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Aims: The effectiveness of early intervention (EI) services for people with first episode psychosis is dependent on meaningful service engagement. Difficulties with engagement in EI services increases risk of drop out which has implications for poorer functioning and poorer clinical outcomes. The purpose of the current study was to explore associations between engagement, clinical, and relational variables, and to investigate factors that predict service engagement in an early intervention service for first episode psychosis. Methods: The study gathered prospective routine date from an early intervention service using a naturalistic cohort of 83 individuals with first episode psychosis in Scotland, UK. Cross sectional associations between engagement, attachment, and carer’s burden of care were explored. Sociodemographic, clinical and psychiatric predictors of engagement were examined using hierarchical and stepwise regression. Results: Poorer clinician engagement as measured by the service engagement scale (SES) was associated with greater positive symptoms and greater disorganisation, poorer insight, more effortful caregiving and higher number of adverse childhood experiences. In regression analysis, only lack of insight predicted engagement at 12-weeks. We found that engagement scores at 12-weeks predicted engagement at 26-weeks. Additionally, engagement scores at an earlier point of treatment were predictive of psychiatric recovery at 12-month follow-up. Conclusions: Our findings suggest that clinicians in early intervention services are well placed to identify those who are at risk of poorer engagement and subsequent poorer psychiatric outcomes which has implications for treatment planning. Additionally, people who lacked insight into their diagnosis of psychosis and need for treatment, as rated by clinicians, were rated with poorer levels of service engagement. This may reflect clinicians framework of psychosis and mental illness and might suggest the need for clinicians to work within the patients own beliefs of their experiences and framework of mental illness to help increase engagement.

Background: Evidence has shown that people who fear psychosis relapse may experience a shorter duration to actual relapse. Therefore, fear of relapse may be an important clinical construct in understanding the transition to relapse. However, relatively little is known about its phenomenology and how individuals make sense of their fears and worries. This study sought to explore the lived experiences of fear of relapse. Method: Four individuals who self-reported as being worried about relapse were recruited from Community Mental Health Teams in NHS Ayrshire & Arran. Semi-structured interviews were conducted. Data were analysed using Interpretative Phenomenological Analysis. Results: Analysis identified two superordinate themes: “I think my worry would be going back to the worst period” which reflected participants’ fears and experiences of worry and “I think a lot of it’s just about feeling in control of it” reflecting participants’ efforts to assert control of their experiences and limit recurrence. Conclusion: Findings provided a rich insight into the diverse and multi-dimensional nature of participants’ experiences of fear of relapse which has implications for both clinical practice and future research.

Background: Compassion fatigue is associated with negative physical and psychological symptoms. Compassion satisfaction occurs when carers experience reward from helping others. Research has concluded that managerial support can protect against compassion fatigue; however, there is limited evidence exploring how older adult care home managers support their staff. Aims: The study aimed to explore care home managers‟ experiences of mitigating compassion fatigue and promoting compassion satisfaction in their staff teams. Method: Semi-structured interviews were carried out with six care home managers. The interviews were transcribed verbatim and analysed using Interpretive Phenomenological Analysis. Results: Three superordinate themes were developed from the data: 1) Navigating staff-resident relationships; 2) Utilising manager resources; and 3) Promoting satisfaction. Conclusions: The participants described their experiences validating and empathising with staff. They reflected on challenges, the need for relationship-based care, and highlighted staff training needs. Implications and recommendations are discussed.

Chapter 1: Systematic review: Integrated approaches to psychological interventions for trauma and psychosis: a systematic review of case studies: Objective: Trauma has been proposed to play a role in the development and maintenance of psychosis. Psychological therapy approaches that integrate both psychosis and traumatic experiences are in their infancy with evidence largely consisting of case reports, case series and single case design studies. This review aimed to synthesise the types of psychological interventions described in case studies, their outcomes and methodological quality. Method: Systematic database searches were conducted using a pre-determined search strategy and inclusion criteria to identify case studies reporting psychological therapies for psychosis and trauma among adults. Studies that met inclusion criteria underwent a process of calibration, inter-rater reliability and data extraction. The review was pre-registered with PROSPERO (registration number: CRD42020178384). Results: 17 case studies met inclusion criteria. Psychological interventions included psychotherapy (n=6), integrated CBT for psychosis and trauma (n=2), and trauma-focused approaches (n=9). Methodological quality ranged between poor (n=4), moderate (n=9) and high (n=4). Case studies reported improvements in trauma-related and psychotic symptoms. Case studies also highlighted symptom exacerbation. Conclusions: This review described a wide range of case studies of psychological interventions, mainly from psychotherapeutic and CBT schools. Methodologically robust research is required and improved adherence to SCRIBE reporting standards. Chapter 2: Major research project: Connection to the Environment with Cognitive Therapy (CONNECT): Exploring trauma, dissociation and voices through targeted psychological intervention using a single-case experimental design. Background: When considering pathways from trauma to psychosis, evidence suggests that dissociation plays a pivotal role. Adopting an interventionist-causal stance, the current study investigated whether targeting dissociation through psychological intervention (Connection to Environment with Cognitive Therapy [CONNECT]) lead to improvements in dissociation, Auditory Hallucination Frequency (AH-F) and Distress (AH-D) for people who have experienced trauma. Methods: This study utilised a randomised multiple baseline single-case experimental design. Four participants with dissociation, AH and trauma were randomised to baselines of two, three of four weeks and received eight sessions of CONNECT. Dissociation, AH-F and AH-D were assessed at baseline, pre-intervention, post-intervention and 1-month follow-up, session-by-session, and daily self-report. Data were analysed using visual analysis, Tau-U analysis and Reliable Change Indices. Results: CONNECT led to a significant improvement in dissociation at combined level and non-significant improvements at the individual level. CONNECT did not lead to significant improvements in AH-D or AH-F at the combined or individual level, with the exception of one participant among whom AH-F significantly decreased. Conclusions: Contrary to evidence that dissociation maintains AH, reducing dissociation through targeted psychological intervention did not lead to improvements in AH. Further research is warranted with particular emphasis on interventionist-causal approaches, digital technology and network analysis.

