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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.

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.

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.

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.

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.

Past research has consistently highlighted the prominence of emotion regulation difficulties in the development, maintenance and treatment of psychopathology. However, especially for young people the evidence from longitudinal studies has been limited, partly due to a lack of appropriate measures and effective interventions. With respect to current prevalence rates of mental health problems in children and young people the present research aims to increase our understanding of the role of emotion regulation in the development, treatment and prevention of youth psychopathology. The first part of the thesis consists of two main studies, which adopted two different statistical approaches to investigate the complex relationship between emotion regulation and psychopathology over time. Both studies utilized data from the UK's Millennium Cohort study, a national longitudinal study. Previous studies have not investigated the bi-directional effects between emotion dysregulation and psychopathology over childhood, as longitudinal studies were either under-powered or simply not available. Hence, the first study aimed to uncover the temporal dynamics between emotion regulation and psychopathology in childhood by conducting a developmental cascade model. The results of the cascade model demonstrated significant bidirectional effects between the two constructs over time. Subsequently, the second study investigated whether and how the two constructs overlap conceptually. A bi-factor analysis examined the level of distinctness and commonality between emotion regulation and psychopathology. The findings suggested a significant overlap between emotion dysregulation and psychopathological symptoms, thereby highlighting the potential of emotion regulation as a transdiagnostic intervention and prevention target. The second part investigated the possibility of targeting emotion regulation difficulties in youth by developing and evaluating a newly mobile app intervention in the school context. An integrated design and development framework is presented that guided the development of the new intervention. In this part, the first study, a systematic review and meta-analysis summarised the effectiveness of existing interventions to improve emotion regulation in youth, and how these changes link to changes in psychopathological symptoms. Furthermore, a series of classroom observations, participatory co-design workshops and prototype testing sessions was conducted, of which the results are presented and how they informed the design and development of the new mobile app intervention. The final study evaluated the usability and acceptability of the new digital intervention as part of an exploratory feasibility trail in primary schools. The results suggested adequate levels of acceptability and engagement from a user perspective. Areas for future improvements were identified. The findings of the school trial suggest that a digital intervention can be used to overcome common barriers that are associated with the implementation of more traditional school-based interventions, which have not been sufficiently adopted if they required too much teacher time or preparation. This is of significant importance, as schools are considered key players in providing mental health support for young people. This research contributes to the current understanding of the complex relationship between emotion regulation and psychopathological symptoms in youth. The employed analytical approaches support the notion that emotion dysregulation processes are a central component in the development of youth psychopathology. The findings highlight new opportunities for the assessment of complex constructs as well as the treatment and prevention of mental health problems through technology-based interventions.

Introduction People aged 65 years and above are frequently excluded from research on the epidemiology of non-affective psychotic disorders; consequently, little is known about the incidence of psychotic disorders in older people. In this thesis, I characterised the incidence of very late-onset schizophrenia-like psychosis (VLOSLP) in relation to socio-demographic factors, and I investigated the association between VLOSLP and subsequent dementia. Methods In Chapter 2, I conducted a systematic review and meta-analysis to synthesise published data on VLOSLP incidence. In Chapter 4, I investigated the incidence of VLOSLP in a Swedish population-based cohort. I conducted a matched cohort study to examine the rate of subsequent dementia in VLOSLP in Chapter 5. In Chapter 6, I assessed the feasibility of a case-control study examining social isolation, loneliness and social cognition in VLOSLP. Results In Chapters 2 and 4, I demonstrated a substantial burden of VLOSLP incidence, with a higher rate in women and migrants. Additionally, in Chapter 4, I found a higher rate of VLOSLP in those with a lower disposable income and those with no partner or children. The rate of subsequent dementia was higher in those with VLOSLP relative to age and calendar-period matched comparisons in Chapter 5. In Chapter 6, I found that the feasibility of the case-control study was limited due to challenges in recruiting patients with VLOSLP. Discussion In this thesis, I characterised the incidence of VLOSLP and identified several potential socio-demographic risk factors and outcomes associated with VLOSLP. My findings indicate that VLOSLP may be more common than was previously realised and suggest that the association between the environment and psychosis may persist into late life, opening up new areas for future investigation. Findings of a higher rate of dementia following VLOSLP may be relevant to clinicians in considering monitoring and treatment options.

Aims: Interpersonal contingency plays an important role in attachment formation. Those with high paranoia have a tendency to over-attribute hostile intentionality in behavioural contingency. This study aimed to use virtual reality to investigate potential associations between attachment, contingency and trust in a psychosis sample. Method: A sample of 22 early intervention psychosis participants with active paranoia completed a series of questionnaires assessing attachment style and psychosis symptoms. During a brief virtual reality scenario, participants engaged in a social interaction with an avatar. Participants were randomly assigned to one of two interpersonal contingency conditions, in which the avatar would be more or less responsive in body language. Both subjective (self-report) and objective (interpersonal distance) indicators of trust were recorded. Results: Fearful attachment was the most predominant attachment style. A significant correlation was found between fearful attachment and trusting behaviour, where more fearful participants would stand further away from the avatar. The difference in interpersonal distance between contingency groups approached significance, indicating that participants found the highly responsive avatar less trustworthy. Findings were less pronounced for subjective trust outcomes, although some trends appeared to be emerging through exploratory graphical analysis. Conclusions: The present findings are considered in the context of a lack of statistical power. Attachment insecurity appears to influence trust in social interactions with strangers. Findings are interpreted in light of the attachment behavioural system. Conceptual mechanisms are explored to understand the aversion to interpersonal contingency observed in the current highly paranoid sample. Future directions for research and clinical implications are discussed.

There has been much interest recently in health behaviours that might reduce the risk of neurodegenerative illnesses that cause dementia. Examples of behaviours that potentially enhance (neuro)cognitive health include exercising, maintaining social connections, cognitive activity, and diet. This thesis explores how anxiety mediates the relationship between cognitive health enhancing behaviours and cognitive functioning in healthy adults. Part I is a systematic literature review examining the impact of psychosocial, cognitive training, and multidomain interventions on cognitive functioning. In total, 31 randomised controlled trials (RCTs) were included in this review. Part II presents a secondary analysis of data collected from a charity called Food for the Brain (FFB). Structural Equation Modelling (SEM) was used to analyse whether different types of anxiety mediate the relationship between cognitive health enhancing behaviours and cognitive functioning. Exploratory analysis of longitudinal data collected at six, 12 and 24 months after baseline, investigated predictors of change in cognitive health enhancing behaviours over time. Part III is a critical appraisal that reflects on my experience of co-production and completing the systematic review for the APPLE-Tree project, methodological problems with the measures in the empirical study and the role that clinical psychology has in public health.

This clinical psychology doctoral thesis is structured into three chapters. The first chapter presents a systematic review of the cognitive and emotional domains affected by transcutaneous vagus nerve stimulation (tVNS). It also aims to present an overview of the experimental designs, psychological tasks, outcome measures, participant groups and stimulation parameters used in the field of tVNS. The second chapter is an empirical paper investigating the potential facilitatory effects of tVNS as an adjunct to compassionate mind training (CMT). The study investigates the effect of tVNS and CMT on state affect, self-compassion/criticism, vagally mediated heart rate variability and emotional face processing in healthy participants. The third chapter is a critical appraisal of the research process of chapter 1 and 2.

