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Paper One: Background: Depression following acquired brain injury (ABI) in adults is common. Psychological therapies are important for treating depression following ABI and improve overall rehabilitation gains. Previous reviews have investigated the literature on psychological therapies for depression following ABI. However, many of these therapies included in the review are not available in the UK's NHS, nor considered 'evidence-based' by NICE guidance. Method: Studies conducted since NICE guidance for depression was released in October 2009 investigating 'evidence-based' psychological therapies for depression in a sample of adults with ABI were included in the review. A total 1,533 studies were screened, leading to the identification of five eligible studies for review. Results: Four studies investigated cognitive behavioural therapy (CBT); two one-to-one CBT studies and two CBT group studies using the Window to Hope protocol. One study investigated behavioural activation (BA). Results were mixed; though, studies reporting non-significant results were methodologically less robust and of lower quality. Two CBT studies and the BA study showed promising results, with reliable change in depression scores at post-treatment compared to baseline. Effect sizes for significant studies were 'medium' to 'large', and were 'very small' and 'small' for non-significant studies. Discussion: The findings suggest that 'evidence-based' therapies for depression in adults with ABI could be effective. However, more high-quality research with robust methodology is needed to reach more substantial conclusions. Suggestions for future research, including investigating other 'evidence-based' therapies, like behavioural couples' therapy and interpersonal therapy, are discussed. Paper Two: Background: Adolescents with acquired brain injury (ABI) commonly experience depression due to difficulties with participation, quality of life (QoL), and performing usual activities. Brief Behavioural Activation (BBA) is a successful, values-based intervention for managing depression in typical adolescents and is investigated using a single-case experimental design with adolescents experiencing depression following ABI. Methods: Five adolescents aged 14-17 years with mild to severe ABI of various aetiologies completed a 6-week course of BBA following at least 2 weeks of baseline measurements. The primary outcome measures were mean daily activity scores out of 10 for 'achievement', 'closeness' and 'enjoyment' (MACES). After baseline MACES collection, activities aligning with participants' values were introduced or targeted during the intervention and further MACES were collected. Depression, QoL, and participation scores at post-treatment and follow-up were compared to baseline. Results: No overall statistical changes in mean activity scores for all participants were found. Though, each participant showed significant change in one area and some changes using visual inspection. All participants reported significant reliable change in depression scores at their follow-up sessions, with three showing clinically significant change. Three participants reported reliable change in QoL. All parents reported reliable change in participants' depression and QoL scores. Discussion: Despite no significant changes in MACES, increased participant insight linking valued activities, mood and positive reinforcement may have positively impacted on participants' depression and QoL outcomes. Rationale is presented for charities and services providing low-intensity interventions to consider trialling BBA for adolescents with depression following ABI. Future research suggestions are discussed.

This thesis explores how interpersonal behavioural patterns, internal working models, personality traits, and positive and negative emotional characteristics interact and impact human behaviour. Part one consists of a systematic review and a meta-analysis exploring the relationship between Attachment and Personality through an examination of the literature in English that examine this relationship. Personality was operationalised through the Big Five model, and Attachment through the standard three Attachment styles. 15 different analyses were conducted in order to explore all the possible combinations of the three Attachment styles and the five Personality traits. The literature was scrutinised through a thorough quality assessment and risk of biases assessment. Part two is an empirical research paper exploring different predictors of Loneliness through the prism of interpersonal behavioral patterns, and an internal working model. These were explored through Attachment, Interpersonal problems, Compassion, and Shame. The aim of this study was to understand better how maladaptive patterns of emotional and behavioural functions can lead an individual to be and feel lonely. This is a quantitative study utilising a battery of five different measures with data from 92 participants. Part three is a critical appraisal offering a reflection on both preceding parts. It emphasizes an overview of the whole process and ends with a reflection on the conclusions of both studies. During the reflection issues regarding Loneliness and better care for clients are raised.

Part 1: The theory of Natural Pedagogy as proposed by Csibra and Gergely (2006, 2010) has provided a comprehensive account of the phenomenon of cultural learning. The theory suggested that ostensive communication in early interaction between the mother-infant dyad plays a crucial role in facilitating the transmission of cultural knowledge. The three ostensive cues identified in that theory are eye contact, being addressed by name and contingent responsivity. This conceptual introduction provides a detailed review of the theory as well as the relevant literature. A critical evaluation of the empirical evidence presented in the body of literature suggests there are major limitations within that evidence, which as a consequence makes the empirical evidence fall short of offering robust support to the theory. This paper concludes by calling for development of a new instrument which allows for collecting data that is necessary for addressing these limitations. Part 2: Aim: (1) To develop the Ostensive Communication Coding System (OCCS). (2) To establish the psychometric properties of the OCCS. Method: Establish the behavioural operational definition and measurements of four ostensive communication – Eye contact, Name addressing, Infant Directed Speech and Contingent responsivity. Apply the OCCS to code videos of mother-infant interaction in two learning paradigms. Due to the occurrence of Covid-19, data collection was interrupted. The second aim of the study could not be fully achieved because of insufficient sample size. 14 infants aged 16 to 22 months took part in the study with their mother. Their interaction in the two learning paradigms are coded with OCCCS. Result: Interrater reliability of OCCS was assessed via intraclass correlation coefficients. Interrater reliability was excellent for all the scale components (> .90). Construct validity was tested with Parenting Stress Index, Fourth Edition Short Form (PSI-4-SF) and The Parental Reflective Functioning Questionnaire (PRFQ) via quasi-qualitative method, individual patterns of scores were observed. The results provided supportive evidence of the construct validity of OCCS Conclusion: The OCCS is likely to be a reliable and valid instruction to assess ostensive communication in natural pedagogical situation. Implications for future development are discussed.

Several studies have shown that positive symptoms of psychosis are highly social in nature. The presence of illusory social agents in psychosis have been reported in studies spanning a number of years in different cultures and etiologies. However, there is currently a limited understanding of the social phenomenology of psychosis and the presence of illusory social agents in the positive symptoms. Part 1 of this thesis is a conceptual introduction that provides an overview of the literature on the social phenomenology of psychosis. The introduction highlights gaps in the literature, including a need for more research that explores illusory social agent representation in the lived experience of psychosis. Part 2 is an interdisciplinary study exploring the characterisation of illusory social agents in the lived experience of community and ward based participants. Corpus linguistics was used to analyze phenomenological data that was gathered using semi-structured interviews. Frameworks from Clinical Psychology and Corpus Linguistics were used to interpret the findings. Illusory social agents were represented as active and dynamic beings that engaged in a range of verbal, mental, behavioural and material processes. Part 2 discusses the impact of these behaviours on participants lives. It concludes with clinical and research implications and ideas for future research. Part 3 offers the considered thoughts on the process of undertaking the study. It considers the strengths and limitation of the study and offers thoughts on how these could be addressed by future researchers.

Whilst patients' questions in psychoanalytic psychotherapy are a 'neglected' topic in psychoanalytic research and literature, some authors recognise its importance. This qualitative study aims to bridge this gap in the literature by exploring the role of patients' questions in short-term psychoanalytic psychotherapy (STPP) with adolescents suffering from moderate-severe depression. This is a single case study, focusing on the interaction between the patient and the therapist when a question was asked by the patient, using conversation analysis (CA) methodology. Data were provided from a random controlled trial (RCT) in which all sessions were audio-recorded. Findings show that 'surprising behaviours' that seemed associated with heightened affect appeared when a patient asked a question. The author reflects on the significance of these findings within the context of the therapeutic relationship and the implication of these findings for treatment technique.

There is evidence to suggest that migrants, refugees and members of ethnic minority groups experience higher risks of mental health difficulties with lower rates of access to mental health help than the general population. There is also limited knowledge available on the psychological help for those less advantaged groups with even less known about the support provided for migrants from Eastern Europe, who constitute one of the largest migrant groups in the United Kingdom. This thesis aims to explore the following research question: what, according to practitioners' perspectives, might be the strengths and limitations of Intercultural therapy, as one of the approaches developed in the 1980s for working with migrants, refugees and ethnic and cultural minorities, in supporting migrants from Eastern Europe? The study mobilised a qualitative methodology with seven semi-structured interviews conducted with expert qualified Intercultural therapy practitioners who were trained in psychodynamic approaches. A thematic analysis was applied to analyse interview material with three main themes developed as a result. This study suggests that, according to the practitioners' perspectives, Intercultural therapy's emphasis on working with culture and the consequences of racism and discrimination could be helpful for migrants from Eastern Europe due to existing cultural differences between Eastern and Western Europe and, associated with these, the potential pressures of 'westernisation' which migrants might experience, as well as Eastern European migrants' being subjects of racialisation and discriminatory practices. This study documents how Intercultural therapy places primary importance on including those experiences into the therapy process and seeing them within the intersectionality framework, and explores practitioners' accounts of the strengths and limitations of cultural and language matching for Eastern European clients. The interpretations and applications arising from this study should be of interest for Counselling psychology practitioners and training programmes, as well as for other mental health professionals, public policy makers and members of the general public who belong to cultural, national and racialised minorities or experience any forms of discrimination. This study concludes by indicating further areas of research into, and the wider application of, Intercultural therapy as a unique approach for working with less advantaged and less settled population groups in the United Kingdom.

Drawing on a variety of theoretical and literary sources, my thesis develops the notion of the 'impasse' to address the affective atmosphere of the present as it unfolds across the Euro-Atlantic world. The impasse points to the experience of living in and through this present-a space of time in which continuity continues, so to speak, but tainted by a sense of socio-economic and ecological fragility. As a conceptual heuristic, the idea of the impasse is conceived as a counterpoint to two interrelated tendencies in political theory: the use of tropes of trauma and catastrophe to describe the crisis-shaped present and an emphasis on rupture and radical discontinuity to think about political change. Through critical comparisons of works by a variety of thinkers, literary authors and artists, I argue the following: (1) realities of intensifying inequalities often emerge in less dramatic ways than scholars drawn to limit events allow for. Rather than focusing on moments of radical negativity, I examine subtler, less acute ways of being and feeling, such as states of drift, irresolution and impassivity. These states, I argue, contribute toward a more comprehensive account of contemporary subjectivity. (2) The impasse calls for a critical framework that in its attention to temporal experiences of ongoingness supplements critical imaginaries bent on scenes of transgression and the sense of change they entail. It asks us to think through the slowness of chronic time, rather than the time of rupture, and the conflicting rhythms of ambivalence, rather than the unambiguous embrace of action. (3) Without renouncing a commitment to social transformation, then, my thesis advances the notion of the impasse as a concept that not only claims descriptive purchase but which also, reflexively, elicits a mode of reading and writing that slows down the movement between interpretive claim and political practice.