Advances in electroencephalography (EEG) and magnetoencephalography (MEG) have allowed the investigation into the neurophysiological basis of perceptual and cognitive disturbances across different stages of psychosis. The EEG/MEG recorded (neuromagnetic) mismatch negativity (MMN(m)) is a component of the event-related potential/field reflecting early pre-attentive auditory processing. Reduced MMN amplitude is a well-replicated finding in chronic schizophrenia patients and there is evidence for a smaller MMN impairment in first episode patients. Interestingly, studies have suggested that MMN deficits may be present even prior to the onset of psychosis in individuals at clinical high risk state for developing psychosis (CHR), suggesting that MMN amplitude could be a potential marker of psychosis risk. However, in contrast to the robust finding of an attenuated MMN amplitude in schizophrenia, results are more inconsistent at the earliest stages of illness. Moreover, to date most studies have used a conventional analysis for assessing MMN amplitudes in different stages of psychosis although brain connectivity measures, such as dynamic causal modelling (DCM) allow investigating effective connectivity in the brain network underlying the MMN generation. Also, two decades of research into characteristics of CHR individuals has revealed that they are functioning poorly regardless of subsequent transition to psychosis. However, while MMN amplitude has been studied as a potential marker for predicting psychosis among CHR individuals in several studies, its utility to predict other clinically relevant outcomes remains unknown. In the current thesis, I sought to examine MEG-recorded MMNm peak amplitude in individuals at different stages of psychosis as well as its association with neuropsychological performance, attenuated psychotic symptoms and psychosocial functioning in CHR individuals (chapter 3). The aim was to assess the potential of MMNm amplitude as a marker for early stages of psychosis and to examine whether MMNm deficits are pronounced in CHR individuals with poor functioning and cognitive deficits. Secondly, I employed DCM to examine whether effective connectivity in the underlying network of duration change detection is altered in CHR individuals compared to controls (chapter 4). Lastly, I investigated whether baseline MMNm amplitude is able to predict the 12-month outcome of CHR individuals in terms of transition to psychosis or sustained subthreshold psychotic symptoms and poor functioning (chapter 5). Given that the current study is the first large study that recruited CHR individuals predominantly from the community, clinical findings will also be reviewed and compared to previous studies with CHR individuals recruited from special early detection and intervention services. The findings in chapter 3 show that compared to controls, MMNm peak amplitudes were intact in CHR individuals as well as in first episode patients. Chapter 3 also indicates a weak positive association between MMNm amplitudes and speed of information processing in CHR individuals. Chapter 4 results indicate that CHR individuals do not have abnormal duration deviant induced changes in frontotemporal connectivity network compared to controls. Collectively these findings suggest that neither the peak amplitude nor the measures of effective connectivity underlying the MMNm response are related to the CHR state. Lastly, chapter 5 indicates that baseline MMNm amplitude is not associated with progression to a first episode psychosis, although this finding needs to be considered limited due to the low transition rate to psychosis, or persistence of subthreshold psychotic symptoms and poor functioning in CHR individuals. Overall, the findings in the thesis do not support the utility of using MMNm as a marker for emerging psychosis. However, future longitudinal studies with several MEG recording time points are required to further determine the timing of MMN deficiency and whether it reflects emerging psychosis or illness progression. The clinical findings of the thesis demonstrate that CHR individuals recruited from the general population are characterised by several clinical concerns and despite the majority of them not developing psychosis and remitting symptomatically over 12 months, CHR individuals were characterised by persistent functional disability, highlighting the importance of evaluating and predicting more systematically psychosocial functioning in this clinically meaningful population. Finally, I discuss the key neurophysiological and clinical findings of the three data chapters in chapter 6 in the context of previous findings as well as the limitations and strengths of the current thesis. I also discuss the possibility and key challenges of implementing electrophysiological measures as part of a multivariate and sequential testing in clinical practice as well as proposals for moving beyond the current UHR paradigm.

Background: The term “congenital heart disease’ (CHD) refers to abnormalities of the heart that are present from birth, and typically require timely medical intervention. The unique stressors faced by mothers whose children have CHD can cause increased psychological distress, impact on quality of life and the capacity for optimal parenting. More research is needed into the lived experiences of mothers whose infants are diagnosed with CHD and undergo surgery to help understand their experiences and target interventions appropriately. Aim: To explore the lived experiences of mothers whose infants received an antenatal diagnosis of CHD and who had undergone surgery within the first year of life. Method: Individual interviews were conducted with 5 mothers to explore their lived experiences. All interviews were transcribed verbatim and were analysed using Interpretative Phenomenological Analysis. Results: One superordinate theme was developed to capture the mothers’ experiences overall: ‘A battle on multiple fronts’. 5 subthemes illustrated the mothers’ battles: The Trauma of the Battle – “Fighting an uphill battle”; The Fight for Survival – “Is it compatible with life?”; A Fight for Family-Centred Care – “A constant battle to be her parent”; Allies – “Everyone is on the same side”; and A Lonely Battle – “They are not there to help me”. Conclusion: Mothers described an inherent fight following an antenatal diagnosis of CHD, throughout which factors exacerbated or mitigated their sense of threat and conflict. Healthcare services need to create a sense of support and togetherness to reduce the experience of additional stressors in the mothers’ battle.

Background & Aims: Despite progressive legislative provisions for Advance Statements (AS), the uptake remains low. This suggests aims of empowering people with human rights on an equal basis with others are not being realised in practice. This study aimed to interview mental health professionals about AS to increase our understanding of low rates of implementation. Methods: Thirteen participants (4 Mental health nurses, 6 community psychiatric nurses and 3 psychiatrists) were recruited. They were purposively sampled because of their involvement in making treatment decisions. They participated in a semi-structured interview which was audio-recorded and transcribed. The data were analysed using Discourse Analysis to explore how participants used language to position themselves in relation to AS. Results: Five positions emerged from the data: Taking Account of Peoples’ Wishes where participants described their understanding of AS; Enabling People to Have Their Say (to a Point), where participants explained that they enable people to become involved in treatment decisions, but only when professionals judged it to be appropriate; We Know What’s Best, where participants used medical discourse when explaining what is best for people, limiting the credibility of AS; Firefighting with Risk where participants described the need to prioritise risk and crisis management over AS; and Leverage and Liability, where participants spoke of the different influences in their work. Conclusions: Legislation is not enough to improve implementation of AS and improving knowledge is unlikely to lead to change. Interventions designed to address the low uptake must consider the complexity of the system which it hopes to change while addressing the disparity in how knowledge derived from lived experience is valued. It is crucial that all stakeholders are involved in these endeavours.

Background: The quality of the early parent-child relationship is linked to a child's neurophysiological, physical and psychological development with relationship difficulties being linked to emotional and physical difficulties throughout the child's life. Parenting interventions, such as Mellow Babies, which focus on the quality of the parent-child relationship, have been found to improve parent and child outcomes. There is currently very little research into the long-term effects of parenting interventions on parents and their children, feasibility studies are necessary in order to guide implementation of larger scale research in the area. Aims: This study aims to explore the feasibility of conducting follow-up research with parents 18 months after taking part in a Mellow Babies intervention in order to inform future larger scale research in the area. The study estimated a 25% attrition rate and aimed to recruit 45 of 60 (75%) potential participants. Methods: Sixty parents who took part in the Mellow Babies intervention as part of the AIM Project were invited to complete questionnaires on their psychological well-being and quality of life. They were also video recorded interacting with their baby to provide information on the quality of the interaction. Parents' scores on all outcomes measures at follow-up were compared to pre- and post-intervention outcomes from the AIM Project. Results: 22 out of a possible 60 (37%) parents were successfully recruited to the study. 18 (30%) could not be contacted by the referrer, 3 (5%) declined participation, 15 (28%) did not respond to the referrer or the researcher. Five of the seven parents of older children who took part in the AIM Project engaged in the long-term follow-up. Those who were successfully recruited to follow-up were more likely to be older than those who did not engage. Small positive effect sizes were observed on measures of global psychological severity, anxiety and quality of life at T3 when compared to T1. However, these results should be interpreted with caution due to the small sample size of the study. Conclusion: It is feasible to recruit parents to follow-up research, however changes in service provision in the region led to difficulties and delays in recruitment. Due to the small sample size assumptions cannot be made from the findings of the outcome evaluation and follow-up research is necessary in order to continue to explore the impact of Mellow Babies on parent and child outcomes.

Many relatives caring for someone experiencing psychosis, display high levels of psychological distress. This can result in poorer mental health for both the carer and patient. Negative symptoms have been shown to especially hamper recovery, although little is known about their development and maintenance. Jansen et al. (2014) found greater metacognitive ability in the caregiver can improve coping and reduce distress in caregivers of those with FEP. This study explores the relationship between caregiver experience and metacognitive ability in those with multi-episodic persistent psychosis, exploring if caregivers with greater metacognitive ability have reduced levels of distress and whether there are indicators that negative symptoms are developed and maintained in a relational context.