This thesis focuses on the mental health and wellbeing of adoptive families. Part 1 reviews the research literature examining post-adoption risk and protective factors associated with adopted children’s mental health and behavioural difficulties, considering parent factors, parent-child relationship factors, family factors and contextual factors. Part 2 reports on a mixed-methods study exploring compassion fatigue and trauma symptoms in adoptive parents, who face the emotional impact of parenting a child that has experienced trauma. Survey results highlight the association of three cognitive styles, psychological inflexibility, thought suppression and rumination with trauma symptoms in adoptive parents. A further finding from the survey highlights the significance of the current emotional and behavioural difficulties, including child-to-parent violence, over the extent of the child’s pre-adoptive trauma in predicting parental trauma responses. Semi-structured interviews with adoptive parents high in primary trauma highlight the emotional and traumatic impact of parenting a child that has experienced early life maltreatment. This related to both the knowledge of what their child had been through, and the current behavioural challenges that they are living with as a result of their early experiences. The knowledge of their child’s past, although traumatic to live with as a parent, also allows many parents to make sense of the behaviours they face and enables them to parent with empathy, patience and compassion. Part 3 reflects on the development and process of conducting the empirical research, including service user involvement. Recruitment challenges and issues of equality, diversity and inclusivity will be discussed, alongside reflections on the impact of the COVID-19 pandemic on the research project.

Aims: Camouflaging autistic traits during social interactions is thought to draw upon high-level cognitive abilities. However, there is little information about which cognitive abilities may facilitate such camouflaging. One potential candidate is verbal intelligence. As such, the current research investigated whether verbal intelligence quotient (VIQ) could predict camouflaging behaviour. Methods: A total of 59 adolescents, aged between 13-17, completed a battery of cognitive and behavioural tasks. Adolescents and parents also completed a series of questionnaires. Three distinct, but related metrics of camouflaging behaviour were calculated. This included a mathematical discrepancy between observer and self-rated autistic status, self-rated camouflaging scores, and parent-rated camouflaging scores. Performance on a short measure of intelligence was used to assess whether VIQ could predict scores on each of these three camouflaging metrics, after controlling for executive functioning and autistic-like traits. Results: Verbal intelligence quotient was able to significantly predict scores on a camouflaging discrepancy measure, and scores on a parent-rated camouflaging questionnaire. However, VIQ was not a significant predictor of self-rated camouflaging. Conclusions: The current results suggest that VIQ is important for successfully camouflaging autistic traits, but appears less influential when someone intends to camouflage. These findings should now be used by clinicians and primary care providers to reduce the possibility of missed or misdiagnosis.

Aim Biological explanations of mental health difficulties have remained dominant in recent decades, particularly in the case of psychosis. Research has shown that these explanations can lead to reduced empathy and a bias towards offering pharmacological rather than psychological intervention. This study aimed to explore whether this bias can be reduced by presenting evidence that CBT for psychosis (CBTp) also brings about neurobiological changes (i.e. neuroplasticity). This was examined both in samples from the general population (Study 1) and mental health clinicians (Study 2). Method An experimental design was employed in which participants read a vignette of a person with psychosis. Participants were asked to report which treatment they would recommend (i.e. medication versus psychological therapy) and how effective they perceived each to be. These ratings were elicited before and after reading information about the effects of CBTp: either control information about its clinical effectiveness or evidence of CBTp-led neuroplasticity. Results In Study 1, the predominantly biological description of psychosis elicited lower therapy effectiveness and higher medication effectiveness ratings compared to the predominantly psychosocial description, replicating previous work. Therapy effectiveness ratings were higher and medication effectiveness ratings were lower after either type of CBTp effectiveness evidence was presented. In Study 2, evidence of CBTp-led neuroplasticity had a greater impact than the control information on treatment recommendation ratings amongst psychologists, but not psychiatrists. Conclusions We replicate a previous finding that when biological factors are emphasised in patient information, it biases people to choose medication rather than psychological therapy as a treatment option. When the general population are presented with any type of evidence that CBTp is an effective treatment, they are likely to rate psychological therapy as a more effective treatment method. The impact amongst clinicians is more varied, depending on their training background.

Aims. Clinical psychology training is demanding, and the multiple competing demands can negatively affect trainees’ wellbeing. This study explored trainees’ levels of wellbeing, maladaptive perfectionism and perfectionistic self-presentation, and explored the relationship between perfectionism and wellbeing. It evaluated the effectiveness of a brief CBT-based perfectionism workshop in reducing unhealthy perfectionism and perfectionistic self-presentation, and altering trainees’ likelihood of, and comfort with, disclosing mental health problems and personal difficulties to others. It also examined whether these changes persisted over time. Methods. The workshop was delivered at four UK clinical psychology doctoral programmes. At the start of the workshop, 117 trainees completed an online survey examining wellbeing, maladaptive perfectionism, perfectionistic self-presentation, and their likelihood of, and comfort with talking about mental health problems and personal difficulties with three recipients: placement supervisor, a member of course staff and a fellow trainee. The survey was repeated immediately after the workshop, and at 11-weeks follow-up (n = 35). Results. Wellbeing deteriorated over time and was negatively correlated with maladaptive perfectionism and perfectionistic self-presentation. The workshop reduced maladaptive perfectionism and perfectionistic self-presentation and, excluding comfort with disclosing mental health problems to course staff, increased trainees’ likelihood and comfort with disclosing mental health problems to all recipients. Conversely, the intervention had no effect on disclosure of personal difficulties. At follow-up, only changes in perfectionism were maintained. Conclusions. The results demonstrate the effectiveness of the workshop at reducing perfectionism and breaking down barriers to disclosure in the training environment. Future research should therefore seek to evaluate the effectiveness of this workshop with larger and more diverse trainee cohorts.

This thesis explores the role of epistemic trust in adolescent therapeutic alliances. The literature review in Chapter 1 draws together research in these areas with related concepts of attachment, mentalizing and social network engagement. This encompassing framework is used to understand presentations characterised by difficulties in these domains, including borderline personality disorder and psychopathy. Hypotheses are formed regarding reasons for difficulty engaging in a therapeutic alliance and avenues for future research are outlined. The empirical study in Chapter 2 carries forward some of these hypotheses to test, using a novel approach to understand therapeutic alliance judgments in adolescents currenting engaging in therapy. These judgments are studied in relation to epistemic trust and mentalizing and contrasted with clinician ratings of the alliance. This is considered in the context of broader patterns of structural and functional social network support. The scope and analysis of the study was revised following data-collection restrictions due to the COVID-19 lockdown. Hence, the empirical paper offers only preliminary evidence of associations between broad study concepts. Most notably epistemic trust related to client presumed clinician alliance judgments, suggesting that some clients may not view clinicians as trustworthy. The findings require greater exploration and replication in larger samples. The critical reflection in Chapter 3 explores some of the future research potential, as well as challenges encountered in the research process. Space is given to consideration of the importance of engagement and cultivating trust in the current global context and with future service development in mind.

Aims & Background: There is an increased prevalence of psychological distress and poorer long-term outcomes for Children and Young People (CYP) living with physical health conditions. To better understand the psychological processes of living with a physical health condition, this study aimed to explore the impact of stigma and visible or less visible differences on concealment, illness attitudes and emotional and peer difficulties in CYP with physical health conditions. Method: 61 CYP were recruited from a specialist national hospital and completed three validated questionnaires to investigate self-reported self-stigma, concealment beliefs and illness attitudes. Measures of visibility, psychosocial difficulties and relevant demographic and medical information were obtained from caregivers. Results: CYP with visible physical health conditions reported significantly poorer illness attitudes and more emotional and peer difficulties with large and moderate effect sizes respectively. Higher reported self-stigma significantly predicted greater concealment, poorer illness attitudes and more emotional and peer difficulties in CYP. Conclusions: The findings suggest that condition-specific factors such as visibility can affect the attitudes CYP have towards their physical health condition, their emotional wellbeing and peer relationships. The visibility of a condition and stigma perceptions should be taken into account when supporting CYP with physical health conditions and their families.

