehensive attempt to answer the question of why we repeat undeniably painful and damaging experience. In the paper Freud delineates an observed phenomenon, that of RC, and follows this descriptive account with a theoretical explanation based on the proposel for the first time of a dual instinct theory. My feeling is that the paper stands at a theoretical crossroads; a point where Freud was strongly nudged in a new theoretical direction suggested by mounting clinical evidence – that of prioritising object relating – but chose to turn back in support of drive theory instead. I argue that with the eventual movement towards prioritising the object, observed in object relations theory, the question of the relationship between RC and its negation of the pleasure principle was forgotten; discarded along with Freud's dual instinct theory. Freud's basic statement on the mechanics of RC can be read as, 'we repeat instead of remember and in these instances what we do not remember is due to repression'. I would say this differently after taking Fairbairn's thought into account as 'we internalize instead of remember and we repeat because of what we have internalized'. For Fairbairn the primary target of repression is neither memories nor impulses, but rather internal(ized) objects and parts of the ego bonded to them, that is object relationships. Following these developments and concerning my own research question, a predominantly Fairbairnian object relations account provides key theoretical entities/processes, that are consolidated in the form of an initial explanatory hypothesis, which is put forward for investigation across multiple cases. The hypothesis, which according to the methodology employed, is necessarily a tentative one (open to reformulation), states broadly that 'dynamically, RC will occur as an outcome of the externalization of a repressed internal object relationship'. Using published case studies as data, I identify the dynamic (as opposed to etiological) causes of RC activity according to whether they qualify as necessary conditions. Analytic Induction is employed as a method of identifying relevant causal conditions, defined in dispositional terms, and my broader aim has been to develop a systematic research approach that employs a conception of causality in terms of tendency or disposition.

A wealth of perceptual load theory research has suggested that different types of attentional demand can have opposite effects on perceptual processing: high perceptual demand reduces such processing whereas high cognitive demand increases it. However, this distinction has not been made within the eating behaviour literature. This thesis applied perceptual load theory to multiple aspects of eating behaviour. A series of behavioural studies tested whether processing of food-related cues and information related to consumption would also be reduced by manipulating the perceptual demand in a central task. Papers one and two used established perceptual load paradigms to investigate external and internal processing of food-related cues. Paper one established that both attentional processing and recognition accuracy of external food stimuli were reduced by high perceptual load. There was tentative evidence that some individual differences (uncontrolled eating, hunger and body mass index) in the recognition accuracy of food stimuli persisted even under high perceptual load. Paper two found that high perceptual load also reduced appetitive-related thoughts. This effect was found across individuals, regardless of the number of appetitive-related thoughts reported under low perceptual load. Papers three and four adapted the perceptual load task to allow simultaneous food consumption. Paper three found no evidence that high perceptual load reduced flavour awareness or influenced intake. Paper four found that participants were unable to respond to internal satiety signals when engaged in the high perceptual load task. This was reflected by failure to reduce intake and experienced satiety in response to consuming a high energy preload. Overall, these studies have suggested that perceptual load theory is a valid framework for understanding eating behaviour. This has implications for both the eating behaviour and attention literatures. Most importantly, perceptual load theory could be used to predict the situations in which attention can be a help or a hindrance to appetite control.

A literature review, empirical study and critical review were conducted into the role of self-conscious emotions (SCEs) following trauma. SCEs such as shame (evaluation of the self), guilt (evaluation of behaviour) and self-disgust (disgust directed towards the self) can cause significant distress and may be particularly high among survivors of trauma. Research has focused on individual SCEs in isolation, often using terms for the different SCEs interchangeably. Therefore, the literature review synthesised the qualitative literature on experiences of SCEs as a whole, among survivors of childhood sexual abuse. Fourteen papers were identified and synthesised using the thematic synthesis method. Three themes emerged: What the abuse means about me, (Dis)connection from others, and SCEs in the recovery journey. Within each theme was a tension between contrasting positions. The self was experienced as both powerlessly vulnerable and potently bad. Connection with others was both deeply threatening and a haven from SCEs. SCEs were both inescapable and the route to healing. Disclosure was instrumental in recovery but could be either de-shaming or re-shaming depending on the response received. The empirical paper examined the relationships between reluctance to disclose traumatic experiences, posttraumatic stress (PTS) and SCEs. Adults with experience of trauma were recruited online (n=443) and completed psychometrics measuring SCEs, reluctance to disclose and PTS. Shame and self-disgust, but not guilt, were significantly correlated with reluctance to disclose and PTS. Self-disgust but not shame moderated the relationship between reluctance to disclose and PTS. Among participants who reported sexual trauma, both shame and self-disgust moderated the relationship between reluctance to disclose and PTS. Reluctance to disclose predicted PTS at all but the highest levels of self-disgust/shame. The critical review reflected on issues of parallel process with the research, the importance of cultural context in understanding SCEs, and implications for clinical psychologists in practice.

Three papers are presented as a thesis for partial fulfilment for the Doctorate in Clinical Psychology (DClinPsy). The first two are presented as papers for submission to the Journal of Autism and Developmental Disorders (JADD), which presents papers related to Autism Spectrum Disorders (ASD) and Developmental Disabilities. The third paper is a reflective paper on the process of undertaking the former two. This is not prepared for publication. Paper 1 is a systematic review of the methodological quality of extant research of 'co-morbid' Autism Spectrum Disorder in children and young people with Fragile X Syndrome. It reviews 13 methodologically sound peer reviewed papers and presents a qualitative synthesis of findings. The synthesis highlights the direction of impairment of particular ASD behavioural phenotypes and a trajectory model for the development of ASD traits in FXS. Paper 2 presents an empirical study of gender differences in FXS and comorbid FXS and ASD (FXS+ASD) presentations, also considering the impact of intellectual disability. The study utilised an online platform and accessed participants via the Fragile X Society database. Participants were parents of children with a diagnosis of FXS. They completed a series of questionnaire measures, which indicated the sample did not differ significantly according to gender; severity of ASD traits was not associated with cognitive ability; and the presence of ASD traits increased with age. The latter finding supported the trajectory model suggested in Paper 1. Paper 3 provides a considered critique and reflective evaluation of the process of undertaking the previous papers. It provides a personal iterative reflection into the impact of the author's prior experiences and the impact of these on the direction of the research thesis. As well as additional reflection on challenges and limitations of the research process; cumulating in highlighting the transformative nature of the research process and the plan for dissemination of findings.