Background: The prevalence of head injury (HI) in juvenile offenders is estimated to be 30%, however no studies report disability after HI in prisoners. Furthermore, a recent Doctoral thesis found that adult offenders with a history of moderate-severe HI were more likely to experience disability, cognitive impairment, and anxiety than those with a mild HI history. Aims: To explore disability, health-related outcomes and offence characteristics associated with HI in juvenile prisoners in Scotland. Methods: HI, mental health, trauma, substance use, cognitive function and offending history were assessed in 78 male juvenile prisoners in HMYOI Polmont. Results: Compared with No/Mild HI, Multiple HI (as defined by the Ohio State University Traumatic Brain Injury Identification Method) was associated with greater substance use, poorer mental health, slower information processing, more violent convictions and prison incidents. Disability and self-report of dysexecutive functioning were associated with Multiple HI in univariate analysis. Regression indicated that a PTSD screening score and not HI group, ADHD, problematic alcohol/drug use, adverse childhood experiences, age or education predicted outcomes. Conclusions: Multiple HI was highly prevalent in juvenile prisoners and had associations with disability, dysexecutive difficulties and offence characteristics. A PTSD screening score was the only significant predictor of disability and dysexecutive difficulties. Those who score above the cut-off on the PTSD screening tool may not be referring to PTSD symptoms alone; clinical interview would be required for PTSD diagnosis. Staff working with juvenile prisoners should be aware of the impact of HI and trauma on their health and offending risk.

Background: Functional disability represents a significant barrier to recovery in people with schizophrenia, often impacting those in in-patient rehabilitation to the greatest extent. There is evidence that social cognition is an important predictor of functional outcomes but the relationship between social cognition and functioning and other key variables such as symptoms remain unclear. Previous research has examined negative symptoms as a unitary construct. This study aims to clarify whether there is a differential association between experiential and expressive symptoms, functioning and social cognition, and whether experiential negative symptoms mediate a relationship between social cognition and functioning. Methods: 11 participants with schizophrenia or schizoaffective disorder were recruited. Participants were administered a battery of cognitive, social cognition and symptoms measures and an observer rated measure of functioning was completed with a named nurse. Results: Due to the sample size obtained, data was visually examined and Spearman's Rho correlations used to estimate effect sizes of linear relationships. Higher levels of experiential but not expressive negative symptoms appeared to be associated with poorer social cognitive ability and worse functioning. Due to recruitment challenges, post-hoc exploration of recruitment feasibility was conducted which demonstrated that recruitment figures were poor with only 33% of eligible patients participating. Ward turnover rates were low and indicate long recruitment periods to be necessary to recruit adequate samples Discussion and conclusion: The small sample reflects the difficulty of testing predictors of functioning in people who, by definition, do not readily engage in everyday roles. With acknowledgement of the limited generalisability, these preliminary data suggest a differential association between experiential and expressive negative symptoms and their relationship to functioning and social cognition. This highlights the importance of motivational constructs in determining functioning and may be a potential pathway from social cognition to functioning. Suggestions are made to address the low recruitment rates and increase participation.

Background: Understanding how interventions work is a key step in the development and evaluation of complex interventions. Based on previous research, autobiographical memory specificity and rumination are candidate mechanisms of change. Our aim was to explore mechanisms of therapeutic change in the context of a pilot trial of Acceptance and Commitment Therapy (ACT) for people with a diagnosis of schizophrenia and major depression. Method: The ACT for Depression After Psychosis Trial (ADAPT; Gumley et al., 2017) provided repeated measures data that allowed exploration of the change process in ACT for depression after psychosis. Participants who met criteria for schizophrenia and major depression were randomly allocated to standard care or standard care plus up to 5-months of individual ACT for depression after psychosis (ACTdp). Primary outcomes administered on entry to the study (pre-randomisation), at 5-months (posttreatment), and at 10-months (follow up) included the Beck Depression Inventory (BDI), Calgary Depression Scale for Schizophrenia (CDSS), the Kentucky Inventory of Mindfulness Skills (KIMS), and the Acceptance and Action Questionnaire (AAQ). Candidate mechanisms of change were assessed using Ruminative Response Scale (RRS) and the Autobiographical Memory Test (AMT). Results: Significant correlations between change scores were found for BDI and proposed mechanisms of change at 5-months (Rumination: r = 0.60, p< .05; Overgeneral memory responses: r = 0.67, p < .05; memory recall latency: r = -0.84, p< .01) and 10-months (Rumination: r = 0.80, p < .01; Overgeneral memory responses: r = 0.61, p < .01). Changes in CDSS depression and rumination scores were significantly correlated at 10-months (Rumination: r = 0.76, p < .01). In order to examine hypotheses that aspects of autobiographical memory specificity would vary by treatment group, cue word valence, and time of assessment, three-way mixed ANOVAs were performed for percentage of overgeneral memories recalled, and emotional tone of events recalled. Significantly more overgeneral responses were recalled for negative cue words (F (1, 22) = 17.817, p < .001, partial eta squared = .447). Additionally, significantly more negative feeling was evoked for memories recalled in response to negative cue words (F (1, 17) = 83.232, p < .001, partial eta squared = .839). A threeway interaction was found for cue word x time point x treatment group's effect on feeling evoked by memories recalled (F (2, 15) = 6.251, p < .013, partial eta squared = .455). Post-hoc analysis found the negative feeling evoked by memories recalled in response to negative cue words was significantly reduced in the ACT group posttreatment. For the ACT group, the difference between mean feeling evoked to negative cue words at baseline and 5-months was 2.72, (95% CI [-5.115, -0.318], p < .013). Application: This study provides insight into the change mechanisms through which interventions like ACTdp may produce beneficial effects. Preliminary findings suggest ACT may facilitate positive change for those experiencing depression after psychosis by reducing cognitive avoidance and enhancing ability to tolerate recollection and discussion of emotionally challenging events.

Chronic schizophrenia (ScZ) is associated with impaired gamma oscillations, reflected by robust alterations in 40 Hz ASSR. Oscillatory deficits may arise from changes in the cortical E/I-balance. However, it is unclear whether aberrant oscillations and potential underlying mechanisms are present also in early and clinical high risk (CHR) stages of psychosis. In this thesis, data from a multimodal CHR study were used to explore auditory oscillatory alterations in CHR individuals, assessed using MEG-recorded 40 Hz Auditory Steady State Response (ASSR) measures, with the aim to establish how deficits may account for early alterations in neural circuits in emerging psychosis. To further map such changes, a group of first episode of psychosis (FEP) participants were also studied, and oscillatory measures were compared with H1-MRS measures of neurotransmitter levels as well as with clinical measures. The thesis first presents a meta-analysis of ASSR findings in ScZ so far, showing that the response is impaired in chronic patients. Each of the following four chapters respectively present separate data analyses, focusing on baseline ASSR data, connectivity analyses, proton magnetic resonance spectroscopy (1H-MRS) analyses, and data assessing longitudinal outcomes. Through these investigations, the thesis demonstrates impairments in RSMG 40 Hz spectral power and ITPC in CHR and FEP, with bidirectional connectivity impairments present between RSMG and primary auditory cortex in CHR participants. In addition, strong beta frequency reductions in power were observed in CHR and FEP participants relative to controls. No clear impairments were detected in 1H-MRS data, but a trend deficit in right auditory GABA levels was seen in FEP patients. Finally, investigations of longitudinal parameters revealed that RSMG oscillatory impairments are related to functioning at the time of scanning, but not to functioning at the one-year follow-up. Moreover, beta frequency power was found to be selectively impaired in individuals with sustained CHR symptoms and low GAF scores (at both baseline and 12 months). Combined, the results of this thesis provide evidence for complex, subtle neural circuit alterations in emerging psychosis, which can be captured non-invasively using the 40 Hz ASSR paradigm.