This thesis is concerned with adolescent mental health and wellbeing. It is presented in three parts. Part One: Literature Review. A systematic review of 20 studies, both cross-sectional and longitudinal, that investigated the relationship between school-related stress and depressive symptoms in adolescents. Significant positive relationships were found between school-related stress and depressive symptoms; however, the causal direction of this relationship is questionable as most studies were cross-sectional. Additionally, a number of studies found effects of moderating and mediating factors, such as gender. Further high-quality, longitudinal studies need to be conducted to assess the strength and direction of this relationship. Part Two: Empirical Paper. This consisted of an exploratory randomised control study to investigate the effectiveness of a three session self-compassion psychoeducation group with an imagery task, compared to a psychoeducation group alone or control group. It was conducted as a joint project with another UCL Clinical Psychology Doctorate student (Tweed, 2019). Improvements in self-compassion and social comparison were found in the psychoeducation group, but not the psychoeducation and imagery group. Within the imagery group there was evidence that the greater the ability of the participants to vividly imagine the imagery task, the greater the improvements they experienced. Acceptability feedback of the intervention sessions was positive, although there were questions regarding the acceptability of inter-session tasks. Part Three: Critical Appraisal. A reflection and appraisal focused on the empirical paper. This includes methodological and practical issues encountered during the study alongside consideration of wider issues relating to school-based research.

In the UK, there are ethnic disparities in the rate of compulsory detention, with Black people being more likely than White British people to be detained against their will. Part I of this thesis explores the reasons underlying the disparities and proposes a new model to explain the underlying causes. The new model considers the contexts in which the Black person being assessed under the mental health act and the healthcare professionals conducting the assessment are situated. It also outlines mechanisms and inter- and intra-personal processes that interact to influence how both parties behave and make decisions during the sectioning process. Part II of the thesis is comprised of an empirical paper exploring four Black women’s experiences of the decision being made for them to be compulsorily detained and the factors that they believe influenced that decision. Interpretative phenomenological analysis (IPA) was used to explore how the women made sense of their experiences. Results demonstrated that the women found the experience of being detained to be distressing and that meaningful relationships helped them to manage. Where care provision did not feel sufficient, they acknowledged the under-resourced nature of the healthcare system. The women believed that their behaviour and mental health needs were primary reasons for the decision being made to compulsorily detain them. Part III of the thesis provides a critical appraisal of the research process, with a particular focus on how the researcher’s identity influenced and interacted with the research topic.

Part 1 – The Conceptual Introduction: The conceptual introduction reviews the current evidence in order to better understand the extent to which the a general psychopathology factor is supported within a child and adolescent sample. Papers exploring the bifactor model of child and adolescent mental disorder were included in the review. Variations in factors included in the final models and the models’ validity and stability over time were also explored. The limitations of the studies were considered in terms of their generalisability to clinical practice in the NHS, therefore setting up the rationale for future research for focus of the empirical paper. Part 2 – The Empirical Paper The empirical paper aims to expand on the current evidence base supporting the notion of a general psychopathology factor within a child and adolescent sample. As well as exploring the potential impact of routinely administered intervention on the expression of child and adolescent psychopathology. The study utilised the Child Outcomes Research Consortium dataset to explore the best fitting model of psychopathology and the extent to which intervention predicted model factor scores at follow-up. Part 3 – The Critical Appraisal The critical appraisal addresses some of the issues related to the use of secondary data that arose while undertaking the research project. This includes the impact of data quality and completeness on the direction of the research and data analysis. As well as the how secondary data may impact on the extent to which the research may address the limitations of previous research and extend the current evidence base.

The current thesis investigated two factors associated with psychosis; childhood trauma and person beliefs. Part one was a systematic review that quantitatively synthesised the existence of person beliefs in people with psychosis and at risk mental state (ARMS) compared to healthy controls, and the association of person beliefs with paranoia. More negative and less positive person evaluations were present in those with psychosis and ARMS, and negative person beliefs were consistently associated with paranoia. The greatest differences and associations were at the lower end of the psychosis continuum. A correlational meta-analysis for positive beliefs and paranoia could not be conducted due to the low number of studies available. The results are discussed in relation to models of persecutory delusions and help-seeking behaviour. Part two used an interactive virtual reality scene with a friendly avatar to examine the impact of childhood trauma and person evaluations on trust (trust appraisal and trusting behaviour). Twenty-two male participants with psychosis experiencing paranoia were recruited. Virtual reality was reported to be a safe and valid tool. Trust appraisal was predicted by childhood trauma exposure, symptom severity and positive other-evaluations, whilst positive self-beliefs predicted trusting behaviour. The implications for clinical work and research were discussed. Part three was a critical appraisal which reflected on the process of recruitment, the complexity of studying psychosis and trauma and methodological considerations from both parts of the thesis. This was a joint project with a fellow trainee, Kate Watchorn. Each thesis had a different focus and work was completed and presented separately.

To smoothly interact with other people requires individuals to generate appropriate responses based on other’s mental states. The ability we rely on is termed mentalizing. As humans it seems that we are endowed with the abilities to rapidly process other’s mental states, either by taking their perspectives or using mindreading skills. These abilities allow us to go beyond our direct experience of reality and to see or infer some of the contents of another’s mental world. Due to the complexity of social contexts, our mentalizing system needs to address a variety of challenges which put different requirements on either time or flexibility. During years of research, investigators have come up with various theories to explain how we cope with these challenges. Among them, the two-system account raised up by Apperly and colleagues (2010) has been favoured by many studies. Concisely, the two-system account claims that we have a fast-initiated mentalizing system which guarantees us to make quick judgments with limited cognitive resource; and a flexible system which allows deliberate thinking and enables mentalizing to generalize to multiple targets. Such a framework provides good explanations to debates such as whether preverbal young children can process mentalizing or not. But it is still largely unknown how healthy adults engage in mentalizing in everyday life. Specifically, why it seems easier for some targets to activate our mentalizing system, but with some others, we frequently fail to consider their perspectives or beliefs? To give an explanation to this question, I adopted a different research orientation in my PhD from the two-system account, which considers the dynamic interactions among three key elements in mentalizing: the self, agent(s), and object(s). I put forward a mentalizing triangle model and assume the interactions in these triadic relationships act as gateways triggering mentalizing. Thus, with some agents, we feel more intimate with them, which makes it easier for us to think about their minds. Similarly, in certain context, the agent may have frequent interactions with the object, thus we become more motivated to engage in mentalizing. In the following chapters, I first reviewed current literatures and illustrate evidence that could support or oppose the triangle model, then examined these triangle hypotheses both from behavioural and neuroimaging levels. In Study 1, I first measured mentalizing in the baseline condition where no interaction in the triangle relationships was provided. By adapting the false belief paradigm used by Kovacs, Teglas, & Endress (2010), I imported the Signal Detection theory to obtain more indices which could reflect participants mentalizing processes. Results of this study showed that people have a weak tendency to ascribe other’s beliefs when there is no interaction. Then, in Study 2, we added another condition which included the ‘agent-object’ interaction factor while using a similar paradigm in Study 1. Results in the noninteractiond condition replicated our findings of Study 1, but adding ‘agent-object’ interactions didn’t boost mentalizing. Study 3 and 4 tested the ‘self-agent’ interaction hypothesis in visual perspective taking (VPT), another basic mentalizing ability. In Study 3, I adopted virtual reality approach and for the first time investigated how people select which perspective to take when exposed to multiple conflicting perspectives. Importantly, I examined whether the propensity to engage in VPT is correlated with how we perceive other people as humans, i.e. the humanization process. Congruent with our hypotheses, participant exhibited stronger propensity to take a more humanised agent’s perspective. Then in Study 4, I used functional near-infrared spectroscopy (fNIRS) and investigated the neural mechanism underlying this finding. In general, the ‘selfagent’ hypothesis in the mentalizing triangle model was supported but not for the ‘agentobject’ hypothesis, which we consider may due to several approach limitations. The findings in this thesis are derived from applying novel approaches to classic experimental paradigms, and have shown the potentials of using new techniques, such as VR and fNIRS, in investigating the philosophical question of mentalizing. It also enlights social cognitive studies by considering classic psychological methods such as the Signal Detection Theory in future research.