This thesis has been prepared in paper based format. It focuses on the treatment acceptability of psychological interventions for suicidal ideation and behaviours; what influences it and how it impacts on engagement with the intervention. Papers 1 and 2 have been prepared for submission to the British Journal of Psychiatry (Appendix A) and the Journal of Psychology, Crime and Law (Appendix B) respectively. Paper 1 provides a comprehensive overview of treatment acceptability research among psychological interventions for suicidal experiences. Fourteen studies were identified that satisfied inclusion criteria for the review. The findings, strengths, and limitations of the studies and the methods for assessing treatment acceptability as a whole are considered throughout the review and recommendations for future research are made. Theoretical and clinical implications are also discussed. Paper 2 explores male prisoners' experiences of engaging in a short-term intensive cognitive behavioural intervention for suicide prevention whilst in prison. The factors that positively and negatively influenced the treatment acceptability of the intervention are discussed. These findings are then used to make recommendations for future intervention delivery in prisons, and for future research in this area. The strengths and limitations are also discussed. Paper 3 is a critical reflection of the submitted papers and research process as a whole. The strengths and limitations of the presented research, methodological considerations and implications for clinical practice and theory are discussed and directions for future research are highlighted.

The thesis focuses on the effectiveness of psychological interventions for treating self-harm, suicide attempts, thoughts and behaviour in people experiencing/diagnosed with borderline personality disorder. The thesis also reports on an investigation of the association between basic emotions in suicide ideation and suicide potential, beyond that already explained by known clinical risk factors such as hopelessness and depression.1 Paper 1 provides a comprehensive systematic review and meta-analysis of the available research on the effectiveness of psychological interventions for suicide prevention in borderline personality disorder. The review aimed to evaluate the effectiveness of psychological interventions in reducing the frequency of self-harm, suicide attempts and severity of suicidal thoughts and behaviour over time. It also set out to determine which interventions were the most effective in reducing suicide risk. The evidence so far suggests that dialectical behaviour therapy is effective for treating self- harm, suicide attempts, suicide ideation in borderline personality disorder and that these benefits are likely to be maintained over 12 months. However, the non-significant gains from other types of interventions such as cognitive and behavioural approaches, psychodynamic psychotherapies and organisational interventions might simply reflect the small number of trials conducted among a small number of participants. It is likely that larger trials would show benefits. Therefore, further research is needed in order to provide solid evidence of effectiveness, cost-effectiveness and implementation potential. Paper 2 describes an investigation into the role of basic emotions in suicide ideation and suicide potential. A total of 101 participants from mental health inpatient and community services completed study questionnaires. The results indicated that suicide ideation and suicide potential presented with different emotional profiles. Emotions such as anger, disgust and fear seemed more relevant to suicide potential, whilst sadness appeared more pertinent to suicide ideation. Multiple regression analyses found that hopelessness and depression predicted suicide ideation, whilst anger, disgust and hopelessness uniquely predicted suicidal potential. The clinical and research implications and limitations are discussed within the paper. Paper 3 provides a personal and critical reflection on the research process. It highlights and discusses clinical and theoretical strengths and limitations of the two papers and considers the methodological processes in more detail. Further reflections on how practice could be adapted in line with the findings are given. Future directions for research are considered, in the hope of maintaining the drive for research with this vulnerable and often overlooked population.

This portfolio has three parts: Part one is a systematic literature review, that aimed to explore staff experience of the implementation of Intensive Interaction within their places of work with people with learning disabilities and/or autism. Nine research papers were analysed using thematic synthesis. Three higher-order themes were generated: 'Personal Doubt, Discordance & Discomfort,' 'A Turning Point' and 'Needing Implementation at All Levels.' The strength of the empirical evidence is evaluated, and findings are discussed in terms of their implications for future research and clinical practice. Part two is an empirical paper, which explores mothers' experiences of Intensive Interaction. Six participants were interviewed. Results were analysed using interpretative phenomenological analysis. The findings suggest that Intensive Interaction was experienced as a beneficial approach and helped some mothers to feel connected with their child. It was also perceived to challenge assumptions and stigma related to people with learning disabilities and/or autism and it is important that the approach is accessible. Clinical and research implications are discussed. Part 3 consists of a set of appendices relating to both the systematic literature review and the empirical paper. Also contained within these appendices are a reflective statement and an epistemological statement, which consider the researcher's experience of conducting the research and the philosophical position and assumptions underlying the research.

There is very little research for females with Fragile X Syndrome (FXS) examining their ASD behaviours, with most research focusing on males. This thesis examines the prevalence of ASD in FXS and the specific behavioural and psychological phenotype for girls with FXS. Literature Review: Whilst up to 60% of males with full-mutation Fragile X syndrome (FXS) meet criteria for autism spectrum disorder (ASD), the prevalence and nature of ASD in females with FXS remains unclear. A systematic literature search identified papers reporting ASD prevalence and/or symptomatology in females with full-mutation or pre-mutation FXS. Meta-analysis estimated pooled prevalence of ASD for the full mutation at 17% (95% CI 11 to 24%), and for the pre-mutation 3% (95% CI 0% to 17%), using a quality effects model. Whilst papers highlighted a number of social and repetitive difficulties, characteristic profiles of impairment are not clear. Possible associations of ASD traits with IQ and levels of fragile X mental retardation protein are suggested, but data are equivocal. Research Report: Whilst Fragile X Syndrome (FXS) is the most common inherited single-gene cause of intellectual disability and Autism Spectrum Disorder (ASD), research is dominated by male samples, and the understanding of ASD-related behaviour and other behavioural/psychological characteristics in females remains relatively unestablished. Parents/caregivers of girls with FXS were compared on ASD-related behaviours, including sensory difficulties, together with ability, mood, activity levels and challenging behaviour with those of boys with FXS and typically developing children. A number of behavioural/psychological difficulties are less pronounced in girls than boys with FXS, but they exceed those associated with typical development. This study also provides the first evidence of sensory processing difficulties in girls with FXS and suggests that they may relate to other elements of ASD-related behaviours and not to lower ability in girls with FXS.

Adolescence is an important developmental period for the self. It is also a time when young people are particularly vulnerable to depression. Despite this, researchers have neglected to examine how young people spontaneously describe their self and how the self is disrupted in adolescent depression. The aim of the four papers in this thesis is to describe the content of the self in young people and examine associations between the self and depression. Adolescents (n = 822) were recruited from three UK secondary schools, one in Northamptonshire and two in Wiltshire. They completed a measure of self-concept, The Twenty Statements Test (Kuhn & McPartland, 1954) and depression symptoms, the Mood and Feelings Questionnaire (MFQ; Costello & Angold, 1988). A sub-sample (n = 584) completed a measure of the possible self, a variant of the ‘I Will Be’ Task (Rathbone, Salgado, Akan, Havelka & Bernsten, 2016). Data from the TST were combined and one large dataset is used in all papers included in this thesis. MFQ data were also combined and is presented in Papers 3 and 4 only. Data from the ‘I Will Be’ Task is described in Paper 4 only. Paper 1 describes data of adolescent generated self-images. They are also presented in a freely available database. The majority of self-images used by adolescents were positive ‘Traits’. These data were compared to adult self-images and demonstrated that adults most often used ‘Social roles’ to describe the self. Paper 2 presents the development of an adolescent-specific classification scheme to categorise self-images into ‘aspects of the self’. Young people most often described themselves in relation to their personal attributes, relationships with family members and their peer group. This classification scheme was used in Paper 3. In the application of this classification scheme in Paper 3, the valence of the self rather its complexity was associated with more severe symptoms of depression. This was consistent with the cognitive theory of depression (Beck, 1967). Adolescents with a more positive self had less severe symptoms of depression. In Paper 4, the possible self and depression symptoms were examined. The valence of possible selves was associated with depression symptoms suggesting that young people with more severe symptoms of depression had a more negative possible self. Together, these results of the four papers suggest that an adolescent ‘self’ is different from an adult ‘self’ and presents an adolescent-specific classification scheme devised to use for this population. These findings also provide partial support for the cognitive theory of depression and suggest that improving self-evaluation in the treatment of depression in young people may be helpful.