Introduction: Scottish prisoners are significantly more likely to have head injury (HI) than the general population. The Scottish government recommend exploring HI and consequent disability in offenders in the criminal justice system. Little research exists on persisting effects of HI in short-term prisoners preparing for release. Aim: To investigate HI-related disability in prisoners within Through-Care services and differences in number of convictions. Methods: 66 participants were recruited from HMP Low Moss. A cross-sectional design was employed. History of HI was screened and individuals were categorised as having mild or moderate/severe HI. Disability, cognitive and mental health outcomes were assessed. Results: Self-reported multiple and moderate-severe HI (MMHI) was associated with disability, with a greater proportion of those with MMHI (72%) rated as 'disabled' compared to those with mild HI (37%); (1)=7.246, p=0.007, φ=0.266, OR= 4.5, 95%CI: 1.45-13.8). A history MMHI was associated with significantly greater reported dysexecutive difficulties (r = 0.26, 95%CI = -13.01--0.37). When controlling for covariates (age, education), HI was a significant predictor of disability (OR = 5.03; 95%CI = 1.56 -16.22, p= 0.007), however the association between HI and dysexecutive difficulties did not remain significant. There was no significant difference in the number of convictions between HI groups. Conclusion: Prisoners in Through-Care preparing to leave prison have a high level of self-reported HI. HI is predictive of disability, which may act as a major constraint on short-term prisoners' prospects, having limited opportunity to access appropriate services for support. Educating Through-Care services on HI, disability and executive difficulties, with the development of prison based interventions, might improve post-release prospects for service users.

Objectives: Episodes of relapse in psychosis can have profound adverse consequences for service users and their families. Efforts to prevent relapse, or minimise its impact, may be supported by the recognition of early warning signs (EWS). However, several challenges exist to both service users' help-seeking and services' provision of care during these periods. It is important that this context is understood if novel interventions are to be effectively implemented in practice. This study therefore aimed to explore staff experiences of providing care at times of EWS or relapse of psychosis. Design: The study was part of an on-going trial of an intervention for early signs monitoring (EMPOWER: ISRCTN 99559262). Data collection and analysis were informed by grounded theory methods. Methods: Five mental health key workers in community mental health teams were interviewed about their experiences of providing care during EWS or relapse. Pre-existing focus group transcripts were also used to check and further refine developing categories. Results: Keyworkers framed their practice around EWS as intertwined with their relationships with service users. Decision making around care at these times was influenced by the keyworkers' appraisals of trust, wider social support networks and constructed knowledge of the service user. EWS episodes were experienced as opportunities for learning for both keyworker and service user. In this way, keyworkers described potential for more attuned care and improved service user expectations of service response to EWS. However, where service users were perceived to lack insight, or did not engage in reflection on past episodes, encouraging earlier help seeking was appraised as difficult or impossible. Conclusion: Keyworkers experience long-term relationships and their knowledge of the service user as key in the provision of care during early relapse. Implications for the development of interventions for early relapse are discussed.

Background: The emotional, social, cognitive and behavioural impact of head injury (HI) can be significant and long lasting. Those with a forensic history are at higher risk of sustaining a HI. There is a growing evidence base on prevalence and linking the effects of HI with offending behaviour. The National Prisoner Healthcare Network (NPHN) recommends evaluation of screening for HI by social workers completing a pre-sentencing Criminal Justice Social Work (CJSW) report. This may help to better understand the role of HI on future offending and guide disposals or interventions. Objectives: The study assessed how many participants undergoing a CJSW assessment would likely benefit from a screening assessment and onward referral following HI. It did this by identifying (a) the prevalence of HI in participants undergoing a CJSW assessment (b) the occurrence of persisting problems, including neuropsychological impairment, emotional difficulties, behavioural difficulties and social disability after HI and (c) whether CJSW reports already indicate HI. The study also investigated relationships between significant HI and re-offending. Method: A cross sectional, between subjects design was utilised. A screening measure that is valid for forensic samples was used to assess severity of HI. Assessments of disability, mental health, cognitive function and effort were carried out on 46 adult participants undergoing assessment at West Dunbartonshire CJSW, Scotland. Participants were grouped by severity of HI (group 1=moderate-severe or multiplemild, group 2=no or mild HI). CJSW reports were scrutinised to identify reference to HI and other impairments (e.g., mental/physical health and disability). Results: HI was reported by 91% of 46 participants. Moderate-severe HI was found in 20% (n=9) and multiple-mild HI in 39% (n=18). HI predicted disability (p=.012) and psychological distress (p=.034) after adjusting for age, education and substance use. Groups performed similarly across cognitive domains. Participants with moderate-severe/multiple-mild HI were more likely to have violent offending histories (p=.002); more convictions (p=.005); and have more prison sentences (p=.007). No CJSW reports identified HI. Conclusions: Disability and psychological distress were more common in participants with more severe HI. Results indicate around 28% of participants would benefit from screening for HI. However, HI was not identified in CJSW reports. Introduction of a HI screening process within CJSW would require training and links with health professionals to be developed. However, this could help to plan and support more appropriate disposals and interventions. Findings are preliminary and further large-scale research is required.

Background: Anxiety and depression are highly prevalent in adults with Cystic Fibrosis (CF) and can lead to numerous negative outcomes including poorer physical health and health related quality of life, reduced treatment adherence and increased healthcare costs. Currently it is recommended that all adults with CF are screened for anxiety and depression on an annual basis. However, there are concerns that these current measures do not adequately detect the range of difficulties that individuals with CF experience. Consequently, the Distress in Cystic Fibrosis Scale (DCFS) was developed to support the detection of distress specifically in an adult CF population. This study was an initial exploration of the structural and psychometric properties of the DCFS in order to support its development as an appropriate screening measure of distress in an adult CF population. Methods: 119 participants were recruited from the West of Scotland Adult Cystic Fibrosis Service (WoSACFS) through inpatient wards and out-patient clinics. Participants completed a battery of questionnaires assessing their mood, quality of life and current distress relating to CF. Psychometric properties of the DCFS were then evaluated with additional exploratory analyses evaluating the structure and practical use of the measure. Results: The results indicated a 1-component model for the DCFS and provided support for it being an appropriate measure of CF distress, with positive findings relating to internal consistency and criterion validity. However, exploratory analyses highlighted that two response categories (N/A and 0) were used inconsistently by participants particularly for those items concerning physical health symptoms. It is possible that this was due to the wording of the rating scale and instructions. Conclusions: The current study provides preliminary support for the DCFS being used as a measure of distress in an adult CF population. Potential improvements to the instructions and response scale were identified and subsequent recommendations made. Future studies should be conducted to further investigate the psychometric properties of the revised tool using a larger sample with a greater range of clinical and demographic characteristics.

Background: Social withdrawal contributes to poor emotional, behavioural, social and occupational functioning. In Japan, social withdrawal affecting adolescents and young adults has been conceptualised as a syndrome called Hikikomori (Saito, 2013). At present no adequate measure exists that would support targeted assessment of the presence and severity of social withdrawal amongst adolescents in Scotland. The Glasgow Hikikomori Scale (GHS) is a new measure developed with the aim of providing an English language rating scale for social withdrawal in young people. Aims: This study aimed to develop and conduct preliminary investigation of a new measure for assessing social withdrawal in young people, the GHS. Methods: The first part of this feasibility study involved refinement of the GHS. Clinicians working in Child and Adolescent Mental Health Services (CAMHS) were invited to take part in the online feedback survey regarding the wording of this scale. The second part of this feasibility study involved recruiting the participants to explore the psychometric properties of the GHS. Participants between the age of 13 and 17 with varying levels of social withdrawal were sought from the NHS GG&C CAMHS. The GHS and a mixture of self-report and observer-report scales were used. Results: Forty-nine clinicians from the NHS Greater Glasgow & Clyde (GG&C) area working in the CAMHS took part in the rating of the GHS items on the scale ranging from 1 (very unclear) to 9 (perfectly clear). The median scores of the items ranged from 6 (IQR: 3, 7) to 9 (IQR: 8, 9). The GHS scale was refined in accordance with the received feedback. We then attempted to examine the utility and psychometric properties of the scale by applying it to the assessment of young people with social withdrawal. Recruitment proved to be very challenging with only five people completing the measures in a period of three months. This sample size did not allow to use statistical methods of analysis that were planned to explore the psychometric properties of the GHS. However, the data provided useful information about the challenges of accessing and engaging this sub-group of withdrawn young people. Conclusions: Although only a very small sample was recruited, it allowed to explore the feasibility of the recruitment of this hard to reach population. It also enabled to estimate the time scale necessary to increase the feasibility of the future studies and identify some of the factors that could hinder the recruitment process. Based on the collected data, the recruitment period needed to get a full sample would be approximately 20 months. Future studies will either need to have very long recruitment timeframes or different research methods may need to be used to access usable data on this withdrawn and socially isolated population.