Background aim: This thesis aimed to explore how qualitative investigations into adolescent experiences of stressors, risk factors and protective factors can further understanding of mental well-being and psychopathology prevention in England. Methodology: (1) A narrative review explored research on adolescent mental well-being and the risk of psychopathology, stressors, and protective factors in adolescence. (2) A qualitative study considered types of stressors and effects on mental well-being in a sample of 54 10- to 16-year-olds in 12 selected geographies across England. (3) A scoping review explored current literature on types of protective factors associated with increases in adolescent mental well-being and the reduction of psychopathology. (4) An ideal-type analysis was applied to examine patterns in reports of protective factors in relation to mental well-being and the risk of psychopathology of 9- to 12-year-olds. (5) A qualitative study explored change in reported protective factors in relation to mental well-being and psychopathology risk over one year for the above sample of 10- to 13-year-olds. Results: (1) The literature review highlighted a lack of qualitative research on the thesis topic in the English context. (2) A thematic analysis identified six overarching types of stressors experienced by adolescents: negative mental states, peer difficulties, bullying, behaviour difficulties, school difficulties and family difficulties, with a total of 32 reported stressors. (3) The scoping review identified 104 protective factors presented in an updated framework. (4) An ideal types typology of protective factors comprised: adolescents with 'Uncertain Sources of Support' (USS, N = 35, 55.55%), 'Self-Initiated Forms of Support' (SIFS, N = 7, 11.11%), and those with 'Multiple Sources of Support' (MSS, N = 21, 33.33%). (5) Exploration of changes in reported protective factors over one year found both continuity and change. Of those that shifted ideal type, 24 participants (40%) moved in a positive direction towards more effective protective factors and (10%) moved towards fewer and less effective protective factors. Conclusion: The qualitative investigations in this thesis identified adolescent perceived protective factors in relation to mental well-being and psychopathology risk. Group-level patterns in protective factors showed continuities and shifts in reports of stressors and protective factors over time. These patterns of stasis and change may have implications for the identification of adolescents at risk of poor mental well-being and/or psychopathology.

There is little doubt that the trait EI (Trait emotional intelligence) theory and measures have been found valid and reliable in several settings. This thesis aims to examine the role of trait EI on psychotherapeutic outcomes. This dissertation provides psychometric evidence of the TEIQue-SF (Trait Emotional Intelligence Questionnaire-Short form) in Chilean general and clinical population (n₁ = 335, n₂ = 120) in studies one and two. The results supported a bi-factor multidimensional structure, besides informing full measurement invariance (through MGCFA, i.e., Multigroup Confirmatory Factor Analysis) between the original and the Chilean adaptation of the TEIQue-SF questionnaire. Since cultural peculiarities may influence trait EI, in study three, the author examined the relationship between trait EI and key sociodemographic variables through analyses of variance (ANOVA) and MGCFA in four countries (n = 2,228). The findings indicated significant trait EI differences across countries for age, gender, educational attainment, civil status, and occupation. Measurement invariance was acceptable, especially for age, gender, and education, supporting the cross-cultural consistency of the TEIQue-SF. The fourth study explored the adequacy of trait EI as a predictor explaining the variance in psychotherapeutic outcome longitudinally through a multilevel, quasi-experimental design across psychotherapist-patient dyads (n₁ = 67, n₂ = 39). Outcome variability was found for most dependent variables from start to the end of treatment. Patient trait EI significantly predicted variations in the overall outcome and symptom distress, whilst therapist trait EI significantly predicted variations in the overall outcome and interpersonal relationships. The alliance interacted with the treatment at a significant degree, although these effects explained less outcome variance than those of trait EI. The interaction between patient trait EI and therapist trait EI was a stronger predictor of symptom distress and the overall outcome than the alliance. Overall, the findings point to the importance of trait EI in psychotherapy.

Introduction: Research suggests an association between psychopathy and rape myth acceptance (RMA). Prior to the perpetration of sexual violence, many people hold attitudes that justify, defend and minimize violence. In this case, it would be useful to understand the extent to which myths about rape relate to psychopathy and its various facets. This is the first review which has systematically reviewed the evidence for the relationship between both primary and secondary psychopathy and RMA. Aims: This systematic review and meta-analysis aimed to examine the evidence for i) the relationship between primary psychopathic traits and RMA and ii) the relationship between secondary psychopathic traits and RMA. Method: Systematic searches of nine databases were performed, using search terms relating to psychopathy and RMA. Articles which reported zero-order correlations specifically for primary and secondary psychopathy and RMA were included. Two meta-analyses were conducted to synthesise effect sizes for both primary and secondary psychopathy and RMA. Results: Thirteen peer-reviewed studies were included in the meta-analyses. A significant small association was found between primary psychopathy and RMA, r =0.26 (95% CI [0.19, 0.33] p < .001). A significant small association was found between secondary psychopathy and RMA, r = 0.25 (95% CI [0.20, 0.29] p < .001). Conclusion: Both primary and secondary psychopathic traits are significantly associated with RMA. Researchers should begin to address the methodological and philosophical issues that surround both the fundamental constructs of psychopathy and rape myths, to inform future therapeutic interventions.

Subjective wellbeing (SWB) refers to an individual's perception of their psychological, emotional and social wellbeing (Keyes, 2002). Persecutory ideation refers to thoughts that an individual will come to harm due to the deliberate intention of other people (Freeman & Garety, 2000). These thoughts are common in the general population. Persecutory ideation has been found to be experienced by up to 18.6% of people per year (Freeman et al., 2011). Persecutory delusions are experienced by 90% of people experiencing first episode psychosis (Moutoussis, Williams, Dayan & Bentall, 2007) and have been associated with distress and poorer clinical outcomes (Freeman, 2016). Several theories of the development and maintenance of persecutory ideation have been proposed. Social factors such as insecure attachment, neglect and physical abuse have been found to be associated with persecutory ideation in clinical and non-clinical samples (Bentall, Wickham, Shevlin & Varese, 2012; Pickering, Simpson & Bentall, 2008; Sitko, Bentall, Shevlin & Sellwood, 2014). Cognitive mechanisms have also been found to be associated with persecutory ideation, including reasoning biases (Garety & Freeman, 1999) and worry (Freeman et al., 2012). The overarching aim of the present thesis is to provide a thorough review and empirical investigation of the complex relationship between persecutory ideation and SWB. Chapter one: The first chapter of this thesis is a systematic review that aimed to investigate the relationship between persecutory ideation and SWB. Due to the variation in terminology used within the literature, studies investigating the relationship between persecutory ideation and the related concept of quality of life (QoL) are also included in the review. In particular, the review sought to answer whether people with higher levels of persecutory ideation have lower levels of SWB. Additionally, it considered whether the relationship between persecutory ideation and both SWB and QoL differs between people whose persecutory ideation is classified as "delusional" and those with lower levels of persecutory ideation. Lastly, it sought to identify variables that influence this relationship. Overall, a moderate negative correlation was found between persecutory ideation and both SWB and QoL, in people with and without a history of mental health difficulties. There was some evidence that this relationship may be stronger in people experiencing non-clinical levels of persecutory ideation, compared to individuals experiencing psychosis. A dearth of literature investigating psychological mechanisms that influence the relationship between persecutory ideation and SWB or QoL was found. Chapter two: The second chapter of this thesis is an empirical paper that aimed to investigate the psychological factors that influence the relationship between persecutory ideation and SWB in the general population. It considered the role of persecution deservedness (believing that perceived persecution is deserved), cognitive fusion (being entangled with one's thoughts and believing them as fact) and sense of coherence (feeling one's environment is understandable, manageable and meaningful) in this relationship. A new conceptual model of these factors was proposed and tested. A negative relationship between persecutory ideation and SWB was found. Sense of coherence was found to predict SWB, beyond the level of persecutory ideation. Additionally, people who have accessed mental health services had higher levels of persecutory ideation and lower levels of SWB than people with no history of mental health difficulties. No significant interaction effects were found and therefore the findings did not support the proposed conceptual model. Overall conclusions: There is strong evidence that there is a negative relationship between persecutory ideation and both SWB and QoL, in both clinical and non-clinical samples. It may be beneficial to consider specific psychological interventions to reduce persecutory ideation in people accessing mental health services, regardless of their diagnosis. Wider interventions could be considered to improve SWB and QoL related to persecutory ideation in the general population. These may target experiences and mechanisms that have been found to be associated with the development of persecutory ideation. Further research is needed to investigate other psychological factors that may influence the relationship between persecutory ideation and both SWB and QoL. Sense of coherence is one factor that has been found to be related to SWB, so may be helpful to consider when providing psychological interventions to individuals experiencing persecutory ideation.

People with learning disabilities (PWLD) have been disproportionately impacted by the Covid-19 pandemic, with reports of significant impacts on psychological wellbeing. Services that support PWLD in the UK have had to make significant adaptations, however there is limited research into the perceptions and impact of these changes. This exploratory study aims to investigate the experiences of psychologists working in UK learning disability services throughout the pandemic, to explore service delivery, impact on the psychological wellbeing of PWLD, and the implications from this going forward. Twelve psychologists were interviewed, and thematic analysis was used to explore patterns and themes. Three superordinate themes were identified. 'Delivering Psychological Services' contained five subordinate themes: 'Context', 'Accessibility and Acceptability', 'Professional Identity', 'Living the Pandemic' and 'Team Connection'. 'Wellbeing of PWLD' contained three subordinate themes: 'Same Storm Different Boat', 'Continued Inequality' and 'Resilience and Re-Evaluation'. 'Learning and Future Practice' contained three subordinate themes: 'Inclusion', 'Choice and Connection' and 'Workforce Wellbeing'. Findings conclude that although a time of immense challenge and loss, the pandemic has triggered significant re-thinking and learning within services. With inequality still evident for PWLD, an emphasis on future services carefully considering potential disadvantage by over-digitisation of services is key. There is hope that future psychological services can be offered with more choice and flexibility. Staff wellbeing, compassionate leadership and reestablishing team connections is essential in the new landscape of services. Recommendation, practical implications, and future research directions are discussed.