Exposure to a traumatic event is associated with a number of adverse outcomes, including the development of posttraumatic stress disorder (PTSD). A significant number of adults currently living with PTSD also have at least one dependent child in their care. Yet, little is understood about how parental PTSD may impact parenting outcomes and the wider family dynamic, specifically from the parent’s perspective. The aim of the current thesis was to gain a deeper understanding of the potential impacts of parental PTSD. Paper 1 presents a systematic review of the parental PTSD literature, investigating the association between parental PTSD and impaired parenting behaviours. While this review found evidence to suggest that parental PTSD may impair certain parenting outcomes, given the limitations of the studies reviewed, only tentative conclusions could be drawn. Paper 2 investigated parental symptoms of PTSD following a trauma experienced by their child (i.e., parental indirect trauma), as well as examining the cross-over effects of the parent’s and child’s mental health on one another. Building on this, in the same sample Paper 3 investigated the impact of parental PTSD, depression and anxiety following their child’s trauma on observed parenting behaviours during two separate tasks. Some findings from Paper 3 were unexpected, highlighting our lack of understanding of parents’ experiences following trauma exposure. Thus, Paper 4 comprised a qualitative study of UK parents with PTSD examining the perceptions of the consequences of their PTSD for their parenting outcomes. Taken together, findings from Papers 2, 3, and 4 offered multiple perspectives on how and why parental PTSD impacts parenting and family dynamics in a Western context. Paper 5 extended these findings to explore the experiences of parents living with PTSD and residing in a high adversity South African township. The overall findings highlight the multiple challenges that parental PTSD can present, and the complex interplay between parental experiences of trauma/PTSD and their parenting role.

The Research of Borderline Personality Disorder: Within the United Kingdom (UK) many clinical psychologists are detached from the traditional medical model, which imposed diagnostic categories for mental health (Kinderman, Read, Moncrieff, & Bentall, 2013). Clinical psychologists have often advocated for a holistic formulation-based approach, which can incorporate the psychological, biological and social aspects of the individual (Johnstone & Dallos, 2014). The recently published Power Threat Meaning Framework (Johnstone et al., 2018) outlines a conceptual alternative to traditional models to combine psychological, sociological and biological aspects of the person. Despite this, the predominant models in many mental health services within the National health Service (NHS) rely on a medical diagnostic-based model. Many of these diagnoses can be stigmatising for the individual but personality disorder arguably remains the most controversial of all mental health diagnoses. Borderline Personality Disorder (BPD) has been defined in the most recent version of the Diagnostic and Statistical Manual for Mental Disorders (DSM5) as a pervasive pattern of instability in affect, interpersonal relationships and impulsivity (American Psychiatric Association, 2013). To get a diagnosis based on the DSM5 criteria, people must meet at least five of the nine defined indicators for BPD. The wide range of subsequent combinations that form a diagnosis of BPD means that two people meeting criteria for a diagnosis may only have one symptom in common (Biskin & Paris, 2012). The most recent version of the International Classification of Diseases (ICD-11; World Health Organisation, 2018) has moved from a categorical approach to diagnosis to a continuum-based approach for personality disorder. The term BPD, however, is still consistently used in healthcare and even in reference to adolescents. The diagnosis is even more controversial in adolescents due to uncertainty around the development of identity at this age (Shapiro, 1990) and the impact that this stigmatising label may have on a person going forward (Rusch et al., 2006). Research suggests however, that BPD traits are present in adolescents (Johnson, Cohen, Kasen, Skodol, & Oldham, 2008) and may predict lifetime chronicity and outcome (McGorry, 2013). Whilst some people may find a diagnosis to be helpful because it explains their difficulties and provides a direction for treatment, others find labels to be a barrier to recovery (British Psycholgoical Society, 2015). The author has reservations about accepting use of this medicalised language but is aware that we cannot ignore that difficulties may exist in young people that can have long term costs to their development and wellbeing. To understand these difficulties and provide early interventions that are effective for young people, it is difficult to not use categories associated with the difficulties. We acknowledge however, the need for the use of this language to be challenged in practice. Thesis Overview: There are two separate papers contained within this thesis. The first is a systematic review, which aimed to assess the association of rumination with dysregulated behaviours that are often present in people with a diagnosis of BPD. These associations were specifically assessed in children and adolescents under the age of 19 years. A systematic search of three databases resulted in 30 studies being found which met all of the inclusion and exclusion criteria. These studies measured numerous types of rumination and dysregulated behaviours. The studies were assessed against a quality framework, which revealed varying levels of quality across the studies. As there were limited studies of high quality and a paucity of evidence for the different types of rumination and behaviours assessed, it was difficult to draw conclusive results from the review. Methodological issues and suggestions for future research were discussed. The second paper in this thesis is an empirical study which sought to understand how adolescents' beliefs about emotions' malleability is associated with Borderline Personality traits and cognitive emotion regulation strategies. This study tested whether adolescents in a mental health inpatient setting would increasingly use cognitive emotion regulation strategies that are generally accepted as more helpful (i.e. cognitive reappraisal) versus those viewed as unhelpful (i.e. rumination). Whilst rumination can at times be helpful, for example dwelling on past mistakes may help a person adapt and improve for similar scenarios in future, higher levels of rumination is generally considered to be more unhelpful for emotion regulation (Kring & Werner, 2004). Higher use of cognitive reappraisal on the other hand, is generally considered to be a more helpful strategy and associated with better wellbeing (Haga, Kraft & Corby, 2009). The importance of beliefs about emotions in mental health was highlighted through the results of this study. The use of virtual reality for psychoeducational purposes was shown to be beneficial for this population. Relevant literature is highlighted throughout the discussion and the limitations of the research are discussed. The information in the two chapters is supplemented by material in the appendices for purpose of examination, which includes publication guidance and documents provided to participants.