Introduction: Individuals living in rural settings who have psychosis experience a number of challenges in accessing support due to their isolated location. These include a lack of public transportation, sparse support services, social isolation and increased stigma. Given these potential barriers, digital technology has been seen as a method to increase access to support. This study explored rural experiences of accessing support for psychosis and participants' perspectives on the potential use of a Smartphone Application (app). Method: Semi-structured interviews were completed with adults with psychosis living in a rural setting (n = 6). During the interviews they were shown a presentation and demonstration of the Empower app. Thematic analysis was utilised to analyse participants' experiences and opinions. Result: Three themes captured the participants' experiences of rural support: rural context, rural community and experiences of support. These highlighted the positive and negative experiences of rurality and accessing support, and the impact these had for the individual. A further two themes were captured from their perspectives on the app: app increasing access and monitoring helps learning. Conclusion: Rural life presents a unique mix of positive and negative characteristics that can influence an individual's experience of psychosis, social isolation and the support they receive. Mental health services need to consider appropriate adaptations, including further integration of digital technology, when supporting this population. A daily monitoring app, blended with peer-support, was viewed as a potentially helpful source of support that may help alleviate rural barriers and isolation.

Background: Research suggests that migrants have reduced access to treatment for psychosis, and more prolonged pathways to care, which could increase their risk for developing psychosis. Factors such as internalised stigma, experiences of social defeat and preference for non-medical treatment could delay help seeking, thereby leading to the development of psychosis. Aims: Our primary aim was to pilot the feasibility of recruiting migrants and non-migrants with psychosis to test a new measure of treatment preferences. We also aimed to explore group differences on experiences of stigma, social defeat and treatment preferences. Methods: Twenty seven individuals in receipt of care for psychosis completed measures of social defeat, internalised stigma and the GlasMPT. Results: Difficulties with recruiting migrants are discussed. Results were also mixed with regards to the tool's psychometric properties, indicating the need for further refinements and testing. Exploratory analysis suggested that most participants preferred psychosocial interventions for their problems, and greater stigma was associated with greater social defeat. Conclusion: Given the relationship between delays in help-seeking and development of psychosis, there is a need to understand barriers to help-seeking, particularly for those at risk, such as migrants. Future studies should draw on our findings to improve migrant recruitment and develop culturally sensitive measures of treatment preferences.

Objective: Family based therapy (FBT) has been identified as the first line treatment for adolescents with anorexia nervosa, and has been implemented in five health boards in the West of Scotland. This research seeks to examine the experiences and beliefs of clinicians delivering FBT to young people with anorexia, with a particular focus on their beliefs around facilitating and detrimental factors to treatment outcomes. Method: Clinicians working in each of the five health boards were invited to take part in the study. Eight clinicians providing FBT to adolescents with anorexia nervosa were recruited. Semi-structured interviews were conducted and data were analysed using thematic analysis. This was then synthe- sised into sub-themes, mapping onto the framework of barriers and facilitators to implementation of FBT. Results: Analysis identified eight facilitating factors and seven potential barriers, from the clini- cians' perspective. Of note, four factors were identified that may act as either a facilitator or a barri- er, depending on other contextual factors. Discussion: The present findings provide insights into the perspective of clinicians providing FBT for anorexia in real world CAMHS services. These insights may suggest potential avenues for addi- tional attention from clinicians, such as areas of potential bias, and where potential barriers can be shaped into facilitators. Future research into clinicians' experiences and strategies that may enhance facilitators and decrease barriers would be beneficial.

Objective: Perceptions of defeat and entrapment are becoming increasingly important psychological constructs within research and clinical work that is focused on understanding the aetiology of mental health and promotion of well-being. Defeat and entrapment have been shown to be associated with depression, anxiety and suicidal behaviour within adult populations. Within the research literature, there is an ongoing debate as to whether defeat and entrapment should be considered as separate or single constructs. This study sought to bridge two gaps in the literature, by investigating the extent to which defeat and entrapment are associated with mental health and well-being measures within an adolescent non-clinical population and to which extent they are best conceptualised as separate or single constructs. Method: In total, 280 secondary school pupils aged 14 to 17 years old (M=14.83, SD=0.7) took part in this cross-sectional questionnaire-based study. Participants completed the study at their respective schools within North Lanarkshire Council, Scotland and participation remained anonymous. Participants completed the defeat and entrapment scale along with a variety of mental health and well-being measures including depression, anxiety, suicidal and self-harm thoughts and behaviour, frequency of alcohol and drug use, stress, self-esteem, optimism and overall life satisfaction. Results: Confirmatory factor analyses indicated that defeat and entrapment show a better fit with a two-factor model indicating that they are separate but highly related constructs. Female participants and those who previously attended mental health services had significantly higher defeat and entrapment scores. Multivariate hierarchical regression analyses reveal that perceptions of defeat were associated with anxiety, depression and stress symptomology and inversely associated with optimism, however these relationships were not significant after controlling for entrapment suggesting mediation. Entrapment was associated with depression, anxiety, deliberate self-harm ideation, stress and inversely associated with life satisfaction. Conclusion: This research has been novel in exploring the conceptual relationship of defeat and entrapment and adolescent mental health and well-being. Strengths, limitations and clinical implications are discussed.

Background: A critique of the traditional two-factor model of recovery style suggests that it does not fully take into account the range of strategies people use in their recovery. A third style of ‘ruminative preoccupation’ is proposed in addition to the existing styles of ‘integration’ and ‘sealing over’. In addition, current tools used to measure recovery style lack construct validity and have limitations such as being outdated or using a simplistic format. The Narrative Recovery Style Scale (NRSS) is a novel method of evaluating recovery style, using interview transcripts to provide a three-dimensional measurement of an individual’s style. Aim: The primary aim of this study was to validate and examine the psychometric properties of the NRSS in a mixed clinical sample of individuals with serious mental illness. Method: 36 participants with either schizophrenia (n=13), bipolar disorder (n=9), or complex trauma (n=14) were recruited to the study from community mental health services in Glasgow. Participants were interviewed using the Narrative Interview for Compassion-Revised (NCS-R), a recorded semi-structured interview designed to measure participants’ experiences of compassion towards the self, from self to others and from others to self. This was transcribed and the NRSS was applied to the narrative in order to obtain recovery style ratings. We examined the relationship between the NRSS and the Recovery Style Questionnaire (RSQ), the Coping Inventory for Stressful Situations (CISS) and the Psychosis Attachment Measure (PAM). Results: No associations were found between the NRSS subscales and the RSQ, the CISS, or the PAM. Regarding the internal structure of the scale, the integration subscale was found to be negatively correlated with the sealing over subscale. No relationship was found between the other subscales. Regarding the characteristics of the sample, a number of significant differences between the diagnostic groups were noted including age, IQ, occupation, attachment avoidance, coping, and RSQ recovery style. Conclusions: Although the results do not support the validity of the NRSS as a three-dimensional measure of recovery style, there are various methodological factors which may have influenced the study results. We recommend the development of a specifically constructed interview designed to activate recovery style, upon which the NRSS can be more reliably applied. A re-examination of the NRSS scoring strategy may also increase the research utility and strengthen the reliability of the measure.