This study examines how the aims and principles of psychoanalytic parent-infant psychotherapy (PPIP) are translated into the words used by the therapist to address the infant in the specific modality of parent-infant psychotherapy treatment (PIP) developed at the Anna Freud Centre. Literature Review. The literature review appraises different modalities of PPIP. It looks at the similarities in their theoretical and treatment frameworks and shows how the way in which the infant is understood in these different frameworks produces a differences in theory and technique. Empirical Paper. The empirical study is a naturalistic observational study of the therapist’s talk when in direct communication with the infant. The aim is to deepen our understanding of the what the therapist actually says and does in a therapy session. The results show that the therapist talks for a significant amount of time directly to the baby, and on a specific number of themes. Even though this is small single case study the findings contribute to our understanding of what therapists do in therapy. Reflective Commentary. The reflective commentary considers the process of engaging with doctoral research around a pre-verbal infant in treatment. It reflects on the personal experience of doing the research and considers how this experience has contributed to my development as a researcher and a child and adolescent psychotherapist.

This study investigates how three participants with traits of Borderline Personality Disorder (BPD) experience changes in their relationship with their infants after engaging in an attachment focussed parent-infant psychotherapy (PIP). It is a sub-study of a wider Randomized Control Trial (RCT) which investigated the outcomes of PIP for parents with mental health problems and their young infants (Fonagy, Sleed & Baradon, 2016). Data was based on a semi-structured interview and subjected to Interpretative Phenomenological Analysis (IPA, Smith 1995, 1996) providing a qualitative perspective to get closer to the lived experience of the three participants. The themes that emerged were separated into improvements in the parent-infant relationship, and continued difficulties in the parent-infant relationship. The data illustrates the factors which supported two participants to experience positive changes between themselves and their infants which were namely; medication changes, support from an inpatient unit, time, praise from others, the ability to locate the source of change within themselves and the PIP sessions. Results in this theme varied for whilst the participant who had the most PIP sessions was able to see some positive changes in how she related to her baby, the participant with the least PIP sessions was able to describe the most positive change in her relationship with her infant. Failures in mentalization (Fonagy & Bateman, 2007), low levels of distress tolerance, poor coping strategies to manage distress, a sense of helplessness and isolation, interpersonal difficulties, continued mental health difficulties and an inability to locate the source of change within themselves are shown to stand as some obstacles for participants to experience changes in the relationship with their infants.

This dissertation represents the first systematic study of William Alanson White’s tenure between 1903 and 1937 at The Government Hospital for the Insane, later known as St. Elizabeths Hospital in Washington, D.C. White’s influential position as superintendent of the largest hospital in the United States had a significant impact on the practice of psychiatry, and the solidification of the technique and language of the psychoanalytic method, in the hospital setting. Historians of psychoanalysis have largely neglected this contribution, alternately portraying White as a populist and unoriginal thinker, or neglecting his contribution altogether. White was most widely known as a hospital administrator. This role appears to have obscured a more nuanced view of his personal involvement in the field of psychiatry and psychoanalysis, and also the significant contributions to the evolution of psychiatric practice that can attributed directly to his administrative policies related to the treatment of patients. There has been no methodical study of archival case material and primary sources as it relates specifically to White and his stewardship of St. Elizabeths. I utilize this material to analyze the formative personal, theoretical, and philosophical influences that contributed to White’s view of hospital psychiatry with particular emphasis on the operationalization of psychoanalytic language and practice. I argue that White was a product of the Progressive Era that embodied an optimism in which the principles of the scientific method, and the emphasis on the importance of environmental adaptation, stood alongside the psychoanalytic method. For White, these ideas were not in conflict, and coexisted effortlessly in the inpatient ward. Case notes by treatment teams, as well as White’s personal correspondence and scholarship, support this broader view in which the intrapsychic and the environmental have mutual influence. Optimism in the scientific method did not, however, always dominate White’s narrative. His personal papers also offer a glimpse into the struggles and complexity of overseeing the magnitude of human suffering found in a large hospital, and reveals a more multifaceted, and more personal representation of White’s life and his work. I argue that twentieth-century American psychiatry, and psychoanalysis, was practiced in parallel tributaries, in both the private consulting rooms, but also in the hospital setting. White’s psychiatry, and his views on the analytic method was informed mostly by the challenges and opportunities of the latter, and the excerpts of the lives of patients documented in the National Archives helps to reconstruct a piece of psychiatric history that has been overlooked.

This study explored parental representations in mothers whose infants were younger than one and went on to develop disorganised attachment. Literature review. The literature review examined the concepts of parental representation and disorganised attachment, their methodological development, assessment and research findings. It also reviewed the current theories of disorganised attachment, based on studying both parent-infant interactions and parental representations. Empirical study. The empirical study was an exploration of the processes that may contribute towards the formation of disorganised attachment in infants by analysing parental representations, assessed in the first year of the infant’s life, in a sample of parents whose infants were classified as disorganised one year later. By using a qualitative exploratory approach, this study analysed parental representations differently from top-down quantitative coding protocols, hence its findings offered a useful insight and comparison with the current theories of disorganised attachment. Reflective Commentary. The dissertation ended with a reflective commentary, which traced and mapped out the process and experience of conducting this research.

Aims: Cognitive Stimulation Therapy (CST) is a well-established psychosocial intervention for individuals with dementia that improves cognition and quality of life. However, a large clinical trial on individualised CST (iCST) delivered by family carers found iCST to be ineffective. The current study aimed to explore whether it is feasible for healthcare professionals to deliver iCST. Feasibility criteria included; (1) ease of recruitment, (2) attendance and (3) drop out/attrition. It also aimed to explore whether the intervention improves quality of life and the psychological and emotional symptoms of dementia. Method: Twenty-nine participants were randomly allocated to the iCST group or control (treatment as usual) group. The iCST group participants were offered 14 twice-weekly 45-minute iCST sessions delivered by trainee clinical psychologists. The following measures were administered for all participants pre- and post-intervention: self- and proxy-reported Quality of Life Alzheimer’s Disease scale, (QoL-AD) Positive Psychology Outcome Measure (PPOM) and Engagement and Independence in Dementia Questionnaire (EIDQ). Results: The feasibility criteria for delivery of iCST by non-family carers (healthcare professionals) were fulfilled. There were no barriers to recruitment as care homes and eligible residents readily expressed interest and were willing to consent to take part. Engagement was high with a 0% dropout for participants who received the iCST and 97% session attendance. There were no significant differences between participants who received iCST and treatment as usual in self- and proxy-reported quality of life and self-reported psychological wellbeing. Conclusion: This study suggests that it is feasible for non-family carers (healthcare professionals) to deliver iCST by non-family carers. The absence of barriers to recruitment suggests this therapy would be popular and the low dropout and high attendance rates indicate good engagement by participants. The study does not support iCST improving quality of life or the psychological and emotional symptoms of dementia. The lack of findings regarding improved quality of life and the psychological and emotional symptoms of dementia could be explained by insufficient statistical power due to the small sample size. It is also possible that the group component of CST is a key factor in its effectiveness and hence the lack of findings from iCST with its one-to-one format.