Objectives: This study seeks to adapt the 18-item Health Anxiety Inventory - Short Version (SHAI; Salkovskis et al., 2002) for use in medical settings and to evaluate the adapted version's psychometric properties. It reports two studies. The objectives of the first study were to use expert opinion 1) to identify the limitations of the SHAI for administration in medical settings, 2) to formulate adaptations to items for use in medical settings through an iterative process of feedback and modification, and 3) to develop an adapted version of the SHAI for medical settings using an evidence-based consensus. The objective of the second study was to evaluate the psychometric properties of the adapted measure in samples with Multiple Sclerosis (MS), myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) and chronic pain. Method: In study one, a Delphi study method was used to adapt the SHAI for medical settings. Eight experts with experience of living with a physical health condition and four experts by profession working within physical health were invited to review the SHAI and suggest adaptations through an iterative developmental process. Study two employed a cross-sectional mixed methods questionnaire design. Individuals with MS, ME/CFS and chronic pain were invited to complete a battery of questionnaires via an online survey, and to complete a second survey one week later, allowing for the psychometric properties of the adapted measure to be evaluated. Results: An evidence-based consensus was reached for an adapted version of the SHAI for medical settings (HAI-M) following study one. Consultation with an expert in the field of health anxiety and a person with personal experience confirmed face validity of the 12-item HAI-M. During study two, 315 participants took part in the online survey of which 80.6% fully completed the HAI-M and 62.86% fully completed the battery of questionnaires. 33.3% completed the follow up questionnaire one week later. All groups rated the HAI-M as more acceptable for assessing their health concerns than the SHAI and no significant differences were found between clinical groups in how they scored on the HAI-M. No significant differences were found between clinical groups in how they scored on the SHAI which was an unexpected finding. The HAI-M demonstrated high internal consistency (.875), good test-retest reliability (.812) and good convergent validity (.801). Divergent validity was also good (.515). The exploratory factor analysis suggests the presence of a 3-factor model and this model is discussed in relation to previous studies reporting the factor structure of the SHAI. Conclusion: This study provides preliminary evidence for a psychometrically sound health anxiety screening tool for use in medical settings. Recommendations are made for further research.

Research shows that poor mental health is a growing concern worldwide particularly among young people. One of the main causes is believed to be the internalisation of stress often associated with the proliferation of examinations that they are required to undertake at school. Early interventions have been acknowledged as a way to prevent and reduce these mental health issues. However, while a number of programmes have been developed, the majority have not involved key stakeholders in the design process. Therefore, the aim of this study was to develop and test the feasibility of a co-produced school-based intervention to improve mental health and well-being in young people. The study was primarily based on stages one and two of the Medical Research Council framework for developing complex interventions, with a pragmatic mixed methods approach used to identify intervention components and outcomes. Co-produced through a six-step process with key stakeholders (students and teachers), the intervention was tested and refined in the school setting over three stages in Year 9 students aged between 12 and 14 years. Based on a review of extant literature and qualitative data collection in schools, the multi-component R.E.A.C.T. (Reducing Exam Anxiety through Activity and Coping Techniques) programme was created to reduce test anxiety and improve mental well-being. The six-week group-based intervention, underpinned by self-regulatory, behavioural and cognitive theoretical components, involved physical activity and psychoeducation elements based on recommendations from teachers and students. Quantitative findings suggested small improvements among the intervention group across the outcome measures (test anxiety, self-efficacy, physical activity) although no statistically significant differences were found. However, qualitative feedback revealed that students were less anxious around examination periods indicating that the programme has value in reducing test anxiety. The results also suggested that the intervention was feasible for teachers to deliver and could be incorporated into the school setting. The findings of this study highlighted the importance of engaging students and teachers in the research process to co-produce interventions. They also suggest the feasibility of a future full Randomised Controlled Trial to determine the effectiveness of the R.E.A.C.T. programme using a larger sample of schools.

Section A: This review sought to investigate the evidence for the impact of clinical supervision on client outcomes in psychological therapies. Professional guidelines and clinical practice reflected a broad assumption that supervision served the interests of the client with a relative lack of research examining this claim. Previous reviews in the area were also deemed to be dated or contained important limitations. Searches in online databases PsychInfo, CINAHL, and ASSIA yielded 12 studies that met eligibility criteria, which were assessed using appraisal criteria. The current review found little evidence that supervision contributes substantially to client welfare, and limited progress appears to have been made since the last review of this kind. Though studies in the area are low in number and evidently contain issues with design and clarity of reporting, the review also reinforced the real challenge in trying to comprehend the links between supervision and therapeutic outcomes. Researchers are encouraged to explore relationships between more proximal variables than those studies included in this review attempted, with the intention of gradually clearing the path between supervision and client wellbeing. Clinicians are encouraged to continue their engagement with the process of supervision, but with a critical eye on assumptions and possibilities in the absence of convincing data for guidance. Section B: This study used reflexive thematic analysis to qualitatively explore the relationship between supervision and the therapeutic alliance from the perspective of trainee clinical psychologists. Based on nine participants' accounts, it appears that supervision offers a model of relating that can be translated to the therapeutic relationship, and a crucible within which change happens, to the benefit or detriment of the alliance. Supervisors and trainees who engaged together with emotional and relational material were perceived as contributing more positively to the trainee-client relationship, whereas supervision which entailed a more detached and inflexible approach to what was brought by trainees was perceived as limiting or mitigating trainee and client security and development. The findings of this study suggest support for attachment and supervisory relationship models of supervision, which see the supervisor as a 'base' from which the supervisee can access security, support, and guidance. The psychodynamic model of supervision suggests a transfer of this relationship to the therapeutic alliance and vice versa, a concept which is seemingly supported by the data in this study. Limitations, and research and clinical implications are discussed. Recommendations for future research include mixed methods longitudinal investigations of trainee experience over time, and concurrent efforts to better understand client and supervisor experinces. In terms of clinical practice, testimony provided by participants in this study illuminates the promise and pitfalls of supervision- its potential to contain so trainees may offer containment to their clients, and its potential to neglect in a way that is felt to be at best limiting and at worst distressing for trainees and, potentially, for clients. Qualified and trainee staff, as well as professional and training institutions, are encouraged to actively engage with the understanding and practice of supervision to avoid harm and to increase safety and effectiveness for the benefit of all parties involved.

Neurovascular coupling (NVC) is the process whereby the brain increases local blood supply in response to neuronal activity, providing neurons with energy. Disruptions to NVC have been implicated in Alzheimer's disease (AD), so a better understanding of how NVC goes wrong, and when, is imperative for better understanding the disease and assisting in the identification of therapeutic targets. The main genetic risk factor for developing AD, expression of Apolipoprotein ε4 (APOE4), is associated with vascular deficits, including pericyte damage and impaired cerebral blood ow. I tested whether expression of APOE4 affected NVC, by studying neuronal activity and vascular responses in visual cortex. To investigate this, mice with humanised APOE4 or APOE3 were crossed with mice expressing a genetically-encoded calcium indicator or with labelled pericytes. Mice were implanted with a cranial window over visual cortex and neuronal and vascular activity was recorded using two-photon microscopy. Baseline and stimulus evoked measurements were taken to determine the effect of ApoE4 on basal energy balance and on the ability of the brain to deliver adequate energy to neurons. Results suggest that there were some baseline alterations in APOE4 mice that may result in a lower energy supply. Compounding this, I found there to be a mismatch in energy supply and demand during sensory stimulation, where neuronal demand was greater, but blood supply was less reliable in APOE4 mice. Together these data suggest that there could be an energy deficit in APOE4 carriers. In vivo studies investigating the role of ApoE4 in NVC are few and the study of individual vessels and neurons across different age points, as done in this body of work, is a novel and unique approach. By better understanding how ApoE4 modulates neurovascular function, we can better understand its role in AD pathology and possibly identify therapeutic targets in the future.

This thesis examines psychiatric knowledge and treatment of trauma in Germany between 1871 and 1969. I argue that psychiatric knowledge is more than a technology of security and must be considered a form of statecraft as it produces sovereign political orders. Drawing on the work of Richard Ashley and Sylvia Wynter, I trace how psychiatric knowledge of trauma functions to produce these orders by inscribing figures of 'Man' and his human Others. I analyse these processes of inscription through a genealogy of psychiatric statecraft, which I conduct through a reading of psychiatric and neurological textbooks, journal articles, expert statements, and conference proceedings. I examine three diagnostic disputes over the genesis and treatment of trauma, involving industrial workers in the 1870s and 1880s, WWI soldiers, and Jewish Holocaust survivors in the post-WWII period. In each of these cases, psychiatric practitioners debated whether or not 'nervous' symptoms in trauma patients actually resulted from a distressing event and thus entitled sufferers to forms of financial compensation. Many psychiatrists argued that only the expectation of a pension generated these symptoms, and that this was most commonly found in persons with an 'abnormal' character or 'inferior' constitution. I observe that the knowledgeable production of political order was subject to shifting dynamics over the 100-year period I scrutinize in the thesis. While some periods were characterized by vigorous disagreement in psychiatric discourse on the 'proper' attributes of the sovereign subject, at other times, psychiatric knowledge ossified into an enforced consensus in which political subjectivity was fully commensurate with the 'fitness' of the physical body. I find that from the 1910s until the late 1950s, German psychiatry produced an account of political subjectivity which located danger in bodily 'inferiority', thus lending authority to a violent politics of marginalization and mass death of racialized and disabled populations.

Paranoia is the unwarranted belief that others intend harm, either now or in the future. It is one of the most predictive factors for transition into psychosis, as well as being the most common content of delusional beliefs, known as persecutory delusions. A prominent theory of psychosis suggests that dopaminergic dysregulation in midbrain regions lead to the production of positive symptoms, such as persecutory delusions, and indeed observational evidence demonstrates that blocking post-synaptic dopamine through the administration of antipsychotics can reduce some of these symptoms. However, most mechanistic evidence that aim to test explanatory frameworks of persecutory delusions has focused on the role of dopamine in non-social learning, general cognition and perception. Focusing on non-social mechanisms strongly neglects the clearly social content of persecutory delusions, and therefore the role dopamine may play in the formation of paranoid beliefs. Further still, the well evidenced role of social attributions in paranoia and persecutory delusions has not been fully explained with reference to potential neurocognitive mechanisms that may underlie them. This thesis aims to fill this knowledge gap by developing an experimental test of social attributions in paranoia, developing a computational model that may explain their development and maintenance, and using a psychopharmacological double-blind placebo cross over study to test the role of dopaminergic mechanisms in their generation. I first demonstrate the psychometric properties of the Beliefs and Values Inventory - a novel measure to assess five themes of belief down three dimensions -in a large online population (n = 1763). Secondly, I utilise large online populations (n = 1754) to test how pre-existing paranoid beliefs may influence in-the-moment attributions of harmful intent during a social task using real human decisions, a modified serial Dictator game. The Dictator game suggested that paranoid beliefs lead to faster and larger harmful intent attributions, but not attributions of self-interest. By applying a computational model to the serial Dictator game data, I also found that pre-existing paranoid beliefs and those most likely to attribute high harmful intent are more uncertain about their partner's policy and are more sensitive to the social environment. Finally, I ran a double-blind, within subjects, randomised-control trial using LDOPA and haloperidol to moderate presynaptic and postsynaptic dopamine, respectively, in 30 healthy participants. Following dosing, participants were asked to fill in the Beliefs and Values Inventory and play the within-subjects dictator game. Results suggested that haloperidol selectively reduced harmful intent attributions and increased self-interest attributions across the board, however, did not affect any other themes of beliefs. We conclude that dopamine is crucial in processing the self-relevance of social intent from others. In sum, this thesis demonstrates that paranoid beliefs i) are along an exponential spectrum in the general populations, ii) influence the live attribution of harmful intent toward ambiguous social actions, iii) increase the probability that in-the-moment harmful intent attributions will be made, iv) increase the uncertainty about another's policy, and v) dopamine is crucial to in-the-moment paranoia. I suggest these results converge and integrate with evidence from adjacent fields of social learning to update current models of paranoia.