Maltreatment in childhood has been linked to a range of physical and mental health difficulties. It is recognised as a major human rights and public health concern that has significant personal, familial, societal and economic consequences. Numerous systematic reviews and meta-analyses have focused on the effects of childhood emotional abuse (CEA). Healthcare providers make important decisions based on systematic reviews, however the quality is often unknown. The first paper is a systematic review of systematic reviews and meta-analyses on the link between CEA and later mental health difficulties. This includes a narrative synthesis of results and a quality assessment using the Assessment of Multiple Systematic Reviews 2 (AMSTAR 2; Shea et al., 2017) with the aim of providing clarity for service providers' decision making. Results from high-quality reviews show a link between CEA and a range of later mental health problems. The implications of these findings are discussed. The second paper is an evaluation of a new psychology service, which was commissioned to meet the mental health needs of children and young people (CYP) with complex trauma histories. The service is providing attachment and trauma informed training for front line staff. Results showed that staff knowledge and confidence increased over the course of training and their worries decreased. Staff perception of how supported they felt also increased, but their wellbeing did not. The service used a variety of measures, two of which were bespoke to the service, so principal component analyses were run to help the service create the most parsimonious measures possible. The final paper is a critical reflection on paper 1 and 2. Decision-making processes are outlined, along with strengths and weakness of the research and clinical implications. The research is situated within national and local policy and context, and plans for dissemination are discussed.

Systematic Literature Review: A systematic literature review explored quantitative papers investigating shame in clinical eating disorder (ED) groups. Following searches of four databases, 30 papers were deemed relevant to the current review and were selected for inclusion. Included studies suggested that shame was significantly correlated with ED symptoms, and that shame was significantly higher in ED groups compared to healthy control groups. Several variables were identified that may affect the relationship between shame and ED symptoms. The results suggested that shame is high in groups diagnosed with an ED but that the variables that affect this relationship have not been fully explored. Empirical Research Project: Research into the group Compassion Focused Therapy for Eating Disorders (CFT-E) protocol has found encouraging results (Gale et al., 2014), but little research has been conducted into individual CFT-E. This research aimed to provide the first qualitative investigation of therapists' understanding of the benefits, challenges and process of individual CFT-E (Part A) and provide a qualitative comparison of the benefits and challenges of group and individual CFT-E (Part B). Participants were therapists who conducted CFT-E in their clinical practice. For Part A, four therapists completed three qualitative interviews per client over the course of individual CFT-E interventions. For Part B, six therapists completed a qualitative interview about the benefits and challenges of individual and group CFT-E. For Part A, the thematic analysis created two major themes: "the therapeutic process of CFT-E" and "working through fears, blocks and resistances in therapy". For Part B, eight themes were created using thematic analysis which reflected benefits and challenges of group and individual CFT-E. The research described the therapeutic process of individual CFT-E and highlighted the importance of fears, blocks and resistances. Clinical implications and suggestions for future research were discussed.

In the first chapter, a systematic literature review explored the experiences of people with learning disabilities (LD) transitioning from long-term, residential care to community-based alternatives. Socio-political changes over the decades have resulted in many people with LD experiencing change to their ccommodation and care. Qualitative research exploring these experiences for people with LD was reviewed, adopting a meta-ethnographic approach. Nineteen papers were included in the review, and subsequently analysed and synthesised. Two over-arching themes regarding people with LD's experiences of residential transitions were identified; From trauma to the unknown; and Striving to belong. The findings highlighted the impact of moving on people with LD, therefore theoretical and clinical implications were discussed. The second chapter presents the findings of an empirical paper, which explored the experiences and perceptions of people with LD who have been diagnosed with a 'personality disorder' ('PD'). Under Transforming Care, more people with LD and complex needs are likely to move to the community. Therefore, the experience of receiving and living with a 'PD' diagnosis was investigated in people using current, community-based services. Eight people were interviewed, and the data analysed through use of Interpretative Phenomenological Analysis. Four super-ordinate themes were developed: Knowledge is power - Diagnosis as the domain of professionals; Understanding difficulties through a trauma lens; The stigma of diagnosis - Feeling different, seeking acceptance; and Taming the 'beast' inside - The journey towards regaining control. Clinical and research implications were discussed. In Chapter 3, a critical appraisal compared the findings of the two papers, whilst exploring the rationale for the research, the concept of 'PD', and the impact of Transforming Care on iv people with LD. Methodological considerations and implications for clinical practice were also discussed.

Approximately 800,000 people die by suicide every year. Moreover, for every fatal outcome approximately 20 people attempt to take their own life. Therefore, increasing our understanding of the vulnerability factors and acute states that trigger suicide and related behaviours is vital in improving suicide prevention efforts and initiatives. This thesis aims to contribute to the evidence base by examining attachment in relation to suicide-related outcomes and, specifically, the role of psychological mechanisms in this relationship. Paper one is a systematic review of quantitative empirical research investigating the role of psychosocial mechanisms in the attachment-suicide relationship. Fifteen papers were identified, most of which carried out mediation analyses. Studies were extremely heterogeneous and there was limited overlap with respect to the psychological mechanisms under investigation. However, there is preliminary evidence that suggests a range of predisposing, precipitating and crisis-state factors mediate the association between attachment styles and suicidality. Studies were critically evaluated and findings were discussed in the context of a developmental model of suicide. Areas for further exploration are considered and clinical implications discussed. Paper two is an original empirical study investigating the mediating role of reflective functioning between adult attachment and suicidality. Sixty-seven participants completed self-report questionnaires measuring adult attachment, suicidal ideation, reflective functioning, depressive symptoms and hopelessness. Mediation analyses did not support an indirect effect of either attachment dimension on suicidal ideation via mentalization impairments. However, a direct relationship was established between avoidant attachment and suicidal ideation. Findings are considered in light of the limitations and cross-sectional methodology. Future research directions are recommended, and clinical implications outlined. Paper three is a critical reflection that aims to provide insight and reflections on the research process. Explanations and justifications of key decisions are offered, and reflections are made in respect to the study design, methodology, recruitment, data analysis and personal experiences of the researcher.

Both the literature review and empirical paper address the impact of childhood victimisation; while the literature review focuses on long term impact of child abuse within the context of future parenting, the empirical paper discusses the more immediate effects of childhood victimisation in the form of cyberbullying. While current literature acknowledges the impact of child abuse on mental health and physiological responses, little is known about the impact of childhood abuse on later parenting ability. This review therefore focuses on understanding the role that a maternal history of child abuse plays in the development of attachment relationships with her child. In particular, this paper discusses the mother child attachment relationships in the context of the child's attachment style, maternal sensitivity and maternal availability. Cyberbullying is prominent within school aged children, however few studies have focussed on using qualitative approaches to understand experiences of cyberbullying. Therefore, this empirical paper aims to provide an understanding of the psychological experiences of children who have been cyberbullied. A qualitative approach using Interpretative Phenomenological Analysis was adopted in order to gain an in depth understanding of experiences. The empirical paper discusses key themes which arose, including the impact of cyberbullying victimisation on self identity and psychological distress. My own experiences of the research process are explored within the reflective paper. This paper uses one model, Gibbs' (1988) reflective cycle, in order to guide the reflective process. The paper addresses the challenges experienced when separating the role of researcher and practitioner and the learning process of the role of researcher. These concepts are explored in relation to learning about Interpretative Phenomenological Analysis, the process of interviewing participants, the believability of the information obtained within the interviews and the literature review process.