The thesis examines compassion-focused imagery and paranoia, and is presented in three parts. Part one presents a conceptual introduction of existing research in the field of compassion-focused imagery and paranoia, in the clinical and the non-clinical (general) populations. A review of the literature found promising results for compassion-focused imagery in reducing paranoia and improving positive and negative affect. Furthermore, the review suggests that game theory paradigms, in particular the Prisoner’s Dilemma Game, provide useful and objective behavioural measures for paranoia. These paradigms present participants with a ‘real life’ interpersonal situation where they have to choose whether to cooperate or compete with the other player, providing key data regarding trust, paranoia, intentions and motivations. However, existing research investigating the impact compassionfocused imagery has on paranoia has not yet used game theory paradigms to measure paranoia. Part two presents an empirical paper investigating the effects of compassionfocused imagery on paranoia, affect, and trust-based cooperative decision-making on the Prisoner’s Dilemma Game in the general population, in comparison to relaxation imagery. Results suggest that compassion-focused imagery reduces paranoia and negative affect, with no impact on positive affect, or trust-based decision-making on the Prisoner’s Dilemma Game (participants choosing to cooperate with another player). Relaxation imagery was found to be comparable with compassion-focused imagery in reducing paranoia and negative affect. This could suggest that either type of mental imagery is beneficial in reducing paranoia and negative affect, although further work would be needed to establish equivalent effectiveness. Part three presents a critical appraisal reflecting upon the process and challenges of conducting doctoral research, with consideration given to the design, and the online nature of the study.

Part one presents a conceptual introduction reviewing the literature on factors related to wellbeing and distress in early psychosis caregivers. It considers factors relating to the caregiver, to the service-user and contextual factors. An evaluation of the type of methodology and approaches to analyses of the typical measurement of the appraisals of caregiving is given. Part two is a quantitative, empirical study into whether caregiving profiles exist of types of appraisals and avoidant coping amongst carers in an early psychosis population. It further considers associations with these profiles and demographics and contextual factors and whether the profiles are related to the measures of wellbeing, depression and anxiety. It involves a secondary dataanalysis of data originally collected from a group of caregivers of service users accessing support from an Early Intervention Service (EIS). Part three is a critical appraisal of the process of undertaking this research described in parts one and two, as well as a reflection on the process of having to start on a new thesis project. It is inclusive of a series of reflections on various stages of the process, including the experience of conducting a piece of secondary data-analysis with complex analysis.

Research consistently finds an association between materialistic values and low wellbeing. The mechanisms behind this relationship, however, are not well understood. As such the present project undertook the following aims. Aims: 1) To determine if the association between materialistic values and low wellbeing is moderated by holding conflicting, universalistic, values 2) To determine if materialistic values serve as a partial mediator between on-going life stressors and low wellbeing Method: The project utilised a secondary data analysis design using structural equation modelling to perform confirmatory factor analyses and moderation and mediation analyses. Results: The results of the analysis found that conflicting values moderated the relationship between materialism and low wellbeing, finding a positive association between holding both materialistic and universalistic values and wellbeing. Materialism also partially mediated the relationship between life stressors and wellbeing. Discussion: The results are discussed in relation to social determination theory and the human values literature noting in particular the novel finding that the interaction of conflicting values reduces the impact of materialism on wellbeing. Issues with the methodology are discussed and the potential for future research is highlighted.

The last couple of decades have seen a significant increase in the fields of research and clinical practice inspired by the theory of mentalising. Mentalisation, the capacity to understand one's own and others' behaviour in terms of mental states, is considered to be a "defining human social and psychological achievement" (Fonagy & Allison, 2014). The dialogue between mentalising theory and other fields such as developmental psychopathology or the neurosciences has added complexity and nuance to the understanding of this mental capacity. However, there is a gap in the research literature concerning the assessment of mentalising during therapeutic sessions. This assessment has often been done at the beginning and end of the treatment, missing session-to-session variations and the possibility to inquire about a mentalising style and its outcome in psychotherapy. This thesis describes the development and preliminary validation of the Mentalising Profile Q-set (MQS), an observer-rated measure that aims to bridge the gap between scientific research and clinical observations by describing the mentalising process of patients undergoing psychotherapy in a jargon-free language. The MQS focuses on the patient and provides a picture of the mentalising process in relation to its four polarities and pre-mentalising modes of experience. The data used in this research was derived from the Randomised Evaluation Study of Dynamic Interpersonal Therapy (REDIT) and the Tavistock Adult Depression Study (TADS), two trials that worked with depressed patients, although with differences in clinical characteristics. The preliminary results suggest that the MQS is an instrument that can differentiate groups of individual mentalising profiles and their likely effect on therapeutic outcomes, as assessed by the HRSD-17, at the beginning of treatment. The MQS contributes to the extant literature on assessment instruments and, at the same time, expands on the role of the capacity to mentalise in the therapeutic outcome.

Background People with severe mental illness (SMI) have an increased risk of cardiovascular disease (CVD). Research in the general population suggests that social support may protect against CVD morbidity and mortality, however little is known about social support and cardiovascular health in people with SMI. Objectives For people with SMI: 1. Assess the effectiveness of CVD risk-reducing interventions that involve supportive others 2. Develop and integrate a social support strategy into a CVD risk-reducing intervention in primary care 3. Explore the relationship between social support and cardiovascular health behaviours 4. Describe how existing social support was explored within initial appointments in a CVD risk reducing intervention in primary care. Methods Systematic review, longitudinal and cross-sectional observational study and qualitative thematic analysis of intervention appointments. Results Few studies were identified on effective interventions that used existing support networks to improve cardiovascular health in people with SMI. Recommendations for involving supportive others in CVD risk reduction were identified from focus groups, workshops and UK clinical guidelines These included exploring how to involve supportive others, respecting confidentiality and identifying strategies for those without social support. Higher social support predicted significantly greater appointment attendance in unadjusted but not adjusted analyses and greater medication adherence. There was no association between higher perceived social support and greater physical activity, healthier diet, lower alcohol use or being a non-smoker. Social support was explored in first appointments, with most participants identifying a supportive other. Reasons to involve others included companionship, positive feedback and health improvements for supportive others and participants. Some participants described family or friends as negative influences on their health. Conclusions Perceived social support may be an important facilitator for adherence to CVD medications, but there was limited evidence for an association between perceived social support and other CVD health behaviours in people with SMI. Harnessing positive social relationships within interventions should be considered as a strategy for encouraging uptake of CVD health behaviours in people with SMI. Further work is needed to develop interventions that increase social support and improve health outcomes for people with SMI who have limited social contacts.