Disturbances in sleep and circadian rhythm are commonly reported in the period preceding deterioration in mental state in people with psychosis. Sleep disturbance may therefore serve as an early sign of impending relapse, for prompting timely, preventative interventions. Also, establishing a temporal association between sleep and symptomatic deterioration would lend support to the hypothesis that sleep plays a causal role in generating psychotic symptoms, and may in itself form an important therapeutic target. I aim to explore both of these questions through a digital phenotyping approach, which harnesses continuous, real-time data from mobile and wearable devices, in real-world settings. In the first chapter of this thesis incorporating publication, I summarise the evidence for sleep-circadian disruption during the relapse prodrome in schizophrenia, and incorporate literature from the bipolar disorder field. I explore the neurobiological mechanisms by which sleep reduction and circadian misalignment may drive psychopathology, and provide an overview of how digital technologies are being harnessed as clinical tools in psychiatry. The second chapter, a systematic review and meta-analysis of case-control actigraphy studies, seeks to understand sleep-circadian dysfunction across the psychosis spectrum by comparing actigraphy parameters in schizophrenia and bipolar disorder, in the non-acute phase of illness. I show that in both disorders, patients show significantly longer total sleep time and time in bed, with lower daytime activity. However, sleep is also more disturbed, with greater sleep latency and fragmentation, pointing to a range of difficulties pervading all aspects of the 24 hour cycle. Effect sizes were greater in schizophrenia; higher antipsychotic dose was associated with longer sleep time, and greater use of sedative medication was associated with reduced sleep latency, suggesting that treatment effects play a role in these findings. This sets the scene for the subsequent examination of dynamic changes, across phases of illness. To date, sleep-circadian and psychopathology variables have not been studied for long enough to allow episodes of deterioration and relapse to be captured. Increasingly ubiquitous mobile and wearable technologies may allow continuous sampling of subjective and objective sleep-circadian variables in the home environment, over extended periods. In chapter three, I describe the findings of a pilot study, undertaken to develop and test the feasibility and acceptability of Sleepsight, a digital platform designed specifically for this objective. Although there were high rates of engagement with the technology, greater negative symptom burden was associated with poorer completion of smart-phone diaries. Importantly, when the study was conducted in a transparent, collaborative manner, concerns over privacy and security were not significant barriers to engagement and adherence. This tool was then used in a substantive study of 36 people with psychosis, each participating for 12 months, in order to capture natural fluctuations in mental state, including relapse episodes. In chapter four, I examine the association between subjective sleep-circadian variables and psychopathology data using the Differential Time Varying Effects Model (DTVEM), a novel analytic approach which elucidates the lag structure between sleep variables and mental state. The results clearly suggest that poorer subjective sleep quality and reduced subjective sleep duration precede deterioration in symptoms by 8-12 days. Although an inverse direction of effect of psychopathology on sleep was also found, this was shorter, and of smaller magnitude. These findings support the hypothesis that sleep disturbance precedes deterioration in psychopathology. In chapter five, I describe how raw digital phenotype data are classified into sleep-circadian variables using a preprocessing pipeline, and employ a range of analytic approaches to explore these data. Visualisation of rest-activity patterns demonstrated a wide range of sleep-circadian phenotypes, some with striking patterns of circadian dysfunction including relative co-ordination and non-24 hour rhythms. A second analysis using the DTVEM method, with objective data, sustained the finding that sleep reduction preceded symptomatic deterioration. Group-level comparisons between relapsing and non-relapsing participants did not demonstrate significant differences in clinical or sleep-circadian variables. However, visualising these variables in the participants who relapsed, centred on relapse event, suggested that a reduction in sleep duration and decrease in activity accompany the period before, during and after relapse. Mathematical modelling was able to simulate major circadian disturbances in a subset of participants, and crucially showed that increasing daylight in the model restored normal circadian rhythmicity. Some of the technological limitations currently inherent in the approach are also discussed. Taken together, these findings suggest that sleep reduction, fragmentation and poorer sleep quality are features of schizophrenia in remission, and are also associated with deterioration and relapse. The evidence supports these changes playing a causal role in the development of psychopathology. Despite technical challenges relating to data quality, these findings also suggest that meaningful objective data can be collected from smartphone and wearable devices, which show promise for use as decision-support tools.

Introduction: Schizophrenia and other psychotic disorders are complex disorders with multifactorial aetiology encompassing genetic and environmental factors. The genetic architecture of these disorders involves many numerous loci implicated in conferring risk for developing the illness. Cognitive impairments are considered as important core features, serving as potential intermediate phenotypes for psychotic disorders. Cognitive biases including jumping to conclusions (JTC) and social cognition impairments such as difficulties in facial emotion recognition (FER) have been reported to be associated with psychosis, yet their link to shared genetic pathways with the disorder, and their contribution to psychotic outcome are still open questions. My thesis aimed to clarify the relation of these two biases with psychosis liability and with outcome. Methods: Data used in this Thesis come from two large-scale studies in which I participated: the multisite incidence and case-control EU-GEI study, and the Biological Phenotypes, Environment, Genes and Psychosis Outcome (GAP follow-up) study. To examine the presence of the JTC bias at first episode psychosis (FEP), taking into account the influence of general cognitive ability, I conducted a mediation analysis between case/control status, JTC, and IQ in a large sample of patients experiencing their FEP, and population controls. I then explored the associations of JTC with both psychosis and general cognition liability, estimating multiple linear regression models using calculated polygenic risk scores for schizophrenia (SZ PRS) and IQ (IQ PRS). Global and specific facial emotion recognition was analysed through fixed and random effects in repeated measures mixed models in the same large sample. Multiple linear regression models were used to investigate the association with FER and SZ PRS. In a London subsample in which I contributed to recruitment and assessment, I then tested both JTC and FER measured at FEP for multi-domain outcome prediction at, on average, 5-year-follow-up, based on estimated linear, ordinal, and multinomial logistic regression models. Finally, to test the stability of jumping to conclusions and facial emotion recognition over the years, intra-class correlations and repeated measures mixed models were performed. Results: The association between JTC and psychosis was shown to be fully mediated by IQ, and JTC was explained by the genetic underpinnings of IQ but not SZ PRS. Psychotic patients were more prone to display deficits in facial emotion recognition than controls, specifically in fear and anger recognition compared to happy or neutral faces. SZ PRS was associated with worse global facial emotion recognition and specifically with impairments in anger recognition. Neither JTC nor FER measured at FEP predicted any outcome domains at follow-up, although JTC showed a small effect on social outcome. Finally, an overall steady pattern of performance over time was detected for JTC and general facial emotion recognition in both patients and controls, with patients making hastier decisions and recognising fewer emotional faces than controls. Conclusions: My thesis contributed to clarifying the association of jumping to conclusions with psychotic disorders as mediated by general cognition; furthermore, JTC appeared not directly associated with common genetic risk variants for the disorder. However, this finding raised also the necessity of improved assessment for the JTC bias to reduce cognitive noise. On the other hand, findings on facial emotion recognition provided more evidence regarding impairment in global and emotion-specific recognition of emotional faces in the context of psychosis, corroborating previous findings from family studies; the results I obtained with polygenic risk score analysis suggested that facial emotion recognition - specifically negative emotions - could serve as intermediate phenotype for psychosis.

It is well documented that regular physical exercise supports physical and mental wellbeing. Despite the promotion of physical activity by world health experts and governments, physical inactivity within the population remains a cause for concern and disorders associated with sedentary lifestyles have continued to increase. Evidence suggests that the uncomfortable private-events people experience during physical exertion can become psychological barriers to participation in physical activity and thus result in avoidant behaviours. Acceptance and commitment therapy (ACT) has been used to promote increased physical exercise by enhancing psychological flexibility in relation to private-events that are perceived as unpleasant. However, relationships between the individual ACT processes and the theories which underpin their use in interventions designed to promote physical activity have yet to be fully explored. Understanding the relationship between ACT processes and physical exercise is key for appropriate and robust intervention development. This thesis aimed to explore the theoretical and practical application of ACT processes in relation to exercise and inform further development of effective brief interventions designed to increase activity levels. The programme of work within this thesis had two phases. The first phase included two studies: a systematic review to explore the existing evidence; and a quantitative survey study to determine if associations exist between physical activity levels and the individual core processes of ACT. Results from phase one found that the reviewed literature failed to explore the use of Relational Frame Theory (RFT) critical to ACT, and a survey suggested that ACT processes of defusion, self-as-context and personal values were likely to play a significant part in activity levels. The second phase comprised of three interrelated quantitative intervention studies designed using RFT. Each explored the ACT processes by measuring task duration and the intensity of private-events experienced during exercise. The first intervention study combined defusion and self-as-context with no significant effects on an exercise task. The second combined defusion, self-as-context and value orientated cues to behaviour change. Exercise duration was significantly increased in the ACT intervention, while there was no decrease in the intensity of private-events. The final study tested a values clarification task with cues to behaviour change and reported significantly increased exercise duration. The thesis demonstrates that relational frame theory applied to ACT processes can influence the duration of exercise although the relationship with private-events remains uncertain. The robust, theory focused approach to this work represents a small but valuable contribution to the development of intervention strategies and has implications for future research. Strategies worked best using a combination of both deictic and hierarchical relations for training cognitive defuison and self-as-context, and especially for the clarification of personal values used as cues to behaviour change. Further research is needed to establish both the external validity and longevity of observed effects.