This portfolio thesis consist of three parts; a systematic literature review, an empirical report and supporting appendices. Part one is a systematic literature review in which empirical papers that study the relationship between identity in adolescents and self-harm is reviewed. A systematic search of databases identified eight studies. A narrative synthesis of the findings was produced alongside the methodological quality of the articles. The implications of the review and directions for future research are discussed. Part two is an empirical paper which used a qualitative methodology to explore possible continua which exist in the narratives of university students who have experiences of self-harm. The paper used a categorical-content and holistic-form analysis to investigate the narratives. The findings are discussed and implications for future research proposed. Part three consists of the appendices which support the systematic literature review and the empirical paper. The appendices also include a reflective statement which focuses on the research process.

This thesis explores individual and interpersonal risk and resiliency factors in primary and secondary trauma across three individual papers. The first paper is a systematic review examining the role of social cognition in the relationship between attachment style and post-traumatic stress disorder (PTSD). The review synthesises the findings of six studies that met the inclusion criteria. Collectively, the results indicate that social cognition has a mediating role. The review suggests that insecure attachment style is a risk factor and secure attachment is a resiliency factor in PTSD. However, it was not possible to draw firm conclusions due to the small number of heterogeneous studies reviewed. The clear need for future research is discussed. Suggestions are made for the use of attachment and social cognition approaches in the psychosocial treatment of PTSD. The second paper is an empirical study investigating individual characteristics, secondary trauma, and burnout in police sexual and violent offending teams. The study used a sample of specialist police staff (N=78) who completed an online questionnaire survey. The results indicate that coping self-efficacy, dispositional mindfulness, and psychological flexibility are resiliency factors and insecure attachment style is a risk factor for secondary trauma, burnout, and mental ill-health. Suggestions are made for the use of mindfulness, acceptance and commitment therapy, and attachment approaches in promoting a resilient police work force. The final chapter expansively discusses the implications of both papers for future research, theory development, and clinical practice. Collectively, the findings suggest that attachment style may serve as an individual and interpersonal risk or resiliency factor in primary and secondary trauma. The socio-interpersonal model of PTSD is referenced as encapsulating the thesis findings in the wider trauma literature.

This thesis comprises three papers, aiming to explore the overlap between Autism Spectrum Disorder (ASD) and Borderline Personality Disorder (BPD) and explore the development of a new measure of camouflaging behaviour. The first paper consists of a literature review examining the connections and comparisons to be made between ASD and BPD. In total, 11 studies met the inclusion criteria and consisted of case studies and quasi-experimental studies. In line with prior research, shared features were noted between the conditions - emotional recognition and regulation difficulties, interpersonal issues and self-injurious behaviour. Rates of comorbidity were found to vary. Condition specific profiles were also explored and the importance of recognising comorbid individuals as a high risk group was identified. Research and clinical implications are discussed. The second paper describes an empirical research study investigating the development of an original measure of camouflaging behaviour. 247 participants, recruited online, completed questionnaires pertaining to autistic traits and traits of social anxiety, and a proposed measure of camouflaging behaviour - the Conscious Social Strategies Questionnaire (CSSQ). Exploratory factor analysis revealed a four factor measure comprising masking strategies, avoidance strategies, an absence of strategies and compensatory strategies. Significant gender differences were also found. Strengths and limitations of the study are explored. The final discussion paper suggests developing current clinical guidance, regarding assessment and intervention of ASD and BPD to prevent misdiagnosis and promote the consideration of comorbid diagnoses. In addition, detailed suggestions for future research and theory development are discussed, including qualitative approaches to exploring ASD and its overlap with mental health conditions. Further studies to validate the CSSQ are also explored. To conclude the paper, my personal reflections on completing this thesis are discussed.

Background. Mindfulness-based Cognitive Therapy (MBCT) is a relapse-prevention treatment for people in remission from major depression (rMDD). The neuropsychological mechanisms of MBCT are largely unknown. The key theoretical mechanisms of MBCT include self-compassion and rumination, with other mindfulness-based studies suggesting mechanisms across domains of attention, emotional processing, and cognitive flexibility. The aims of this thesis were to investigate the neuropsychological and neuroimaging mechanisms of MBCT in rMDD and to investigate relationships with relapse six months beyond MBCT. Paper One. 40 MBCT, 33 Treatment As Usual (TAU), and 42 healthy volunteers (HVs) took part. Experimental tasks for self-compassion and rumination were completed at baseline and post-session, alongside self-report questionnaires. Results showed increases for self-compassion following MBCT, with non-specific reductions for rumination. Paper Two. 40 MBCT, 33 TAU, and 42 HV participants took part. Tasks of attention, emotional processing, and cognitive flexibility were completed at baseline and post-session. Results showed increases in positive emotions post-MBCT, with non-specific changes for face emotion recognition and affective attentional bias tasks both post-MBCT and TAU. There were no changes over time for sustained attention or cognitive flexibility. Paper Three. 16 rMDD participants completed baseline and post-MBCT fMRI tasks of sustained attention and self-blame. Results showed reduced activation over time in the bilateral dACC in self-blame contrasts but no activation changes for sustained attention. Paper Four. 69 rMDD participants (38 MBCT & 31 TAU) completed task-based and self-report assessments up to six months follow-up. Non-relapsing MBCT participants showed increased self-compassion post-session which was maintained in follow-up. MBCT non-relapsing and TAU participants showed reduced rumination post-session and in follow-up. Conclusions. MBCT encourages a move towards more self-compassionate, positive processing but does not alter more automatic, bottom-up levels of processing. MBCT initiates a process for change beyond the course, particularly for self-compassion. Findings have theoretical and clinical implications and extend our understanding of the mechanisms of MBCT in rMDD participants.

This thesis explores the experiences and perceptions of healthcare professionals working with people with eating disorders (EDs). Paper 1 is a metaethnography on the lived experiences of healthcare professionals working with people with EDs; Paper 2 is a qualitative study exploring the perceptions of clinicians working in adult ED services towards the concept of the 'anorexic voice' (AV), and Paper 3 is a critical examination of papers 1 and 2.