Psychotherapy process research is important in developing technique and enhancing clinical skills. Silence, as an aspect of child and adolescent psychoanalytic psychotherapy, has been a neglected area of research, despite it being acknowledged as an often challenging yet therapeutically useful aspect of the work. This study aims to explore silence in adolescent psychoanalytic psychotherapy, by studying the emergence of silence in therapy sessions and the adolescents' views. Three Short Term Psychoanalytic Psychotherapies of adolescents with depression were sampled, and silences occurring in six sessions of each therapy were coded using the Pausing Inventory Categorization System (PICS). The study identified that in the three therapies sampled, on average almost one-third of session time was spent in silence, and that most of this silence was coded as 'obstructive'. The study also found that the change in silence amount through each stage of therapy was different in each patient-therapist dyad. Follow-up interviews conducted with the adolescents were analysed using thematic analysis and found that the adolescents expressed negative feelings about silence in their therapy. Findings from the follow-up interviews were related to silence and outcome data to suggest processes that may have been taking place in each of the therapies. A key hypothesis was that the majority of the silence in the therapies sampled appeared to relate to conflict, which could be viewed as both an aspect of the developmental stage of adolescence, and a symptom of depression. Clinical implications of the findings indicated that long silence do not appear to be useful in adolescent therapy in the way they are considered to be in adult therapy, and so adaptation of therapeutic technique is required.

Cognitive Stimulation Therapy (CST) is an evidence-based group intervention, which has been shown to improve cognition and quality of life in individuals with dementia. CST and longer-term Maintenance CST (MCST) are both widely implemented across the NHS. The broad objective of this project was to conduct the necessary groundwork to complete the next steps in developing and validating a measure of group process in CST for a dementia population. Part 1 systematically reviewed and assessed the literature on questionnairebased measures of group process. Thirteen measures were described in the final analysis and a quality evaluation was undertaken using established criteria. The developed list highlighted a range of measures that can be used by clinicians and researchers seeking to assess either specific therapeutic group mechanisms, or overall group experiences in therapy. Part 2 qualitatively identified group processes from the perspective of group members and facilitators of CST and MCST groups. Twenty one semi-structured in-depth interviews were conducted. A thematic analysis approach identified six themes of group experiences: group expression, group bond, group entertainment, group relationships, group support and group stimulation. Part 3 is a reflective summary of the research conducted in this report. This included the influence of my personal interests and theoretical assumptions on the research process, a reflection on my experiences of conducting qualitative interviews and a discussion on possible areas of future work.

Aim: To determine how relationship quality, conceptualised across a number of different levels, is related to materialism, including an individual’s relationship to self (self-esteem and attachment), relationships with others (family, peers and intimate partners) and relationships in the broader social context (online and community). Methods: Young adults between 18-30 years old were invited to complete an online self-report questionnaire that assessed materialism, self-esteem, attachment style as well as a number of relationship variables of interest. Results: Low self-esteem, anxious attachment and poor quality of family relationships were significant predictors of higher level of materialism after controlling for demographic and socio-economic variables. Conclusion: This study is the first one in the field to investigate how materialism is related to different types of relationships using an overarching theoretical framework, whilst controlling for a number of individual level demographic and socioeconomic factors. These findings contribute to -and address gaps in- the existing literature, as well as emphasise the need for future longitudinal research to explore the underlying mechanisms and development of materialism.

Aim: To explore the effects of two interventions on pain anxiety in the context of chronic pain. Methods: The study used a mixed measures, multiple single-case A-B-A-C design. Six participants (adults with chronic pain) received two baseline (A) and two intervention phases (B and C): a brief CBT intervention and the ‘Go-With-the Flow’ (GWtF) sonification of movement. Participants completed a daily movement (that is usually painful) with associated measures (anxiety and pain ratings, heart-rate and degrees of bend achieved). At the end of each phase, participants additionally videoed their movements (which were independently rated for ‘guarding’ by pain physiotherapists) and completed the Pain Self-Efficacy and Pain Catastrophising Scale questionnaires (PSEQ/PCS). Qualitative data about participants’ experiences of the two interventions were collected at the end of participation. Quantitative data were analysed visually and statistically using Tau-U methods and McNemar tests. PSEQ and PCS data were assessed for reliable change, and qualitative data were thematically analysed. Results: The impact of each intervention on pain anxiety was variable across participants. Qualitative data indicated that brief CBT was generally the preferred intervention but neither intervention yielded a statistically significant improvement in pain anxiety in most cases. GWtF was associated with a statistically significant increase in bend achieved from baseline for the group as a collective. However, this finding was balanced by qualitative data which indicated that most participants would not use GWtF in its current format. Conclusion: Both interventions were associated with benefit for some participants, and successfully used at home without significant difficulty. As such, both could, with further development, increase accessibility to psychologically-informed intervention for problems associated with chronic pain.

This thesis set out to further understanding of mental health disclosure decision-making amongst UK-based mental health professionals. Part one is a conceptual introduction looking at the factors associated with the disclosure of mental health problems amongst this population, including a literature review of research published in the past decade. Part Two consists of an empirical paper in which the Disclosure Process Model (DPM) is applied to baseline data collected from the Honest, Open, Proud for Mental Health Professionals (HOP-MHP) pilot randomised controlled trial (RCT) – a guided self-help intervention designed to aid mental health professionals with mental health problems with disclosure decision-making. This is part of a joint project carried out by two trainee clinical psychologists. The paper outlines the researcher’s role in the development and running of the pilot RCT and details the application of the DPM to elucidate the disclosure experiences of participants. Part three is a critical appraisal of the research undertaken in this thesis, presenting personal reflections on the research process and discussing the challenges involved in researching disclosure-decision making amongst mental health professionals. It concludes with a reflection on the implications of the study.

Antisocial behaviour in adolescence is a growing public concern and contributes to significant societal burden. This thesis focuses on the usual services available to this population of young people and comprises of three parts. Part One is a systematic review examining the evidence base for multisystemic Therapy (MST). It focuses on of the role of management-as-usual (MAU) conditions within the evidence base. Whilst several included studies often support the efficacy of MST, the outcome data are mixed. Socio-political context is implicated in these differences, acknowledging that within differing contexts usual service provision differs and therefore so too does MAU in empirical studies. It demonstrates that where MAU is used as a comparator trial outcome must be considered relative to the context in which it was conducted and highlights the need for researchers to thoroughly document MAU to enable replicability and generalisability. Part Two is an empirical study that uses the data from the Systemic Therapy for At Risk Teens (START) trial to consider usual service provision across the United Kingdom. It identifies specific risks through bifactor analyses of clinical measures, and then considers the dynamic and reciprocal nature of risks by identifying profiles of risks and needs using latent profile analysis (LPA). It then assesses the degree to which MAU is differentially provided based upon risk and need, in line with risk-need-responsivity. Part Three provides a critical appraisal of the research. It discusses the challenges associated with risk-focused research and the ethical dilemmas that such research poses.

This thesis examines the concept of programme fidelity as related to multi-component mental health interventions for severe mental health difficulties. Part 1, the literature review, explores existing measures in the field to identify the ‘best standards’ for programme fidelity assessment and an initial articulation of their typology. 31 papers are examined using a narrative synthesis approach. The content and psychometric properties of the 12 identified measures are described, identifying common practices, and highlighting neglected assessment areas. Findings highlight a scarcity of measures despite their increasing relevance to the field of implementation science. Further, although arguably consistent in design, assessment procedures, and scoring, there is great variability in the domains covered. Part 2, the empirical paper, describes the development, piloting and implementation of the Community Mental Health Fidelity Scale (CoMFideS), as part of the Open Dialogue: Development and Evaluation of a Social Network Intervention for Severe Mental Illness (ODDESSI) trial. The ODDESSI trial aims to assess whether Open Dialogue (OD) –when integrated within standard NHS mental health services for adults in crisis– improves the clinical and cost-effectiveness of traditional crisis and continuing community mental health care (CAU). CoMFideS was developed based on findings from the systematic review and drawing from expertise and existing measures in the field. CoMFideS was piloted in 6 OD and 6 CAU services. Findings suggests that CoMFideS may be a reliable and feasible programme fidelity measure of high-quality CAU and specific OD features. Part 3, the critical appraisal, provides some final thoughts about the research project, including a discussion on some methodological and theoretical considerations, as well as some reflections on the research process as a whole.