Background: Research indicates that male farmers have higher levels of depression than non-farmers and that offering mental health support online may overcome several barriers to help-seeking in farmers. This study investigated the feasibility of delivering a computerised Cognitive Behavioural Therapy (cCBT) based course to farmers. Methods: Farmers with depressive symptoms in the normal to moderate range were recruited using adverts into a single-arm feasibility study. Participants were given access to a cCBT-based course consisting of 5 core modules and weekly automated and personalised email support. Self-reported depression, anxiety, and social functioning were measured at baseline and 8-week follow-up. Telephone interviews explored participant use of and satisfaction with the course and were analysed using thematic analysis. Results: 56 participants were recruited, with 48% recruited using social media. In total, 35 (63%) participants logged onto the course and 15 (27%) completed follow-up measures. Of those who logged on, only 14% (n = 5/35) completed all core modules. Most participants had no or minimal depressive symptoms (71%); 67% had at least mild anxiety; and 54% had mild to moderate functional impairment. Qualitative interviews (n = 8) indicated that farmers may not help-seek due to heavy workloads and mental health stigma within the farming community. Participants therefore thought online support was helpful because it was convenient and anonymous. There were concerns that older people and those with limited internet connection may have difficulty accessing the course. Suggestions regarding the layout and content of the course were provided. Exploratory analyses showed a significant reduction in anxiety over time (p< .05); no significant change in depression or in functioning was observed. Conclusions: Online courses may be effective and convenient ways of offering mental health support to some in the farming community. Difficulties in recruiting and retaining farmers may indicate that cCBT may need to be modified further to engage farmers better with short stand-alone modules and the ability to download content for reading offline.

Background: Negative symptoms in schizophrenia are an important area of research due to their relationship with reduced quality of life. Interventions targeting defeatist beliefs have been found to improve negative symptoms, which are also associated with poor meta-cognition and autobiographical memory. Understanding metacognition may help us to understand the processes that affect social problem-solving (SPS) and negative symptoms, and together this information may help focus newer, more effective interventions. Aims: The aims of this study were to examine how negative symptoms experienced by people with schizophrenia interact with meta-cognitive, autobiographical memory and social problem-solving deficits. Method: This was a cross-sectional study of 14 inpatients from the community mental health inpatient and forensic directorate wards across GGandC who had a diagnosis of schizophrenia and were experiencing difficulties with negative symptoms. Participants were asked to complete measures of social problem-solving, mood and negative symptoms. They were then asked to complete four social problem-solving scenarios, then asked questions about their life using the Indiana Psychiatric Illness Inventory (IPII) and finally they were presented with the AM task which consisted of 15 words and each required the participant to attribute the word to a specific memory. Finally, participants were categorized into predominant or prominent symptom profiles for comparison between groups. Results: Participants were found to have lower levels of avolition and alogia if they have a positive orientation to solving problems and are able to consider various options when trying to solve a problem. In addition the meta-cognition subscale of mastery was positively related to actual problem-solving performance and effectiveness. Conclusion: Post hoc analysis found that the negative symptoms of avolition and alogia are positively associated with the functional problem-solving constructs of rational problem-solving and positive problem orientation. Whilst this study experienced major methodological limitations the findings could guide future studies to focus on attitudes and actual problem-solving ability, which could be important factors in relation to interventions for negative symptoms.

Background: A disproportionate number of people with psychosis end their own lives in comparison to those in the general population. One of the risky times for this group is during their first episode of psychosis (FEP). This study interviewed individuals with FEP about making a suicide attempt. It also explored how individuals with a FEP made sense of their suicide attempt, what role, if any, their psychosis had in that experience and how they coped after their suicide attempt. Methods: Participants were recruited from Early Intervention Services for individuals with FEP in the West of Scotland. Participants were those who had a diagnosis of FEP. Interviews were conducted using a semi-structured interview guide and the transcribed data were analysed using Interpretative Phenomenological Analysis. Results: Three super-ordinate themes with inter-related subthemes emerged from the analysis. 1) Psychosis exposed self-evaluation: this theme explored how experiencing psychosis prompted participants to make self-evaluations. This shaped their perception of how others viewed them, and impacted on how they interacted with others. 2) Psychosis triggered the suicide attempt: this theme explored participants’ appraisals of being out of control, their fear of their hallucinations and their belief about suicide as a means of protecting others. 3) Increased awareness: this theme explored how participants became more observant of their thought content following their suicide attempt as they viewed it as a way of preventing themselves from re- experiencing psychosis. Conclusions: Central to participants’ experience of suicide was how they evaluated and responded to their psychotic experiences. These accounts provide a rich insight into the experience of a suicide attempt for those with FEP and highlights implications for future research.

Schizophrenia is a serious psychiatric disorder characterised by a breakdown in thought, emotion and perception, which leads to alterations of normal behaviour and feelings, a withdrawal from reality and an impression of mental defragmentation. Of the positive, negative and cognitive symptoms, the positive symptoms are perhaps the most striking. However, it is the severity of cognitive deficits that are most closely associated with a patients’ functional outcome in the long-term. Despite this, the successful treatment of the cognitive deficits has been met with difficulty, partly due to a lack of suitable animal models. There is an urgent need for animal models with appropriate face, construct and predictive validity for schizophrenia so that improved drug targets can be identified, and new drugs tested. In 2012, Winchester et al. discovered that sequence variations in the Map2k7 gene were associated with increased risk for schizophrenia, and Map2k7 mRNA was decreased in the prefrontal cortex of the post mortem brains of patients. The primary aim of this thesis is to behaviourally and molecularly characterise mice which are heterozygous for Map2k7 (Map2k7+/- mice) as a potential animal model of relevance to schizophrenia. Sequence variants in the Map2k7 gene are moderately common in the population and they almost double the disease risk (OR~1.9); hence, alterations of the Map2k7 gene in mice represent an ideal basis for an animal model with good construct validity. The Map2k7 gene produces the MKK7 protein, a kinase within the stress-activated JNK pathway, and is involved in a diverse range of cellular processes, such as apoptosis, synaptic plasticity and regulation of the immune response. First and foremost, the components of the MKK7/JNK pathway were quantified in Map2k7+/- mice and MKK7γ was found to be significantly decreased in the prefrontal cortex compared to their wildtype (WT) littermates, a highly disrupted brain region in patients with schizophrenia. Map2k7+/- mice also exhibited behavioural phenotypes relevant to schizophrenia: hyperactivity in the open field and attentional dysfunction. Minocycline showed promise in alleviating the attentional deficits and hyperactivity in the open field, but did not influence protein levels of signalling pathway components. Map2k7+/- mice did not show a decrease in sensorimotor gating as many patients do; however, they exhibited signs of altered response to amphetamine administration just prior to testing of sensorimotor gating, compared to WT mice. Decision-making abilities were also investigated: Map2k7+/- mice showed normal learning and performance of the rodent gambling task. Additionally, all mice were able to alter their choice pattern to be more optimal when the task contingencies were subtly switched, which was the first time this has been shown in mice in the touchscreen apparatus. However, when the task demands were altered such that ‘punishment’ no longer featured as prominently, Map2k7+/- mice showed huge difficulty compared to their WT littermates in shifting their choice pattern to be more optimal, suggesting they have a deficit in aspects of cognitive flexibility. Finally, Map2k7+/- mice were investigated as a gene x environment interaction model, by injecting pregnant dams with Poly I:C and examining the resultant immune response in maternal serum and embryonic brain. Map2k7+/- dams exhibited an altered immune response to Poly I:C compared to WT dams; however, future experiments will be required to confirm whether this altered cytokine response is also present in embryonic brain. Overall, Map2k7+/- mice show utility for dissecting the cognitive deficits and some aspects of the positive symptoms of schizophrenia that could be targeted by novel compounds. This would be aimed at restoring the function of the MKK7/JNK pathway. Further molecular and behavioural characterisation will be required, particularly into the potential gene x environment interaction model. Although no mouse model can recapitulate the full symptom spectrum of a human neuropsychiatric disorder, Map2k7+/- mice exhibit an interesting accumulation of phenotypic abnormalities relevant to schizophrenia.