Paper one is a literature review of ten empirical studies. It reviews what is known about the relationship between killing in combat and PTSD, exploring the question within a military and veteran population. The findings highlighted that those who kill in combat are more likely to report greater severity of PTSD symptoms, although there is some disparity. Other factors, such as victim characteristics and gender, may influence this relationship. Some of the studies were limited by lack of a representative sample and generalisability. There were also issues with transparency, which limits the reliability of some of the conclusions made. Paper two is an empirical study. This was internet-mediated research which explored the relationship between PTSD, guilt, shame and moral injury in a British veteran population. 104 participants took part in the study. A standard multiple regression analysis was conducted on the data. Findings indicated a significant relationship between PTSD and moral injury. The results did not support the hypothesis that guilt and shame would predict moral injury. The findings are discussed, along with their clinical implications, limitations and direction for future research. Paper three is an executive summary. This has been written as an accessible document intended for dissemination of the findings of the empirical study to a veteran and general population. The research method, findings and clinical implications have been summarised within this report.

Objective The aim of this literature review was to examine and summarise research investigating the relationship between coping and post-traumatic stress disorder (PTSD) symptoms in adults who have experienced trauma of a sexual nature. Trauma of a sexual nature was chosen as women are more likely to develop PTSD symptoms and be sexually assaulted. Method In May 2017; MEDLINE, CINAHL, PSYCInfo, PSYCArticles, SPORTDiscus, eBook Collection, PsycBOOKS, Web of Science, Cochrane Library and the British Library EThos were searched. Additional studies were hand searched from reference sections of identified studies and related reviews. Results Seventeen papers were identified and are included in the review. All of the papers used quantitative methods, and all looked at the relationship between coping to PTSD symptoms in adults who had been sexually assaulted . Conclusions The findings suggest there is a relationship between coping and PTSD symptoms in adults who have experienced trauma of a sexual nature. In particular there appears to be a relationship between maladaptive coping and increased PTSD symptoms, and maladaptive coping styles should be targeted during interventions. However the findings need to be considered with caution due to methodological flaws. Future research looking at the relationship is needed in different samples including males, and a much broader approach to research in this field is needed.

This thesis focusses on the topic vicarious post-traumatic growth (VPTG). The thesis has been written in the format of four papers: a systematic review, two empirical papers and a critical reflection paper. Paper one presents a systematic review of quantitative studies exploring VPTG in health professionals. Eighteen studies were identified that fulfilled the reviews inclusion criteria. A narrative synthesis was completed. Results indicated an array of variables have been explored in relation to VPTG. The reviews clinical implications, recommendations of future research and limitations of the review are considered. The first empirical paper (2a) presents a Q-Methodology study aimed to explore the views of VPTG in staff members working within a specialist cancer centre. A two-factor solution evolved from the Q-sort analysis, factor 1 - 'enriching and exposing to the transience of life.', factor 2 - 'connection neighbouring disconnection'. Recommendations for future research, as well as, clinical implications are discussed. The second empirical paper (2b) presents a quantitative study of VPTG in staff members working within a specialist cancer centre. 40 staff members completed an adapted version of the Post-Traumatic Growth Inventory (PTGI) and professionals' quality of life (ProQOL) scale. Results indicated an array of relationships between VPTG, ProQOL and staff members demographics. Clinical implications and recommendations for future research are considered. Paper three presents a critical reflection on the process of completing this thesis. Unlike the other papers, this paper is not intended for publication. Personal and professional development reflections are offered. A dissemination of research results is also shared.

Suicide is a significant public health problem that is now prioritised in many healthcare agendas in attempts to prevent future suicide. It has a devastating impact not only for the tragic loss of life but also for the bereaved family and friends and professional services. A considerable amount of research has been devoted to understanding the risk and resilience factors for suicide and the mechanisms that lead to both suicide ideation and suicide behaviour. Although significantly advancing understanding of suicide less is known about the cognitive processes involved in the initiation and maintenance of suicide ideation, a known risk factor for suicide behaviour. In the first paper, models and understanding of suicide are considered alongside current understanding of the attitudes held towards suicide. A systematic literature review was conducted examining the relationship between attitudes held towards suicide and suicide ideation and behaviour with 44 articles identified. A clear association was found between accepting attitudes towards suicide and suicide behaviour. There was some inconsistency in the literature with the relationship between attitudes towards suicide and suicide ideation. Clinical and theoretical implications are discussed with future research suggested. Incorporating an individual's attitude toward suicide into a risk assessment and formulation will allow for a more detailed understanding of an individual's presenting risk of suicide. The second, empirical paper, provides the first evidence of a relationship between metacognitive beliefs about suicide ideation and suicide ideation. Experience sampling methodology was utilised to examine this relationship. Both positive and negative metacognitive beliefs about suicide ideation are held in those currently experiencing suicide ideation. There is a significant relationship between these beliefs and suicide ideation even when known correlates of suicide are controlled for (defeat, entrapment, negative affect and hopelessness). Stronger metacognitive beliefs about suicide ideation are associated with increased suicide ideation. The results are considered in terms of the clinical and theoretical implications with suggestion that future research continues to develop an understanding of the role of metacognition in both suicide ideation and behaviour. The final paper provides a critical reflection on the research process overall. A more detailed account of the methodological approach of both papers is provided with consideration of the paper's strengths and weaknesses. Additional theoretical considerations are made with further suggestions for future research with the hope of continuing development of a metacognitive understanding of suicide.

Episodic Future Thinking (EFT) is the ability to imagine oneself experiencing events in the future (Atance and O'Neill, 2001). This cognitive ability is often referred to as future Mental Time Travel (MTT) (Berntsen & Jacobsen, 2008). The first part of this thesis is a systematic review and narrative synthesis of 16 papers that critically evaluates the relationship between EFT and measures of anxiety. Interest in this topic was generated from the theoretical and clinical accounts of anxiety that make reference to the expectation of future life events. Whilst there is not consensus across the papers, the review indicates some preliminary support in favour of a positive correlation between anxiety and frequency of EFT. It also discusses results that suggest how anxiety is associated with EFT that has abstract and negative content. Consideration for the clinical implications of the findings are also reviewed. The second part of this thesis is an empirical paper that investigates whether there is a direct relationship between the recall of episodic memory (past MTT) and the ability to engage in EFT (future MTT). It also examines whether deficits in MTT can be explained by an impaired search and retrieval strategy, as opposed to fragmented scene representation. Two female patients with focal hippocampal damage and documented autobiographical memory impairment, were asked to describe six events from their past and imagine six events they could potentially experience in their future. The GaltonCrovitz-Schiffman cue-word technique (Crovitz-Schiffman, 1974; Galton, 1879) was used to generate event descriptions. The patients were then prompted to elaborate on their descriptions using a pre-determined list of questions. The level of detail in their unprompted and prompted descriptions of past and future events was compared with five age-matched neurotypical controls. The empirical paper presents two preliminary findings. Firstly, that scaffolding, in the provision of verbal cues assisted both patients to provide more detail for their past events. Secondly, that there may be a dissociation between the two directions of MTT; one of the patients displayed a strong trend towards a selective deficit in her prompted future descriptions.