We live in a time in which 'mental health' problems have been described as the 'epidemic' of gravest concern. The incidence of 'mental health' problems is increasing year-on-year, yet we remain fixed on one course of action with a psychopharmacology trajectory of understanding and treatment; this being the basis of our psychiatric system and the default medical encounter, it too readily insists upon all forms of psychic suffering being reduced to chemical imbalances within the brain. It is against this backdrop that I introduce the potential and necessity for a return to the theory of R.D. Laing. Laing was a psychiatrist whose most prominent mark was made in the 1960s. With an unwavering commitment to establish more humane treatment for those diagnosed 'schizophrenic', he developed a philosophical method of enquiry grounded in existential-phenomenology. Through this methodological lens, Laing argued that 'intelligibility' of experience could be revealed within even the most psychotic of patients. It is only with intelligibility that a true knowledge of persons can be gained, and help given. Laing provides us with a theory to challenge the all-compassing dominance that psychiatry wields upon the self, allowing us to consider how psychiatric discourse affects society beyond diagnosis, and think differently about what constitutes 'mental illness' and diagnosis. This thesis clarifies and develops Laing's theory from 1960 to 1970, offering a contrasting reading to the modular format frequently represented within secondary sources and producing instead a unified framework. Emphasising and reworking the concept of 'ontological insecurity' as a logical, but painful, existential response to dysfunctional interpersonal dynamics within our worldly immersion. Supported further by his lesser appreciated concept of 'self-consciousness', a political application is developed that highlights the potential value of Laing's theory as a means of understanding our current 'mental health' situation. In the process of conducting this re-evaluation, scientism is drawn into focus. Extending beyond the clinical encounter and placed within the interpersonal dynamics of everyday existence, it is proposed that western culture is increasingly allowing itself to be defined within a scientific paradigm that incurs a collective existential degradation. This is a significant source for ontological insecurity and thus contributes to the experience of psychic suffering.

Bipolar Disorder (BD) is a chronic, severe mental illness characterised by recurring mood episodes of depression, mania or hypomania, interspersed with periods of euthymia (stability). Episode change is a core aspect of living with BD yet qualitative findings in this area derive from a cross-sectional approach that highlights the impact of living with BD episodes rather than the experience and process of mood change itself. No study has examined what it is like to experience successive mood states over time. Nor has any work explored the experience of first BD mood episode and early intervention services, despite their recognised potential to improve outcomes. This thesis explores the experience of mood change and early intervention for people diagnosed with BD. Two empirical studies are presented, using Interpretative Phenomenological Analysis. The first study uses a longitudinal approach to explore the experience of three women during BD moods and euthymia. Idiographic trajectories reveal the participants' changing sense of disconnection with self, other people and their environment, along with an ongoing struggle for self-coherency. BD moods are shown to create significant changes in agency, felt connection, temporality and relational balance, leading to confusion and shame. In the second study, eleven young people are interviewed about their experience of first-episode psychotic BD and NHS early intervention services. Dramatic changes in their sense of interpersonal control during first episode are illustrated and the benefit of existing early intervention provision is highlighted. However, findings also illustrate a complex tension between self-renewal, compromise and risk of relapse during their journey. Mood change for people with BD is suggested to be all-encompassing and cumulative, creating identity loss and ongoing incoherency during both early and late stages of the illness. The value of existing early intervention provision is illustrated and possibilities for tailoring services to people in this group are proposed.

Overview: This thesis explored the concept of stigma as experienced by people with functional neurological disorder (FND) and assessed a mindfulness-based intervention for people experiencing functional seizures (FS). Systematic Literature Review: The systematic literature review used a qualitative meta-synthesis approach to explore the experience of stigma amongst people experiencing FND. The review identified four themes: delegitimization; excluded, isolated and abandoned - the social cost of stigma; the cost of attempts to manage stigma and; threats to identity and the meaning of mental health. Stigma appears to be a central experience for those with an FND diagnosis. Empirical Paper: The empirical paper comprised of a single case experimental design (SCED) which assessed the effect of a mindfulness training intervention delivered through a smartphone app for people experiencing FS. Four participants completed the study and a fifth completed it partially. Results found that two participants showed reliable and clinically significant changes on the outcome measure of quality of life and distress as well as process measures of experiential avoidance and mindfulness. However, clinically significant outcomes were not observed for the remainder. The implications of these results are discussed. Critical Appraisal: This paper shared reflections on the process of this research and provided additional background to some of the key decisions taken over the course of the study while offering a critical analysis of the project.

Counselling psychologists are at the forefront of ongoing debate around the use of psychiatric diagnosis in clinical practice. Despite numerous concerns, diagnosis rates worldwide have increased exponentially in recent decades, particularly 'bipolar disorder' among young people (10-24 years). There is however no existing research examining young people's accounts of receiving this diagnosis in the UK. Given that UK mental health services continue to be structured around the biomedical model with diagnosis and powerful psychotropic drugs dominating 'treatment', it is important such accounts are examined. This study uses a qualitative research design, involving a purposive sample of six participants aged 12-22 years at time of diagnosis and 20-24 years at interview. Semi-structured interviews were conducted and transcripts analysed using Interpretative Phenomenological Analysis (IPA) to gain an in-depth understanding of participants' accounts. Main themes identified include Authority is knowledge (Doctor knows best); A poisoned chalice; and Being(s) on drugs (Pharmaceuticalisation). These findings highlight the overshadowing nature of authoritative knowledge in participants' sense-making, the paradoxical nature of the psychological and emotional consequences of this knowledge, and the fundamental role of psychiatric drugs in diagnosis. It is hoped inclusion of young people's accounts in this domain will help us understand the experience of receiving this diagnosis as a young person more fully and help shape professional approaches to young people's health problems accordingly.

During Mindfulness-Based Stress Reduction (MBSR) courses, participants are taught to be more present with stressful experience in order to respond to it more effectively. The meditation-based experiential pedagogy is supported by didactic teaching about stress to increase awareness of patterns of reaction and to support the application of mindfulness to self-regulation. The content of teaching about stress, and how it is best taught within the pedagogy, is an important practical and theoretical consideration. This thesis addresses a gap in knowledge by focussing on this little-regarded area of practice. The aim of this research was to develop practical and theoretical knowledge about the inclusion in the MBSR curriculum of the Workable Ranges Model of stress and emotional regulation, developed by the author. This visual model lays out regulated states and both mobilised and immobilised threat-based reactions in relation to each other. The main research question was: how does the Workable Ranges Model complement MBSR? Three key themes were identified in the literature and began to address the research questions. They were: the role of didactic teaching about stress; the notion that how difficult experiences are negotiated is a paradoxical mechanism; and that the Workable Ranges Model provides a novel perspective on participants’ progression through mindfulness-based programmes. Qualitative research was conducted as an illuminative evaluation of the practice innovation. An enactivist, embodied-mind epistemology was used to consider both embodied and verbal forms of knowledge. The application of mindfulness-based, first-person phenomenological methodology, within the frame of the conceptual encounter method, functioned as both learning and data-collection processes. The first phase focussed on the inclusion of the model in three MBSR courses. Data were gathered from participants in classes using diagrams and a question schedule. A template analysis elucidated engagement and resonance, awareness of the features of regulated and dysregulated states and patterns of reactivity, ways of responding to dysregulated states and applications linked with MBSR. In the second phase, seven course graduates engaged in a diary exercise, post-meditation reflective inquiry and a group discussion. Thematic analysis identified an overarching theme that the Workable Ranges Model provides a dynamic map for the mindful exploration of stability and stress. Three interrelated processes were evident: charting regulated and dysregulated states, embodied application in mindfulness practice, and orienting to and resourcing regulation and self-care. The themes from phase two shaped a broader meaning to both data sets. Three functions of the model as a map were identified and discussed. It worked: (i) as a method for teaching about healthy balance and stress; (ii) as a heuristic for self-exploration and developing insight; and (iii) as a guide for mindfulness-based self-regulation and self-care. Together, these aspects acted as aids to teaching and learning about mindfulness-based self-regulation. Theoretical and practical implications are discussed.

Within the National Health Service (NHS), when a serious incident (SI) occurs that harms a patient, understandably, the patient and their families are the primary focus. However, Wu (2000) recognised that the medical doctors involved in the SI, whom he termed "second victims", can also experience psychological distress. This research aimed to explore the lived experiences of second victims, to better understand the second victim phenomenon, as given. The rationale for this research is highlighted through a critical review of the relevant existing literature, which revealed this to be predominately empirically driven, or otherwise interpreted or thematicised. Seven medical doctors were interviewed utilizing a semi-structured interview questionnaire. A Descriptive Phenomenological Analysis was undertaken to conduct an in-depth analysis of the data. The data were sectioned into meaning units and further scrutinised, to identify any psychologically sensitive elements. These were then transformed into nine constituents, which were synthesised to construct the general psychological second victim phenomenon. The findings indicate that doctors experience profound psychological distress at the moment they realise a SI has occurred, from which they never fully recover, concealing and suppressing the emotions the SI has provoked to their own psychological detriment. They feel changed, subsequently altering their work practices, becoming hypervigilant and avoidant. Their self-identities are damaged along with their sense of expertise as doctors, with symptoms indicative of post-traumatic stress disorder manifesting. Nonetheless, they do not consider seeking psychological support, as it is not a part of the clinical culture they have been socialised into since medical school. These findings provide a unique insight into the lived experience of doctors who have been involved in SIs. The clinical implications are discussed in the context of the current literature, leading to recommendations for training and psychological support for clinicians as crucial interventions to help alleviate the psychological distress of second victims.

Background: Integrating religious perspectives into psychological therapies is increasingly recommended by regulatory bodies (NICE, BPS, APA). However, there are no core competencies for clinicians working with a religious population such that for many therapists, faith (religious or spiritual), is treated as one aggregate psychological domain, if at all. This lack of nuance results in spiritually avoidant care, misaligned treatment goals between therapist and client, and poor therapeutic outcomes. Nowhere more so than with Christian clients who, due to the recent and rapid growth of 'born-again' Independent Protestantism, have largely evaded psychological inquiry. To address these shortcomings, a nuanced understanding of their self-concept and therapeutic implications are investigated. Methods: A Glaserian Grounded Theory on nine participants was performed. Results: The dominant reason born-again clients have poor agreement with therapeutic treatment is that their theory of sanctification conflicts with psychological theories of transformation. Their true-self, created by God, is discoverable only in relationship to Jesus and becoming like him through self-awareness, self-acceptance and self-surrender. This sanctification process constitutes Christ-actualisation, with implications for psychotherapy centring around how their true-self is understood. This include Christians' distrust of emotions, specific types of cognitive restructuring, and spiritual aetiology of distress and fears around opening-up to any authority other than Jesus. Conclusions: A redefinition of being 'Christian' is needed as being in relationship. The nature of this relationship can be ascertained in assessment, formulation and treatment plan. Several models are provided to help the Psychologist decide upon an appropriate therapeutic modality, to aid formulation and frame a nuanced engagement with emotions and cognitions, and to help ascertain treatment goals in alignments with sanctification.