Background: Individuals who suffer acquired brain injury (ABI) commonly demonstrate deficits in awareness. This may contribute to poor motivation for participation in neurorehabilitation, as a result of problems with self-regulation, goal-setting, and risk awareness. Research has suggested that preparing individuals for therapeutic interventions can improve engagement and promote more accurate expectations of interventions. For example, recent evidence suggests that providing structured information about treatment rationale and therapy tasks can increase treatment engagement motivation (Campbell et al. 2017). Objectives: To determine feasibility of providing a video of preparatory information within ABI inpatient services, and to investigate the use of this video in increasing insight, motivation, and rehabilitation behaviour (attendance and engagement). Method: Participants (N=11) were recruited from a brain injury inpatient unit, and randomised to immediate or lagged exposure to the video. A preparatory video aimed at improving insight and increasing motivation was shown regularly over a period of four weeks. Multi-disciplinary clinical staff evaluated the feasibility of delivering the video intervention using structured ratings Additionally, pre- and post-trial measures of motivation for rehabilitation, insight and rehabilitation behaviours were recorded. Results: Staff rated the use of the video as feasible, in terms of the intervention itself, resource consequences, and evaluation. In addition, management and senior staff reported intent to continue use of the video. Preliminary exploration of secondary measures of motivation, awareness of deficits, and rehabilitation behaviour suggests there were some indicators of change at individual levels. Due to the main study focus on feasibility, these clinical effects are to be treated as highly preliminary. Conclusions: Further piloting of this preparatory information video intervention is recommended to further explore the effects of such intervention on the motivation and awareness of deficits in people with ABI. There is a need for future trials to include formal process evaluation.

Traditionally, early visual cortex (V1-3) was thought of as merely a relay centre for feedforward retinal input, providing entry to the cortical visual processing steam. However, in addition to feedforward retinal input, V1 receives a large amount of intracortical information through feedback and lateral connections. Human visual perception is constructed from combining feedforward inputs with these feedback and lateral contributions. Feedback connections allow the visual cortical response to feedforward information to be affected by expectation, knowledge, and context; even at the level of early visual cortex. In Chapter 1 we discuss the feedforward and feedback visual processing streams. We consider historical philosophical and scientific propositions about constructive vision. We introduce modern theories of constructive vision, which suggest that vision is an active process that aims to infer or predict the cause of sensory inputs. We discuss how V1 therefore represents not only retinal input but also high-level effects related to constructive predictive perception. Visual illusions are a ‘side effect’ of constructive and inferential visual perception. For the vast majority of stimulus inputs, integration with context and knowledge facilitates clearer, more veridical perception. In illusion these constructive mechanisms produce incorrect percepts. Illusory effects can be observed in early visual cortex, even when there is no change in the feedforward visual input. We suggest that illusions therefore provide us with a tool to probe feedforward and feedback integration, as they exploit the difference between retinal stimulation and resulting perception. Thus, illusions allow us to see the changes in activation and perception induced only by feedback without changes in feedforward input. We discuss a few specific examples of illusion generation through feedback and the accompanying effects on V1 processing. In Schizophrenia, the integration of feedback and feedforward information is thought to be dysfunctional, with unbalanced contributions of the two sources. This is evidenced by disrupted contextual binding in visual perception and corresponding deficits in contextual illusion perception. We propose that illusions can provide a window into constructive and inferential visual perception in Schizophrenia. Use of illusion paradigms could help elucidate the deficits existing within feedback and feedforward integration. If we can establish clear effects of illusory feedback to V1 in a typical population, we can apply this knowledge to clinical subjects to observe the differences in feedback and feedforward information. Chapter 2 describes a behavioural study of the rubber hand illusion. We probe how multimodal illusory experience arises under varying reliabilities of visuotactile feedforward input. We recorded Likert ratings of illusion experience from subjects, after their hidden hand was stimulated either synchronously or asynchronously with a visible rubber hand (200, 300, 400, or 600ms visuotactile asynchronicity). We used two groups, assessed by a questionnaire measuring a subject’s risk of developing Schizophrenia - moderate/high scorers and a control group of zero-scorers. We therefore consider how schizotypal symptoms contribute to rubber hand illusory experience and interact with visuotactile reliability. Our results reveal that the impact of feedforward information on higher level illusory body schema is modulated by its reliability. Less reliable feedforward inputs (increasing asynchronicity) reduce illusion perception. Our data suggests that some illusions may not be affected on a spectrum of schizotypal traits but only in the full schizophrenic disorder, as we found no effect of group on illusion perception. In Chapter 3 we present an fMRI investigation of the rubber hand illusion in typical participants. Cortical feedback allows information about other modalities and about cognitive states to be represented at the level of V1. Using a multimodal illusion, we investigated whether crossmodal and illusory states could be represented in early visual cortex in the absence of differential visual input. We found increased BOLD activity in motion area V5 and global V1 when the feedforward tactile information and the illusory outcome were incoherent (for example when the subject was experiencing the illusion during asynchronous stimulation). This is suggestive of increased predictive error, supporting predictive coding models of cognitive function. Additionally, we reveal that early visual cortex contains pattern representations specific to the illusory state, irrespective of tactile stimulation and under identical feedforward visual input. In Chapter 4 we use the motion-induced blindness illusion to demonstrate that feedback modulates stimulus representations in V1 during illusory disappearance. We recorded fMRI data from subjects viewing a 2D cross array rotating around a central axis, passing over an oriented Gabor patch target (45°/ 135°). We attempted to decode the target orientation from V1 when the target was either visible or invisible to subjects. Target information could be decoded during target visibility but not during motion-induced blindness. This demonstrates that the target representation in V1 is distorted or destroyed when the target is perceptually invisible. This illusion therefore has effects not only at higher cortical levels, as previously shown, but also in early sensory areas. The representation of the stimulus in V1 is related to perceptual awareness. Importantly, Chapter 4 demonstrated that intracortical processing can disturb constant feedforward information and overwrite feedforward representations. We suggest that the distortion observed occurs through feedback from V5 about the cross array in motion, overwriting feedforward orientation information. The flashed face distortion illusion is a relatively newly discovered illusion in which quickly presented faces become monstrously distorted. The neural underpinnings of the illusion remain unclear; however it has been hypothesised to be a face-specific effect. In Chapter 5 we challenged this account by exploiting two hallmarks of face-specific processing - the other-race effect and left visual field superiority. In two experiments, two ethnic groups of subjects viewed faces presented bilaterally in the visual periphery. We varied the race of the faces presented (same or different than subject), the visual field that the faces were presented in, and the duration of successive presentations (250, 500, 750 or 1000ms per face before replacement). We found that perceived distortion was not affected by stimulus race, visual field, or duration of successive presentations (measured by forced choice in experiment 1 and Likert scale in experiment 2). We therefore provide convincing evidence that FFD is not face-specific and instead suggest that it is an object-general effect created by comparisons between successive stimuli. These comparisons are underlined by a fed back higher level model which dictates that objects cannot immediately replace one another in the same retinotopic space without movement. In Chapter 6 we unify these findings. We discuss how our data show fed back effects on perception to produce visual illusion; effects which cannot be explained through purely feedforward activity processing. We deliberate how lateral connections and attention effects may contribute to our results. We describe known neural mechanisms which allow for the integration of feedback and feedforward information. We discuss how this integration allows V1 to represent the content of visual awareness, including during some of the illusions presented in this thesis. We suggest that a unifying theory of brain computation, Predictive Coding, may explain why feedback exerts top-down effects on feedforward processing., Lastly we discuss how our findings, and others that demonstrate feedback and prediction effects, could help develop the study and understanding of schizophrenia, including our understanding of the underlying neurological pathologies.