The thesis is comprised of three sections. The first is a Literature Review covering studies published in the English language that investigate mentalizing skills amongst adolescents either with diagnosis of Borderline Personality Disorder or with behavioural traits characteristic of this condition. There is increased acceptance the psychological difficulties and behaviours that comprise the diagnosis of BPD in adults begin in childhood & adolescence. The Review examines the studies to date investigating the role of mentalization in the onset and maintenance of these difficulties, with suggestions for further research in this area. The second section describes a quantitative study exploring mentalization functioning of a group of adolescents who have been adopted, compared with a group of age and gender-matched non-adopted adolescents. Early adversity (e.g. child abuse and neglect, admission into foster care) has been associated with a range of later life negative outcomes, including mental health. For the adopted group, analyses were also undertaken to explore for relationships between current functioning (emotional, behavioural, mentalization, communication skills) and early experiences. Results of statistical analyses are presented, followed by discussion. The study findings are considered with respect to areas for future research. References for the first and second papers are included after each paper, respectively. The third section consists of Appendices, including a Public Domain briefing paper, quality estimations of the research studies reviewed, and a summary table of each study article. Information for participants, and consent and ethics documentation relating to the empirical paper, are also included.

This thesis is presented in two volumes; the research component (Volume One) and the clinical component (Volume Two). Volume One presents three research papers focusing on understanding interventions and change processes for people with severe and enduring mental health problems. The first paper is a meta-analysis evaluating the use of Acceptance and Commitment Therapy for people with severe and enduring mental health problems. The second is an empirical study examining the role of shame and psychological flexibility in the relationship between mental health and substance use in people with severe and enduring mental health problems. The third is a report written to disseminate the research findings to the research participants and health care professionals. Volume Two consists of five clinical practice reports (CPRs); CPR 1 formulates a lady presenting obsessive-compulsive disorder, CPR 2 is a service evaluation, CPR 3 presents a single case experiment evaluating a cognitive-behavioural intervention for a man diagnosed with obsessive-compulsive disorder, CPR 4 presents a case study of a compassion-focused intervention, and the abstract of CPR five, an oral case presentation, presents a case study of a man presenting with psychosis.

The paper provides an overview of the Literature Review and Empirical Paper. The Literature Review explores higher-order repetitive behaviours in individuals with an intellectual disability and measured processes that may play an aetiological role in repetitive behaviour. Nineteen studies were selected for review based on inclusion and exclusion criteria. The review demonstrates that higher-order repetitive behaviour (HRB) has been associated with biological, cognitive and sensory constructs, specifically basal ganglia structural volume, executive functions and sensory sensitivity. Few causal inferences could be made, a finding which appears to be associated with the large number of factors shown to impact on repetitive behaviour. The Empirical Paper aimed to pilot a battery of thirteen executive functioning tests with individuals with intellectual disabilities (ID). Twelve individuals were administered a computerised executive function battery. Feasibility: none of the participants completed the entire EF battery, two completed nine of the thirteen subtasks. Convergent validity: No clear difference was evidenced in the EF battery between high IS and low IS individuals. Concurrent validity: Little consistency found between standardised measure of behavioural indicators of executive dysfunction, and corresponding tasks of the EF battery. The findings provide important information to direct development of the EF battery to ensure sustained motivation and make completion more feasible for participants of lower developmental levels.

Background: There is presently a lack of consistency in research designed to measure executive functioning (EF) in autism that may be attributable to lack of homogeneity or comorbid conditions (i.e. learning disability or additional diagnosis) in test samples. Aim: A systematic review focused on a subset of EF (verbal fluency: VF) was conducted, using only studies of high-functioning individuals with autism (HFA) without an additional diagnosis or learning disability. An empirical study was conducted comparing the executive functioning profile of individuals with HFA and typically developed (TD) individuals. Method: For the systematic review, 16 studies met the specified inclusion criteria, depicting 15 semantic (category), 14 phonological (letter), and 6 switching (categories) VF tasks. In order to assess potential bias, the available VF information of the included papers was scrutinised by the author and an independent clinical practitioner. For the empirical paper, 22 HFA and 22 TD participants (mean age = 28, range = 17-73, 52% male) without a comorbid condition, learning disability or brain injury completed three subtests from the WAIS-IV (vocabulary, block design and digit span) and all subtests of the Delis–Kaplan Executive Functioning System (D-KEFS). Results: For the systematic review, a minority of semantic and phonological VF studies reported a significant difference between typically developed and HFA populations. Five of the six semantic switching studies reported a significant difference between groups. All papers included were of good or adequate quality and inter-rater reliability was high. For the empirical paper, the HFA group performed significantly poorer on the switching condition of the design fluency task, semantic conditions of the verbal fluency task and on the word context task overall. No other significant differences were observed. Summary: Although the systematic review concluded that there was insufficient evidence to support that disfluency can be attributed to autistic symptomology, the empirical study found that the HFA group performed poorer than TD in semantic VF and other subtests designed to measure generating novel ‘imaginative’ ideas, without visual cues to aid performance. The deficit on these subtests was increased when there was the added condition requiring the participant to switch between newly formed concepts. Conclusions: Although in VF, results are mixed, the empirical study demonstrates that even in a group of high-functioning individuals there are still measurable differences in EF between TD and HFA samples that may not be apparent through more general cognitive testing. Implications for using a neuropsychological profile for adults with HFA are discussed.

The current thesis has been prepared in journal format and it reports a systematic literature review, an empirical research study, and a paper on relevant critical reflections. Based on a hybrid cognitive and metacognitive model for social anxiety disorder and on a metacognitive approach to emotional difficulties, the main aim of the thesis was to investigate the potential contributions of metacognitive beliefs to social anxiety over and above that of cognitive beliefs. To this effect, the systematic literature review investigated the nature and strength of the associations between social anxiety and two types of beliefs: cognitive beliefs, referred to as social beliefs, (i.e., conditional and unconditional self-beliefs, and high standards) and metacognitive beliefs (i.e., beliefs about thoughts and thinking processes). Cross-sectional, longitudinal and experimental studies were included, and correlation and regression coefficients, as well as results from group comparisons were extracted. Twenty three papers were reviewed using narrative synthesis. The results showed a robust positive association between social beliefs and social anxiety and suggested a possible mediation effect of cognitive processes. Metacognitive beliefs were also positively associated with social anxiety both directly and indirectly, through cognitive processes. The empirical study expanded on these results by investigating the potential prospective associations between metacognitive beliefs and social anxiety. A sample of 156 university students and staff completed a battery of questionnaires twice, two months apart. Regression analyses showed that irrespective of social beliefs, metacognitive beliefs about the uncontrollability and dangerousness of thoughts were individual positive predictors of and explained additional variance in social anxiety two months later. This effect was partly mediated by self-focused attention. Social beliefs did not show a prospective individual contribution to social anxiety. Following the above, the critical reflections paper focused on the process of conducting these studies. The adopted epistemological stance is discussed and the process of decision making during the various stages of research is expounded. The strengths and limitations, the findings in the context of wider research, and the implications for clinical practice and future research are discussed.