Introduction: Schizophrenia symptomatology exists on a continuum ranging from subclinical psychotic-like experiences in the general population (schizotypy) to full-blown clinical symptoms. High schizotypy individuals are at an increased risk for developing clinical diagnoses, yet previous work has not investigated key neural abnormalities of schizophrenia in these samples. Methods: To ensure findings are informative for clinical risk, we only recruited individuals scoring at the extreme low/high end of the Schizotypy Personality Questionnaire. 27 high schizotypy (HS) and 26 low schizotypy (LS) individuals to take part in two functional magnetic resonance imaging (fMRI) tasks assessing social learning. Participants also underwent a resting state fMRI and a magnetic resonance spectroscopy scan. Results: HS subjects, compared to LS, present with abnormal learning of social information. HS overestimate the volatility of social cues and are slower to learn about global changes in social context. Furthermore, HS subjects show reduced neural activity in the dopaminergic midbrain and increased frontal cortex activity in response to prediction errors during social learning. HS subjects also present with a reduced resting-state functional connectivity between hippocampus and striatum/thalamus and with reduced GABA and Glu metabolite levels in the prefrontal cortex. Discussion: HS subjects, representing the earliest risk for clinical transition to schizophrenia, already present with key neural abnormalities implicated in progression, mainly abnormal hippocampal functioning and abnormal GABA/Glu levels. These results encourage investigations of HS to facilitate a comprehensive view of risk/protective factors for clinical transition. The results also show that HS subjects already present with abnormal hierarchical learning as seen in clinical samples. HS subjects neutrally underweight prediction errors indicating an improper processing of these learning cues. They also present with compensatory activity in frontal cortex enabling behavioural performance similar to LS. The abnormal learning from social cues could explain not only the social functioning deficits key to schizophrenia, but also other cognitive biases observed in these populations.

Schizophrenia is a complex psychiatric disorder with positive, negative, and cognitive symptoms. The causes are not yet fully understood, but it is believed that together with a strong genetic foundation, a 'second environmental hit' may be responsible to triggering a psychotic episode. Early-onset schizophrenia (EOS) a rare and more severe form of the disorder compared to its adult-onset counterpart and it is regarded to be more genetically loaded. This being as children and adolescents are less likely to have accumulated environmental triggers that are often considered risks to develop schizophrenia. Neurotic personality and anxiety symptoms are considered candidate schizophrenia risk factors. Working memory (WM) performance, the ability to hold information "online" in the matter of a few seconds, as well as its neural correlates are severely impaired in EOS, and such impairment is considered endophenotypic to the disorder. In addition, the expression of neurophysiological indices of cognition such as the mismatch negativity (MMN) and P300 event-related potentials (ERPs) are consistently demonstrated to be reliable biomarkers for the disorder, as shown by electroencephalography. This thesis on one hand, explores the influence of neuroticism and anxiety levels in healthy participants in ERPs during the auditory roving oddball and the hollow mask illusion experiments that are continually shown to be affected in schizophrenia literature. On the other hand, it explores meta-analytically convergent structural and functional brain abnormalities in EOS literature and follows a longitudinal fMRI cohort of EOS and healthy adolescents who were scanned twice in a 4-year span, while they performed the n-back task (WM task). These experiments are aimed to reveal brain areas that may qualify as endophenotypic markers of impaired WM neurodevelopment in schizophrenia. Our results showed that anxiety and neuroticism do not fully explain their status as schizophrenia risk factors by their relationship with the schizophrenia biomarker ERPs (P50 sensory gating, MMN, P300 and P600). The meta- analysis strongly indicates that a dysfunction in the functional network that underlies salience and other executive functions related to incentive and goal-oriented processes may be central across cognitive paradigms in EOS. Longitudinally, functional connectivity and maturation impairments are prevalent in the WM functional substrate of adolescents with EOS as they undergo neurodevelopmental processes by transitioning into early adulthood.

Background: Health Locus of Control (HLoC), and health beliefs in general, have been found to play a role in the way in which people manage their healthcare needs. Increasingly, patients are being encouraged to self-manage a variety of health conditions, including chronic physical health conditions, such as diabetes, and mental health conditions, such as depression and anxiety. However, evidence regarding which factors might be related to response to self-management is limited. HLoC may help to explain why some take well to the self-management of health conditions, or respond to recommended remote therapies, whereas others struggle to implement advised changes. Similarly, attitudes towards eHealth (AteH) may play a role in engagement with specific remote therapies. Aims & Objectives: The current thesis project aims to consolidate the existing research into the relationship between HLoC and diabetes self-management by conducting a systematic review of the literature (chapter 1), before exploring the concept of HLoC and AteH as potential predictors of response to computerised Cognitive Behavioural Therapy (cCBT), as defined by uptake (starting treatment), adherence (extent to which treatment is completed), and clinical outcome (magnitude of symptom reductions) in chapter 2. Methodology: In chapter 1, a systematic review of the literature was conducted across three electronic databases (PsychINFO, Ovid MEDLINE, and Embase) to examine and critically appraise the literature regarding the relationship between HLoC and adherence to diabetes self management. Studies included research investigating diabetes self-management in relation to HLoC. In chapter 2, a longitudinal study with three major time-points was conducted across N=2130 patients accessing cCBT services in Scotland to individually explore predictors of uptake, adherence and clinical outcomes. Results: N=17 studies were identified and critically reviewed using the AXIS tool in chapter 1. Most were deemed to be of good methodological quality, with a small number of exceptions. The review revealed that the majority of studies found evidence to suggest that stronger internal HLoC beliefs were associated with better adherence to diabetes self-management regimens, however inconsistencies were found across certain HLoC domains, and the heterogeneity of predictor and outcome measures posed a challenge to inter-study comparisons. In chapter 2, neither of the healthcare belief-related factors were found to significantly predict uptake in cCBT services, however both HLoC and AteH predicted higher adherence to cCBT, and various HLoC domains predicted magnitude of clinical changes across treatment. Other significant sociodemographic and clinical predictors of adherence and reductions were found and discussed. Conclusions & Clinical Implications: Chapter 1 concluded that stronger internal HLoC beliefs are positively related with adherence to diabetes self-management regimens, which may improve health outcomes for those self-managing diabetes. However, further research is needed to apply causality to this model. Chapter 2 demonstrated interesting insights into the theoretical factors predicting response to cCBT, which may help inform clinicians in making referrals to the service.

An overarching goal of multisensory research is to understand multisensory behaviour in a wider context but still within a unified framework. Modelling has been a useful tool to understand how information from different senses is combined to produce behaviour. For example, different models have been used to understand the improvement in speed or precision of multisensory relative to unisensory decisions (Ernst & Banks, 2002; Raab, 1962). However, these modelling approaches are limited to address a single measure of multisensory decisions, for example, models of speed cannot explain precision and models of precision cannot explain speed. The field is still working towards developing a unified modelling framework that can link the different aspects of multisensory decisions together. In aim of this, I addressed three gaps in research on multisensory decision making, which I believe is essential to address the missing linkage between studies of multisensory behaviour. Firstly, most multisensory modelling work has used an implicit assumption, which states that processing of a unisensory signal and processing of the corresponding unisensory component of a multisensory signals are identical. However, the validity of this assumption, has not been tested. I offered a way to understand this assumption under experimental settings and proved that it is most likely violated. This suggests that studies of multisensory behaviour should rather consider the influence of context in modelling work. Secondly, I addressed that multisensory response at neuronal and behavioural level can be linked. The spatial principle, which is found in neuronal studies, can be mapped to behaviour and accounted for by a race model. Thirdly, I attempt to address the link between speed and precision of multisensory behaviour. In the past, the two have rarely been studied within a unified paradigm. I found that when both measures were required, participants are far from achieving optimality in either speed or precision, and it is possible that they are switching strategies towards favouring one of the measures in such decisions. The race model is a strong candidate to be refined and developed in future research to incorporate more aspects of multisensory decisions, as I have address it is not limited to explain speedup in simple detection task, but also influence of context, space, and precision in more complex experimental tasks.

There is substantial evidence suggesting that psychological therapies are largely effective for the treatment of mental health difficulties. However, the evidence-base has also demonstrated that some individuals do not improve after psychotherapy and others actually deteriorate. Therefore, there is a pressing need to understand how to improve outcomes in psychotherapy. One approach to this is understanding the factors that predict good treatment response, so that therapists can make treatment decisions based on empirically based prognostic indicators. There is a well-documented literature highlighting social support as a relevant factor for mental health difficulties, especially for individuals with depression. However there remains considerable uncertainty about the extent to which social support may be associated with depression treatment outcomes. Part I of this thesis is a systematic review and meta-analysis exploring associations between pre-treatment social support and psychotherapy outcomes for adults with depression. The results of 25 studies, including 7576 patients, were identified and synthesised and, of these, 12 studies were meta-analysed. Studies included randomised controlled trials and observational cohort studies. The quality of studies was assessed, ranging from low to high quality; however, the study quality did not influence the results. Higher levels of social support before psychotherapy were found to be significantly associated with lower depression severity following psychotherapy, especially in studies that used Cognitive Behavioural Therapy (CBT). This suggests that assessments of social support and early interventions aimed at increasing social support may be beneficial for improving depression outcomes, especially in CBT.

Research examining psychological therapists' personal experiences of bereavement is limited, despite existing research and anecdotal accounts indicating its profound impact on the self and therapeutic practice. Situated in the context of existing literature on wounded healers and the use of self in therapy, the aim of this qualitative study was to examine the experiences of psychological therapists who experienced the death of a parent in childhood. Seven psychological therapists from a range of professions and therapeutic modalities participated in semi-structured interviews exploring how this experience impacted them personally and professionally, in their therapeutic work with clients. Using interpretative phenomenological analysis, three master themes emerged: A loss beyond words; Navigating in a strange landscape; and Something lost, something gained. These themes reflected how the impact of the parent dying was experienced throughout participants' lives, from childhood through to adulthood, and into their psychotherapeutic practice. Areas of convergence and divergence between these findings and previous theory and research are discussed, particularly with respect to literature on grieving and the self of the therapist. Implications for therapeutic practice, supervision, and training are highlighted, including the importance of self-reflection and supervision in facilitating the use of self, and the value of therapeutic training incorporating self-of-the-therapist work.