AIMS: This study aimed to investigate the effect of a compassion-focused imagery intervention and a compassionate psycho-education intervention on levels of self-compassion, self-criticism and state mood compared with a control condition in healthy adolescents. METHOD: Fifty-one participants were randomly allocated to a compassionate imagery and psychoeducation group, a compassionate psychoeducation group or a no-intervention control. The interventions were delivered in three secondary schools in London. State measures of self-compassion, self-criticism, and mood were collected at pre- and post-intervention, and at a two-week follow up. Participants were asked to complete daily homework tasks related to each intervention. RESULTS: Self-compassion was found to increase with a large effect size following the psychoeducation group but not in the imagery condition. Contrasting patterns were found across groups for different elements of self-compassion. Compassionate behaviour increased in the imagery group with a large effect size but not in the psychoeducation group, and uncompassionate behaviour decreased only in the psychoeducation condition with a medium-to-large effect size. Higher levels of self-compassion were associated with lower levels of self-criticism at baseline, however, no effects were found on self-criticism and state mood following the interventions. CONCLUSIONS: This randomised-controlled study provided evidence for the potential of a brief compassionate psychoeducation intervention to increase self-compassion in adolescents. The results were inconclusive on the impact of compassionate mental imagery but it may be effective at enhancing the ‘positive elements’ of self-compassion, including self-kindness, mindfulness and common humanity. The absence of an effect on self-criticism suggests the potential existence of different pathways to enhancing self-compassion and reducing self-criticism. Future research is needed to address the shortfalls of this exploratory study, which was limited by a small sample size.

This three-part thesis examines the role and development of practitioner adherence measures for multimodal interventions for individuals with complex mental health difficulties. Part 1: Literature Review. A systematic review of the literature on practitioner adherence measures for multimodal interventions for complex mental health conditions. Results are presented and narratively synthesized examining measure content, development and use. The review revealed the lack of consensus around measure development and highlighted the need for guidelines for researchers. Part 2: Empirical Paper. A multimodal approach to the development and psychometric formalisation of an Open Dialogue (OD) practitioner adherence measure. This research describes the process of measure development using a Modified Delphi technique as well as inter-rater reliability and internal consistency analyses. Preliminary outcomes suggest that the OD Adherence Measure is a reliable and valid way of measuring practitioner adherence to OD principles within network meetings. Future directions for measure development and use are described. Part 3: Critical Appraisal. A reflection and appraisal of the research process. This includes reasons for undertaking research in this area, challenges of working in a multisite research project and a more detailed discussion of the limitations of this work.

Aims: This is a feasibility pilot study that aimed to capture committee member and technical team experiences of current informal consensus practices, previous experiences of formal consensus methods, and expectations for the planned use of the Nominal Group Technique (NGT) formal consensus method. Method: Twelve participants, including committee and technical team members across two guideline groups engaged in semi-structured interviews before using NGT. All of the committee members of one guideline group then answered Likert-scale questions about their experience after using NGT. Results: Themes were extracted from the interviews and corroborated by the quantitative data. Themes included: Formal consensus (credibility, effort and resource intensiveness), Methodology (guideline interpretation and implementation, interpretation of evidence, and the restrictiveness of NICE process), Group processes (management of expertise, anonymity, leadership, and discussion), and Continuity of group members. Data were further analysed in the context of participant professional background. Conclusions: Participants identified beneficial elements across formal and informal consensus approaches, and it is likely a hybrid of methods is best suited to healthcare guidelines given their task of combining diverse and complex knowledge to achieve specific guidelines. The results are interpreted in the context of theory and recommendations are made on the future use and conduct of consensus methods.

Background: People living with dementia and mild cognitive impairment (MCI) commonly experience anxiety and depression, and cognitive behavioural therapy (CBT) is a recommended treatment for adults, commonly provided through national Improving Access to Psychological Therapies (IAPT) services. This study explored the barriers and facilitators to providing CBT interventions in IAPT for people living with dementia or MCI, as perceived by IAPT clinicians. Method: An interview topic guide was developed based on implementation theory and a consultation process. 14 participants were recruited through IAPT services and interviewed about their experience of working with individuals with dementia or MCI, and their ideas about factors that enhance or hinder offering CBT in IAPT to this group. Interview recordings were transcribed and results analysed using thematic analysis. Credibility checks were incorporated throughout the process. Results: Three main themes were identified: attitudes towards dementia, competing demands of offering a service to people with dementia/MCI, and pressure without support. Barriers included high pressures on staff with a low level of support, negative attitudes towards dementia and older adults, and a restrictive service model perceived to be at odds with offering a service adapted to peoples’ needs. Perceived facilitators were positive engagement and outcomes for people with dementia and MCI, positive attitudes of IAPT clinicians and the ability of some services to be flexible. Conclusions: Multiple perceived barriers and facilitators were identified, and there are implications for commissioning practices within the NHS relating to the tension between minimal resources and adequate care, as well as supporting clinicians working within this context.

Deliberate self-harm, attempted suicide and Borderline Personality Disorder are problems affecting a significant number of people within the United Kingdom. Part 1 of this thesis provides a systematic review of Dialectical Behaviour Therapy (DBT) based interventions under the length of six months for these problems. 20 studies were identified assessing the effectiveness or efficacy of the interventions. The nature of the interventions being provided as well as the strength of the evidence for their effectiveness were assessed in the review. Group based skills interventions and six-month implementations of full DBT were reported to have evidence supporting their effectiveness. The need for further research on the effectiveness of shorter implementations of full DBT, in particular RCTs, is highlighted in the conclusions. Part 2 is a qualitative study exploring the experiences and views of people who repeatedly use Accident & Emergency services (A&E) for self-harm or attempted suicide and do not go on to receive input from mental health services. This was a joint project, conducted with another trainee Clinical Psychologist. Ten service users with past or present experience of visiting A&E for risk to self were interviewed. Using thematic analysis, ten themes were developed, divided into three domains. The first domain focussed on the experiences participants had in A&E, how they interpreted these experiences, and the consequences of these experiences. The second explored the beliefs participants held about themselves, clinicians and the availability of services. The final domain focussed on barriers and facilitators to accessing further care. Part 3 is a reflection on the process of planning research, recruiting participants, and the journey of reflexivity in the research.