'Dissociation' describes a range of anomalous perceptual, cognitive and affective experiences that occur transdiagnostically. Examples include mental blanks, and feeling 'unreal'. Whilst its ubiquity is becoming accepted by clinicians, there is currently little understanding of the mechanistic role played by dissociation in clinically important presentations. The present thesis addresses this gap in two ways: by establishing the role dissociation plays in a key clinical presentation (youth deliberate self-harm; [DSH]), and by offering an updated measure of dissociation for use in future research. In Paper A, a review of nineteen eligible studies found an association between deliberate self-harm and dissociation, with more severe dissociation associated with more severe DSH, DSH in more locations on the body, and use of multiple methods of DSH. However, the review was unable to conclusively determine the direction of the association, largely due to limitations in studies' research designs. In Paper B, the development and psychometric properties of a new, clinically useful and up-to-date measure of dissociation are described. Clinician and service user consultation were used in the early stages to ensure a comprehensive representation of dissociative experiences. The result is a measure with five subscales with good validity and reliability. Suggestions for further validation of the measure are also made.

Background: Aphasia is a language impairment affecting approximately one third of people after stroke. It can disrupt speaking, comprehension, reading and writing. This thesis concerned people with aphasia (PWA) with spelling and writing impairments (some also had reading difficulties) but relatively preserved speech and comprehension. Aims: 1. Consider the evidence for writing treatment interventions with a systematic review of the literature; 2. Conduct a pilot study testing the acceptability of a compensatory narrative writing treatment intervention using assistive technology (AT) software; 3. Report an empirical study which designed, delivered and evaluated a program to train ten PWA to operate two mainstream AT packages (Dragon NaturallySpeaking™, a voice recognition software (VRS) to support writing via dictation, and ClaroRead™, supporting reading via auditory processing). The study tested whether: a) AT could be used to produce functional narrative writing, b) reading support promoted writing success c) the intervention could be customised to suit individual goals. Methods: 1. Systematic literature review Electronic databases were searched; 53 papers meeting inclusion criteria were identified. Data were extracted, papers were critically appraised and their findings described. 2. Pilot Ten week AT training with two PWA to test acceptability of the intervention, design training schedule and materials, and test quantitative assessments and qualitative data collection methods for the main study 3. Main study Design and setting: Small group study with mixed methods, repeated measures design. Assessments and AT training in participants’ homes or at City, University of London. Participants: Ten participants meeting eligibility criteria (over 18 years old, medically stable, no significant cognitive impairment, aphasia due to stroke, presenting with acquired dysgraphia) were recruited via convenience sampling. They were not receiving speech and language therapy, had no marked evidence of neuromuscular, structural or motor-speech impairments, nor self-reported history of developmental dyslexia. Measures and procedure. Participants received 7-10 one-hour individual training sessions. Screening (language, cognition) and diagnostic (single word writing, single word reading) assessments took place at T1 (first baseline). Outcome measures (narrative writing, reading comprehension, quality of life, mood) were taken at T1 and repeated at T2 (second baseline), T3 (end of intervention) and T4 (three month follow up). Participant observation occurred throughout training; qualitative semi-structured interviews, a social participation assessment and cognitive monitoring took place at T2, T3 and T4. Results: 1. Systematic literature review Writing treatments were effective but often focused on single word production and seldom tested functional generalisation. Most were single case or small case series studies with remediatory goals; few used qualitative methodologies or investigated the impact of reading deficits. All narrative writing therapies were delivered via technology. 2. Pilot The intervention was acceptable to participants. Training schedule and materials were created and refined; quantitative outcome measures were finalised; emphasis on participant observation was increased. 3. Main study: Keyboard narrative writing was significantly improved by AT (Friedman’s χ² (3) = 8.27, p = .041), as was keyboard reading comprehension (Friedman’s χ² (3) = 21.07, p < .001), indicating compensatory effects of both AT. There was no change over time in pen and paper assessments of writing or reading, indicating no remediatory effect. A wide range of written genres were produced. Social network size significantly increased. There were no significant changes in mood or quality of life. Individual success rates varied; diagnostic and observation data suggested contributing factors were attitude, creativity, preserved speech production skills, spectrum of other aphasic traits, therapeutic goals, and cognition. Conclusion: The compensatory customisable AT training was acceptable to eight of ten participants, and resulted in significantly improved narrative writing performance. Implications: Compensatory AT interventions serve as a useful adjunct to remediatory spelling interventions, and are particularly useful for supporting functional narrative writing.

This thesis has been written in the format of three papers: a systematic review, an empirical paper and a critical reflection paper. Paper one presents a systematic review into the effectiveness of psychological treatments for treatment resistant depression in adults. Paper two presents a qualitative study aimed to explore utility of family liaison meetings in an adult mental health rehabilitation and recovery unit. Paper three presents a critical reflection on the process of conducting the research contained in this thesis and as such is not intended for publication. The implications of the research for clinical practice and the relevance for clinical psychology, and adult psychiatric care are discussed. Reflections on personal and professional development are also explored.

Psychotherapies for borderline personality disorder (BPD) utilise a variety of theoretical models and practical approaches to effect changes that ultimately lead to a reduction in BPD symptomatology or related improvements (e.g. quality of life). Different psychotherapies vary in the underlying mechanisms that are theoretically proposed to effect this change. Accordingly, they are composed of differing proposed therapeutic components. This thesis aimed to identify effective therapeutic components in psychotherapies for BPD broadly, and Systems Training for Emotional Predictability and Problem Solving (STEPPS) specifically. Part one of this portfolio presents a review of the empirical literature that specifically examines effective therapeutic components in psychotherapies for BPD. Semantic complexities inherent in conducting this type of process research are considered, and the specific scope of this portfolio within the wider ‘mechanisms of change’ literature is defined. Results synthesise identified effective therapeutic components into four themes that illustrate the broader landscape within which the empirical paper is set. Part two of this portfolio presents an empirical paper that investigated effective therapeutic components in STEPPS, a psychoeducational group treatment for BPD. Results support an association between acquisition of behaviour and emotion regulation skills (the primary treatment component proposed in the STEPPS manual) and improvement in BPD symptoms. Results also support an association between group process (a potential effective therapeutic component related to group alliance) and improvement in BPD symptoms, reflecting results from wider literature. Parts three and four of this portfolio summarise the clinical experience gained on placements throughout the PsychD course, and all other written assignments completed.