Psychological theory and research has sought to explore paranoia, self-esteem, and trust extensively across clinical, social, behavioural, evolutionary, and neuropsychological fields. Understanding the role of these psychological mechanisms and the potential relationship between them is essential in order to develop psychological interventions for clinical practice. Research has found that negative self-esteem is associated with severe mental health difficulties such as depression and paranoia. In addition, paranoia is associated with mistrust and insecure attachment styles, which appear to interact with negative self-esteem. To contribute to our understanding of how psychological mechanisms may influence emotional and psychosocial functioning and the potential relationships between them, this research examined whether a novel evaluative conditioning paradigm would increase implicit self-esteem and implicit trust, and consequently reduce paranoia and depression. Part I of this thesis presents a systematic review which aimed to explore the relationship between paranoia and trustworthiness judgments of faces. Eleven relevant articles were included in this review; conceptualisation and operationalisation of paranoia and trust were examined and the relationship between these two variables assessed. Overall, the findings of this review were mixed regarding conceptualisation and operationalisation of paranoia and trustworthiness judgments of faces and the relationship between them. Study design, quality, conceptualisation, and measurement of the key variables did not appear to influence whether a relationship was found. This review was limited by the small number of eligible studies and the heterogeneity between study quality, designs, and analysis, and consequently a meta-analytic review was not possible. Future research is needed using consistent study designs, conceptualisations, and measures of paranoia and trust to further explore the relationship between the variables of interest and provide opportunities for a meta-analytic review. Future research would also benefit from incorporating additional measures of mood e.g., depression and anxiety, to control for potential confounding variables. Part II of this thesis presents an experimental causal-interventionist study which aimed to investigate whether a novel evaluative conditioning task would improve implicit self-esteem and trust and therefore decrease paranoia and depression. An analogue sample of 211 participants was randomly allocated into either the experimental evaluative conditioning task or an equivalent control conditioning task. Baseline trait measures of psychological difficulties and attachment were collected in addition to pre- and post- measures of implicit and explicit self-esteem, paranoia, trust, and attachment. Although the evaluative conditioning paradigm did improve implicit self-esteem, this did not result in improved trustworthiness judgements or decrease subclinical paranoia or depression. There was a marginal increase in explicit self-esteem for both the experimental and control conditions. Following the evaluative conditioning paradigm, attachment anxiety unexpectedly deteriorated. The study's findings that increasing implicit self-esteem did not improve trustworthiness judgements or reduce paranoia or depression contrasts with psychological research and theory. Consequently, replication to confirm the findings of this study in future research is necessary. In addition, future studies should seek to test this paradigm with a clinical sample. The limitations of this study are discussed, alongside clinical implications and recommendations for future research.

There is debate regarding the definition and development of psychiatric delusions, but they are typically defined as false, idiosyncratic beliefs. The extent to which delusional themes differ across the world and according to demographic factors is unclear. The first section of this thesis includes a meta-analytic review of the prevalence of five common delusional themes (persecutory, reference, grandiose, control, and religious) across the world, including sub-group and meta-regression analyses. There were 117 studies (130 samples) included in the systematic review and 109 samples were meta-analysed with a total of 17,922 participants. Persecutory delusions were most common delusional theme, followed by reference, grandiose, control, then religious delusions. Prevalence rates of delusions did not significantly differ between developed and developing countries or according to study quality or year of publication. Persecutory and religious delusions were more prevalent in younger samples, and grandiose, control, and religious delusions were more prevalent in males. As predicted, persecutory delusions are the most common delusion across the world. The prevalence of delusional themes did not differ between developed and developing countries, but they were influenced by age and gender, suggesting that delusions reflect universal human concerns that vary according to stages of life and gender. Prevalence rates of delusional themes may differ according to other cultural factors, such as the level of individualism and income inequality. Grandiose delusions have received relatively little empirical investigation and the second section includes two empirical studies on grandiosity in the general population. Based on past research on predictors of paranoia and other strongly held beliefs, the first study was a cross-sectional survey investigating factors associated with grandiosity. Younger age, male gender, non-white ethnicity, paranoia, religiosity, and narcissism were associated with grandiosity. Paranoia was associated with grandiosity, attachment anxiety, negative self-esteem, and younger age. Grandiose delusions have been described as providing a sense of meaning in life and Terror Management Theory proposes that human's boost their selfesteem to protect against existential anxiety. Therefore, the second study aimed to test whether grandiosity reflects a defence against existential anxiety. An online between-subjects experiment investigated changes in participant's grandiosity and self-esteem after being primed to think about their mortality or dental pain, as a control condition. There was no effect of mortality salience on changes in self-esteem or grandiosity, as self-esteem significantly increased, and grandiosity significantly decreased in both conditions. Interestingly, males and non-white participant's grandiosity decreased in the dental pain group, but not in the mortality salience group, whereas female and white participant's grandiosity decreased in both conditions. Taken together, the findings suggest that male gender, non-white ethnicity, high religiosity, narcissism, and paranoia are associated with increased grandiosity. Future research is needed to replicate these findings in clinical populations with more diverse samples and include different subtypes of grandiose beliefs.

Bipolar disorders are characterised by recurrent periods of depressive (feeling intensely low) and manic (feeling extremely happy) symptoms with disturbances in cognitive and motor activity of varying severity, duration, and frequency. The chronicity associated with bipolar disorders often leads to poor psychological outcomes with an elevated risk of suicide and psychiatric comorbidity. Bipolar disorders are highly heritable, and a positive family history remains the strongest predictor for the development of a bipolar disorder. Clinically, bipolar disorders have proven difficult to identify which is partly due to a lack of consensus around diagnostic definitions and difficulties differentiating bipolar subtypes from one another. Current categorical approaches are limited in their ability to capture the heterogenous nature of bipolar disorders or their relationships with other symptoms of psychopathology. To contribute to our understanding of bipolar disorders, this project examined the structure of bipolar disorders and processes that may lead to affective disorders. The first section of this thesis reviews the literature concerned with Akiskal's model of affective temperament and its relationship to mood disorders. Temperament is defined as an individual's predisposition towards patterns of emotional reactivity, which remain stable over time and are inheritable. Akiskal's theory describes five affective temperaments (depressive, hyperthymic, irritable, cyclothymic and anxious) that are thought to constitute the behavioural phenotypes in the pre-morbid course of affective disorders. The review provides partial support for a continuum model of temperament in which individuals with a bipolar disorder generally yielded higher scores on a measure of temperament than genetically at-risk first-degree relatives across depressive, irritable, cyclothymic and anxious subtypes. Although mixed, the findings have implications for identifying those at risk or within prodromal phases of bipolar disorder and could provide important insights into the clinical evolution of mood disorders. However, this review was based on a limited number of studies, of varying quality, and should therefore be interpreted with caution. To investigate the structure and development of bipolar disorders the second section of the thesis includes a network analysis of bipolar disorder symptoms and common psychiatric diagnoses to explore comorbidity and pathways from psychopathological states. According to network models, mental disorders (clusters of symptoms) occur, not because the symptoms have common underlying causes, but because symptoms are connected in a network of causal relationships. Networks were constructed using symptoms scores of 7076 participants from a general population sample. Results revealed symptoms of energy and activity as core features of bipolar disorders given their centrality and connectivity within the bipolar network. In addition, community analyses revealed four communities including a 'pure mania' community and a 'mixed' community consisting of irritability, distractibility and racing thoughts amongst depression and anxiety disorders. Analyses highlighted 'racing thoughts' as a possible bridge between communities, suggesting the presence of racing thoughts as a risk factor for convergence or comorbidity. The findings have clinical implications such as the development of interventions that target key connections to decouple strongly connected symptoms and 'deactivate' networks. However, as symptoms were assessed cross-sectionally they provide limited insight into how networks may change over time.

This portfolio provides evidence submitted towards the fulfilment of the five competencies for the Health Psychology Doctorate. Whilst undertaking the Doctorate, a work placement as an Activity Coordinator for a private mental health hospital in the North West was undertaken. Behaviour Change Interventions (BCI): A face-to-face, one-to-one, stress management BCI was completed with a nurse at a private mental health clinic. Secondly, a six-week group BCI was delivered for staff at work who aspired to reduce or quit smoking. Consultancy: A case study was completed with a manager from a private Wellbeing clinic in the North West of England who requested a stress management training workshop. Teaching and Training: A smoking reduction training programme for the development of new applications and understanding in Health Psychology was completed at the work placement for inpatients at a private mental health hospital. A Teaching and Training Diary is also included that demonstrates the author's development as a teacher/trainer. Research: Three research projects were completed for the portfolio. A systematic review was conducted which examined Heart Rate Variability Biofeedback (HRVB) intervention studies within a variety of psychiatric conditions. In addition, a quantitative and qualitative research project explored Heart Rate Variability (HRV) coherence interventions for individuals with Gastrointestinal Disorders (GID). A reflective commentary on all the three research projects is also provided. Professional skills: A reflective report is presented which validates skill development, meta-reflection, working with clients and respecting them, following ethical guidelines, laws and codes of conduct as a Health Psychologist in Training. An reflective diary is included which was maintained throughout the whole period of completing the course. Conclusions The one-to-one BCI showed ways to control high levels of burnout and compassion fatigue in healthcare professionals. The group BCI smoking reduction programme was very successful; having been trailed on one ward it was then successfully rolled out on two 5 additional wards. The research revealed some promising conclusions for the effectiveness of Heart Rate Variability interventions in the respect of both patients with gastrointestinal disorders, and within the psychiatric population, as evidenced from the systematic review.

Understanding the extent to which psychological therapy is effective, and under which conditions, is important for the provision of mental health treatment. Historically, there has been a large weighting for evidence generated from research methodologies that possess high internal validity (e.g., randomised-controlled trials). Unfortunately, treatments evaluated with these methodologies, usually conducted in University settings, often fail to represent various aspects of routine care settings and treatments which they are purposefully intended for (e.g., lower levels of client heterogeneity and risk, fixed treatment lengths, manualised treatments). Due to this distinction (i.e., efficacy vs. effectiveness), it is subsequently important to establish the extent to which treatments remain effective when delivered within routine care. Since the turn of the century there has been a marked increase in the amount of evidence from routine care settings regarding the effectiveness of psychological therapy. The first chapter of this thesis was a comprehensive review of this body of literature, focusing on one-to-one, face-to-face psychological treatments within naturalistic settings. 252 studies were identified, comprising a total of 298 different therapy samples. These samples were analysed quantitatively using meta-analysis. The findings demonstrated that psychological therapy produces marked improvements (i.e., large effect-sizes) across each self-reported outcome domain explored (depression, anxiety, general distress). Effect-sizes tended to be larger under certain conditions: (i) studies conducted in the UK/North America, (ii) studies which only include patients who complete treatment, and (iii) studies with low risk of bias. This was the largest review of routine practice studies concerning psychological therapy which has been conducted to date. The second chapter of this thesis was an evaluation of how patients respond to psychological treatment from a UK tertiary care psychological therapy service. Evidence arising from these settings is highly scarce. Such treatments are intended to be across longer periods and for more distressed/complex presentations than treatments delivered in other care settings (primary and/or secondary care). The current study found that while tertiary care therapy is effective, the amount of change is smaller than available benchmarks. Rates of improvement were suppressed by a sub-set of patients who appeared to not respond to treatment. The three forms of psychological therapy offered were not significantly different in effectiveness. Patient rate of improvement (positive growth) reduced with each session. There was limited evidence to support continuing treatment beyond 100 sessions. Taken together, the chapters presented provide further evidence that psychological therapy is effective across a wide range of routine care settings. Similar to prior findings, there was limited support for long-form psychological treatments. Support was shown for the potential utility of routine outcome measures as a tool to determine when a patient is no longer benefiting from treatment. The evidence considered in these chapters predominantly concerns self-report outcome measures. Further research is needed to determine consistency of findings through other measures of effectiveness (e.g., clinician-rated change, health-care cost/utilisation, reduction in harm events). Further research is needed which focuses upon how improvements made during therapy are maintained beyond treatment ending.