AIMS: Antisocial behaviour is a major health and social problem which is known to affect males significantly more than females. Antisocial behaviour is also known to be highly comorbid with a number of other difficulties, including anxiety, depression, hyperactivity/inattention and callous-unemotional (CU) traits, which are themselves known to differentially affect males and females. This study aims to investigate the roles of these comorbid difficulties as risk factors for antisocial behaviour, and to examine the extent to which sex differences in these factors may account for the sex difference in antisocial behaviour. METHOD: This study used self-report data from the Systemic Therapy for At Risk Teens (START) trial, an 18-month randomised controlled trial conducted with 683 adolescents (433 boys and 250 girls) with moderate-to-severe antisocial behaviour, to examine sex differences in the associations between each of the above difficulties and antisocial behaviour. Structural equation models were used to test these associations cross-sectionally at baseline, and cross-lagged panel models (CLPMs) were used to test longitudinal associations across the 18-month period of the trial. RESULTS: Within this sample there were no sex differences in volume of self-reported antisocial behaviour. Results showed that depression, hyperactivity/inattention and CU traits, but not anxiety, were significant predictors of self-reported antisocial behaviour at baseline. Although girls in the sample were more likely to report anxiety, depression and hyperactivity/inattention than boys, there was no moderating effect of sex on the relationship between any of the four factors examined and self-reported antisocial behaviour. Results of the CLPMs suggest that anxiety and CU traits may be more strongly associated with concurrent antisocial behaviour for boys, while depression may be more likely to predict later antisocial behaviour for girls. CONCLUSION: The present study suggests that overall there are more similarities than differences between boys and girls who engage in antisocial behaviour, and it is not possible to draw conclusions from these results about whether sex differences in comorbid anxiety, depression, hyperactivity/inattention or CU traits account for sex differences in antisocial behaviour in the general population. However, in line with previous research, anxiety and depression do appear to influence engagement in antisocial behaviour in different ways for boys and girls over time, suggesting that there may be different causal mechanisms operating for each sex.

Algorithm-based decisions and personalised treatment are two major contemporary healthcare trends. This thesis investigates their utility and potential impact. Part One is a literature review on the effectiveness of predictive decision support algorithms to improve mental health outcomes. It examines thirty papers to indicate their efficacy in practice and risks to uptake. Overall these systems are effective, but have a number of practical and psychological barriers to overcome to be implemented successfully. The review summarises eight hypotheses for effectiveness, which act as guidelines for designing future decision support systems. Part Two examines a previously developed decision support algorithm and its ability to influence mental health recovery and improvement rates through individualised therapy allocation. Several ways of modelling the original algorithm are developed and compared on their ability to predict clinical outcomes, and then used to investigate historical trends in recovery rates at a particular service. Over time, service clinicians appear to naturally allocate more appropriate therapeutic intensities. Allocation as usual was compared with the decision support algorithm for clinical utility. The algorithm did not improve clinical outcomes but was more cost-effective. Part Three is a critical appraisal and reflection on the research process in the context of wider technological and epistemological trends. It discusses the past role of people in research and how they may be involved in future scientific discovery given rapid advances in automating research procedures. It then examines the research project using conclusions from the literature review to inform a critical evaluation.

Background: Intellectual disability stigma is widespread and has significant negative implications for individuals with intellectual disabilities. Stigma resistance is associated with positive outcomes across stigmatised groups of individuals, and is implicated as a target for interventions tackling stigma at the intrapersonal level. However, to date there have been no interventions that seek to directly manipulate stigma resistance in individuals with intellectual disabilities. Aims: The present study contributes to a multi-part feasibility and pilot study of a psychosocial intervention aimed at increasing the capacity of individuals with intellectual disabilities to manage and resist stigma. Specifically, it aimed to (1) examine the feasibility and acceptability of assessing longer-term outcomes of the intervention through (a) Qualitative interviews with group members, group facilitators and significant others four months from baseline and (b) standardised outcome measures completed by group members seven months from baseline; and (2) preliminarily assess the longer-term outcomes of the intervention. Method: The intervention consists of five manualised sessions delivered by facilitators of existing self-advocacy, social and educational groups for people with intellectual disabilities. Recruitment and retention rates were explored, and quantitative data assessing self-esteem, psychological distress, experienced discrimination and sense of social power were compared at baseline, intervention completion and follow-up. Qualitative interviews with group members, group facilitators and significant others were completed at follow-up and analysed using thematic analysis (Braun & Clarke, 2006). Results: Assessing the longer-term outcomes of the intervention through qualitative interviews with group members, facilitators and significant others four months from baseline and standardised outcome measures completed by group members seven months from baseline was both feasible and acceptable. No statistically significant changes in scores of self-esteem, psychological distress, experienced discrimination or sense of power were found between baseline and follow-up. However, increases in self-esteem and sense of power and decreases in psychological distress and experienced discrimination, all with small effect sizes, were found. Qualitative findings demonstrated long-term benefits of the intervention for group members, facilitators and significant others. Benefits to group members indicated increases in stigma resistance at the personal, peer and public levels. Conclusions: Preliminary findings of the long-term benefits of the intervention and feasibility and acceptability of the proposed methods of assessment of the outcomes indicate the appropriateness of a further controlled trial of the intervention. Recommendations for improving the feasibility and acceptability of assessing the longer-term outcomes of the intervention are made.

This three-part thesis provides a systematic meta-review of reviews evaluating dyadic interventions for community-dwelling people living with dementia and their carers. It details the development of a dyadic intervention for this population, and critically appraises the process of conducting research in this area. Part 1: Stand Alone Paper. A systematic meta-review and narrative synthesis of reviews evaluating dyadic interventions for community dwelling people living with dementia and their carers. Material was drawn from 6 systematic reviews of dyadic psycho-social interventions for community dwelling people living with dementia and their carers. There is a good theoretical and evidence-based rationale for the use of a dyadic approach. Improvements have been made in the direct assessment of the person living with dementia and interventions have been shown to be acceptable and beneficial for both members of the dyad. However, interventions fail to consider the interpersonal landscape when assessing efficacy. Further research needs to be done to create a dyadic model of stress which includes the impact of interpersonal factors which can be used to guide the development and evaluation of interventions in this area. Part 2: Empirical paper. The development of a dementia disclosure support programme for people living with dementia and their supporters is detailed. The intervention was piloted with seven people living with dementia and their seven supporters. A semi-structured interview was conducted after the intervention to explore participants’ experience of the group and the impact of the group on their experience of living with dementia. Four themes were generated: “a cross on my back”; “denial and acceptance”, a “safe space”; and “wanting more” from the group. Participants in this study were aware of the public stigma that surrounds this diagnosis, and this was found to inform their attitudes towards dementia disclosure. The group not only afforded them a safe space to discuss dementia disclosure, but it also increased communication within dyads. The findings also highlighted participants’ unmet needs regarding the wider issue of diagnostic adjustment and support afforded to the dyad post-diagnosis. Part 3: Critical Appraisal. Reflections on the challenges of adapting an intervention for dementia dyads were considered along with a review of the study design, recruitment methods used, challenges faced in the administration of study materials and reflections on the process of thematic analysis. Future implications for research and practice were also considered.

This thesis explores the feasibility and preliminary outcomes of a guided self-help intervention designed to support disclosure decisions regarding lived experience among mental health professionals. Part one is a conceptual introduction, examining the concepts of stigma and disclosure before considering mental health stigma interventions. It then focuses on decision making around disclosure of a mental health difficulty including important factors in disclosure such as shame, self-stigma and concealment. It considers research into interventions developed to aid those with mental health difficulties in reaching disclosure decisions, and introduces the Honest, Open, Proud (HOP) programme. Part two presents an empirical study which employed a pilot randomised controlled trial to investigate the feasibility and preliminary outcomes of the Honest, Open, Proud for Mental Health Professionals (HOP-MHP) guided self-help intervention. Utilising mixed methods HOP-MHP was deemed feasible but requiring improvements and adaptations to promote engagement and support individuals further, given the complexity of making disclosure decisions for this population. Consideration of research into complimentary interventions at structural levels of society and culture are discussed. Data collection for the empirical paper was conducted jointly with a fellow trainee (Smith, 2019). Part three offers a critical appraisal, reflecting on the process of engaging in the research as a mental health professional with lived experience and the challenges this presented.