A significant number of people worldwide suffer from mental disorders such as depression, bipolar and neurodegenerative disorders. These disorders adversely impact the life quality of people and have a significant economic impact on health-care providers. The World Health Organisation (WHO) considers depression as a common mental disorder, with more than 300 million people of all ages affected by depression. Similarly, Bipolar disorder affects more than 60 million individuals, which makes it among the most spread mental disorders worldwide. Even though the treatment of mental disorders has proved to be efficient in most situations, incorrect diagnosis is a common obstacle. This is because self-administered questionnaires and clinical interviews are the only available methods for diagnosis. These methods are influenced by subjective bias from clinicians or patients, time-consuming and hard to repeat. There is growing attention on early diagnosis of mental disorders as evolving treatments are expected to be more effective before irrevocable changes have occurred in the brain. The integration of novel methods based on the automatic analysis of visual signals may provide more information about a person's mental state, which could contribute to the clinical diagnostic process. This thesis demonstrates that eye features extracted from video recordings of patients' answers to a clinician's questions can help in the automated diagnosis of depression. Results show that there is eye blink abnormality among depressed patients due to psychomotor retardation. This manifests as longer eye blink duration. The efficacy of these features demonstrated in depression severity prediction where it achieved mean absolute error (MAE) of 8.30 and classification accuracy of 93% using the Audio/Visual Emotion Challenge 2014 (AVEC2014) dataset. Furthermore, visual features of eye movements combined with head pose features extracted from video recordings of patient's during a clinical interview in a specialist memory clinic for the development of an automated visual screening method to support the preliminary detection of patients with cognitive concerns related to progressive neurodegenerative disorders (ND), FunctionalMemory Disorder (FMD) mild Cognitive Impairment (MCI). Finally, a novel automatic diagnosis method for bipolar disorder developed based on deep learning. The proposed method investigated the application of several deep neural network architectures to extract the complex temporal trajectories of physiological behaviours that occur at multiple time scales. Results achieved shows that this model can be used as a universal automatic feature extractor for mental disorders. This is confirmed by testing the proposed model on AVEC2018 bipolar disorder dataset and AVEC2014 depression dataset. In the AVEC2018 dataset, individuals with bipolar disorder are classified into states of remission, hypo-mania and mania. The proposed model achieved Unweighted Average Recall (UAR) of 55.56%. Using the same model on AVEC2014 depression dataset, Mean Absolute Error (MAE) of 7.65 achieved which outperforms most of the previous studies on the same dataset. These results confirm the generalisability of the proposed deep learning model and that it can be used as a tool for multi-scale feature extraction.

In the past few decades, there has been an apparent rise in individuals who identify as Asexual. Asexuality has been defined as the lack of sexual attraction to anyone or anything. The current thesis explores this phenomenon from a psychoanalytic perspective and considers the possible implications for therapeutic work with Asexual individuals. This thesis incorporates three main investigative tenets. First, the research focuses on the process of the development of, and identification with, an Asexual identity as well as the subjective meaning of this identity for them. Second, it considers the current understanding of the lack of sexual desire within the psychoanalytic framework and proposes three hypotheses in the form of developmental pathways to understand the diverse range of sexual and gender identity expression in the Asexual community. The consideration of these developmental pathways re-evaluates the psychoanalytic understanding lack of sexual desire - beyond a manifestation of psychic conflict. Finally, it considers the implications of working therapeutically with an Asexual client. In doing so, it investigates how sexual inhibition and lack of sexual desire are treated in clinical and therapeutic settings; and examines with the help of case studies how the process may be different (and other practical implications)in therapeutic work with Asexually identified individuals.

Self-disorders have long been considered as a central nucleus of the schizophrenic experience. It has been suggested that such self-disturbances might be associated with abnormal multisensory integration and abnormal bodily self-awareness. The primary goal of this thesis was to explore the behavioural and neurophysiological markers of self-disturbances in schizophrenia and in high schizotypy (i.e. a sub-clinical trait linked to schizophrenia). Specifically, we aimed at (i) investigating the temporal acuity in individuals with low and high schizotypy (ii) measuring aspects of the neural responses to multisensory integration in low and high schizotypes (iii) exploring how body representation abnormalities in both schizophrenic patients and high schizotypes affect basic processes of self-perception. In line with previous research showing a reduced multisensory acuity in schizophrenia, results from Chapter Three revealed a significant relationship between the temporal window within which two stimuli are integrated (i.e. TWI), and schizotypal personality traits; namely, higher schizotypal traits are associated with wider TWIs. In Chapter Four, we provided evidence of a selective relationship between the TWI for visuo-tactile stimuli and the individual beta frequency (IBF), i.e, slower IBFs accounts for larger TWIs, and between the TWI and schizotypy, i.e. wider TWIs are linked to higher schizotypal traits. In Chapter Five, we have demonstrated that patients with schizophrenia possess more malleable body representations and that these abnormalities are linked to early markers of vulnerability to the disorder (i.e. basic symptoms). Finally, findings from Chapter Six revealed that the abnormalities in bodily self-awareness observed in schizophrenia might extend to schizotypy, suggesting that such abnormalities could represent a trait marker for schizophrenia proneness. All in all, our results suggest that the abnormalities in multisensory integration and bodily awareness observed in schizophrenia spectrum disorders might produce a distortion in the structure of self-experience and contribute to the emergence of the disorder.

Literature Review: The literature review explored the factor structures of the RBANS reported in existing literature. With the systematic search of four databases, 11 quantitative papers were identified as relevant and included in this review. Six reported two-factor solutions, two suggested five-factor solutions, one found three-factor model, one demonstrated bi-factor model and the other one reported second-order factor model. Research to date showed that limited empirical support to the original RBANS structure has been found and there was little consensus regarding the factor structure of the RBANS. Given the important role that neuropsychological measures play in the neuro-rehabilitation services, this should be privileged in future research. Empirical Research Project: The foremost aim of neuropsychological assessment is usually multifaceted and aims to aid clinicians in making clinical decisions about clients by utilising neuropsychological test batteries to identify the cognitive strengths and impairments of the clients. The present study aimed to explore the latent constructs of the SPANS in two independent samples: non-clinical (n=393) and clinical (n=121). Principal axis EFA was conducted to analyse the common variance from the SPANS subtests and two three-factor solutions were derived respectively from the non-clinical and clinical samples with different factors emergent. The three factors derived from the non-clinical sample comprise: Visual, learning and memory retention of the newly learned information, recognition memory, and general knowledge and attention and working memory. The three factors emerged from the clinical sample consist of: Visuo-motor and efficiency, receptive and expressive language, and learning and retention. The findings had a few clinical implications, limitations of the study and future research ideas were discussed.

Transgender and gender nonconforming (TGNC) people must deal with a cisgender, heteronormative society that assumes people are either men or women and heterosexual. These social constructions can affect the psychosocial aspects of TGNC people's lives, as individuals and within society. This thesis examines such impacts at these different levels; experiences of coping with minority stress in society, and the influence of psychosocial factors on transmasculine individuals' decisional conflict over fertility. Together these add to understanding the psychosocial impact of gender identity and transition within cis/heteronormative society. Systematic literature review: Difficulties experienced by TGNC people can be attributed to minority stressors that they are frequently exposed to. These experiences can decrease gender affirmation and impact psychological and social wellbeing. However, voluntary coping strategies may help protect against this. A systematic search found nine studies that included voluntary coping responses and, through framework synthesis, a new conceptual model of coping responses for TGNC individuals was developed. This included four themes under psychological affirmation and four themes under social affirmation. These provide direction on more active ways of engaging with, or resisting, minority stress and non-affirmative experiences. Empirical project: Transitioning is typically beneficial to wellbeing, but some gender affirmative treatments may counter this due to increasing the risk of infertility. Despite this, there is low uptake of fertility preservation amongst TGNC people. Research in TGNC fertility, oncology, and decision-making highlight specific psychosocial variables may potentiate decisional conflict about this, particularly for transmasculine individuals. An online questionnaire was completed by 69 participants. Statistical analysis and content analysis explored the prevalence and relationships between variables. Decisional conflict was found to be high overall but none of the variables were significantly associated with it, but additional analyses indicate that psychosocial factors may have some relevance to experiencing decisional conflict about fertility.

Accurate assessment and categorisation of cognitive impairment after an acquired brain injury is vital for the creation of targeted rehabilitation plans and the planning and provision of care. To be useful neuropsychological assessment tools must be able to predict patient outcomes and accurately classify the presence/absence of impairment. Literature Review: The ability of domain-specific assessment tools used post-stroke, to predict later functional outcomes was reviewed. Tools assessing the domains of executive function, visuospatial perception/construction and visual memory were selected for review, due to previous evidence of their relationship with functional outcomes. It was concluded that all domains were predictive of a range of functional outcomes at many time-points post-stroke. Individual assessment tools showing evidence of predictive validity were identified for clinical use. Empirical Report: This study assessed the diagnostic ability of the Short Parallel Assessments of Neuropsychological Status (SPANS) in acquired brain injury (ABI) samples. The ability of the SPANS to accurately distinguish between a sample of patients who had suffered an ABI and a sample of age and education matched healthy norms was investigated using five different clinical samples: ≤ 6-months post-ABI, ≥ 1-year post-ABI, high school educated, college/vocationally educated and university educated. The SPANS total score and individual indices had high diagnostic validity in the acute ABI sample, indicating it is a valid general and domain-specific screen in this setting. The /SPANS total score also had high diagnostic validity in the long-term ABI sample indicating it is a valid general cognitive screen in this setting. Scores for individual indices in this sample were mixed, this could be because of recovery of functioning in particular domains or a lack of sensitivity in subtests. Education level and time-since injury had a large impact on optimal cut-off scores, the implications for the use of 'one- size-fits-all' cut-offs is discussed.