Objective: Is it feasible to recruit mothers with infants in a neonatal unit (NNU) to engage in 14 days of data collection and use of relaxation? Background: In a NNU mothers may express breast milk for their infant. The NNU has specific stressors, which may impact on emotional wellbeing and ability to provide expressed milk. Relaxation significantly increased the quantity of expressed milk for American mothers. This has not been replicated in the UK, where rates of breastfeeding are low, therefore a feasibility study is needed. Method: A random allocation (treatment as usual vs relaxation), repeated measures design was used. Mothers providing expressed milk were eligible to participate. If mothers chose not to participate their reasons were recorded. Mothers accessed relaxation through a MP3 or personal CD. Mothers completed expression logs (14 days), Edinburgh Postnatal Depression Scale, and Parental Stressor Scale: Neonatal Intensive Care Unit (day 1,7 and 14). Mothers answered questions about their use of relaxation after 14 days. Results: 192 mothers were eligible to participate. Fifteen mothers were recruited (Relaxation n=8, TAU n=7) in 6 months. One dropped out from each group. Not having enough time was the most commonly reported reason for not participating. 100% (n=7) of mothers who used relaxation would recommend it to other mothers. Only 28% (n=2) believed the practice helped them feed their infant. Mothers reported the intervention could be improved by making better use of technology. Due to a small sample no inferential statistics could be completed on milk or emotional wellbeing data. Conclusions: Due to the importance mothers placed on their time, the accessibility of research information and relaxation are discussed. Suggestions of how to reduce barriers in future research, which could determine if relaxation supports mothers’ emotional wellbeing and milk production, are made.

Background: Impairments in executive functioning and autobiographical memory (AM) are common in people with schizophrenia spectrum disorders (SSD). There is a need for greater understanding of how neurocognitive factors such as these relate to recovery. This is important because improving treatments requires better understanding of the psychological process involved in recovery from SSD. Aims: We aimed to determine the feasibility of assessing AM and metacognitive functioning in the acute phase of psychosis during inpatient admission. Relationships between neuropsychiatric measures and autobiographical memory were explored with a view to refining the use of this assessment battery with participants who are acutely psychotic. Methods: Twelve people diagnosed with a schizophrenia spectrum disorder were recruited from adult inpatient psychiatric wards shortly after admission. They completed the Autobiographical Memory Interview, Indiana Psychiatric Illness Interview, Hayling Sentence Completion Task, BMIPB Story Recall Task and the Positive and Negative Syndrome Scale (PANSS) interview in baseline assessment. Four participants were re-tested prior to discharge and rated their own recovery using the Questionnaire on the Process of Recovery. Ward clinicians also rated recovery in terms of symptom remission for eleven of the participants. Results: A moderate correlation between metacognition and semantic AM (r=.716) was identified at baseline. Correlations of moderate strength were identified between clinician ratings of recovery and metacognition (r=-.725) and PANSS (r=.877) scores at baseline assessment. Conclusions: The study faced difficulties recruiting sufficient numbers of eligible participants at baseline and retaining them to allow for follow up assessment. Hence, the results are preliminary but the data do suggest possible neuropsychological correlates of recovery from acute psychosis. If the recruitment and retention issues could be addressed, this paradigm could be applied to a larger sample to test the findings of this pilot study.

Health, social, and economic burden related to schizophrenia is significant for both patients and wider society (Knapp, 2000; Chong et al., 2016). Depression is common in people with schizophrenia (Whitehead et al., 2002) and is associated with particularly high levels of health care use (Steel et al., 2015). Developing and disseminating cost-effective interventions for people with depression in the context of psychosis is therefore indicated. The ADAPT trial was a pilot randomised controlled trial (RCT) of Acceptance and Commitment Therapy for depression after psychosis (ACTdp) for individuals with a diagnosis of schizophrenia who also met diagnostic criteria for major depression (Gumley et al., 2015; Gumley et al., 2017). A total of 29 participants were randomised to ACTdp+ Standard Care (SC) (n=15) or SC alone (n=14). The aim of the present study was to explore outcomes relating to cost-effectiveness of ACTdp and to consider the feasibility of conducting an economic evaluation alongside a larger, definitive trial. Cost-effectiveness was explored in a cost-utility analysis (CUA) with quality-adjusted life years (QALYs) as the primary outcome. QALYs were calculated from the EuroQol (EQ-5D-5L) and cost data were collected using the Client Service Receipt Inventory (CSRI). The incremental cost-effectiveness ratio (ICER) for ACTdp was £8,339 which falls below the assumed threshold of £20,000 per incremental QALY used by NICE (2012). A trend towards better outcomes and partial cost-offsets in the ACTdp group suggests that ACTdp may be a cost-effective treatment and that a larger, definitive trial to explore this further would be justified.

Objectives. Recent literature indicates variance in psychosocial treatment preferences for negative symptoms of schizophrenia. Attempts at defining therapeutic aims and outcomes for negative symptoms to date have not included major stakeholder groups. The aim of the present study was to address this gap through qualitative methods. Design. Thematic Analysis was applied to qualitative semi-structured interview data to gather the opinions of people who experience negative symptoms, carers, and healthcare professionals. Participants were recruited from two mental health sites (inpatient/community) to increase generalisability of results. Ten people participated in the research. Methods. Semi-structured interview scripts were designed utilising evidence from the review in Chapter 1 of effective psychosocial intervention components for specific negative symptoms. Interviews were audio recorded and transcribed verbatim. Thematic analysis was employed to analyse data. Results. A common theme across groups was the need for a personalised approach to intervention for negative symptoms. Other themes indicated different opinions in relation to treatment targets and the need for a sensitive and graded approach to all aspects of therapy. This approach needs to be supported across systemic levels of organisation with specific training needs for staff addressed. Conclusions. There is disparity in treatment preferences for negative symptoms across major stakeholders. The findings suggest an individualised approach to intervention of negative symptoms that is consistent with recovery. Implementation barriers and facilitators were identified and discussed. There remains a need to develop a better understanding of treatment preferences for patients.

Introduction: It has been argued that a capacity for metacognition in relation to others could be a key underpinning quality required in a mental health worker to develop positive therapeutic relationships. It is likely that forensic mental health staff are exposed to difficult and potentially threatening situations as a result of their patients’ complex backgrounds and risk. Aims: The study aimed to pilot and develop a methodology to explore and code metacognition and causal attributions in the context of staff reflecting on their experiences of resolved and unresolved therapeutic ruptures. In addition the study sought to explore associations between metacognition and measures of ward atmosphere and staff burnout. Methods: Twenty members of staff working within a medium secure forensic mental health service volunteered to participate in the study. Participants were asked to recall two experiences where there had been a rupture in the therapeutic relationship, one where the situation had been resolved, and one where it was unresolved. Participants also completed the Ward Atmosphere Scale (WAS) and the Maslach Burnout Inventory (MBI). Interviews were transcribed and coded using the Metacognitive Assessment Scale (MAS) and the Leeds Attributional Coding System (LACS). Results: Analysis of the MAS found that participants had significantly lower levels of metacognition for the unresolved situation than the resolved situation. Positive correlations were found between overall MAS scores and three of the WAS subscales. The majority of attributions made were where the patient was the Agent/Cause and the staff-member/speaker was the Target. Discussion & Conclusion: We were able to identify changes in metacognition across different experiences of ruptures in the therapeutic relationship. These findings have implications regarding the suggestion of further research on a larger scale with improved methodology. These studies may prove useful in developing methods to enhance staff metacognition in response to therapeutic ruptures.

Objective: Following transfer of responsibility of health care for people in prisons in Scotland to the NHS in 2011, there has been growing interest in understanding the service-need for people with head injury (HI). As an initial step, this review systematically assesses the literature on the prevalence of HI in people in prisons and the proportion of these with persisting disability. Methods: Searches were carried out using electronic databases (PsycINFO, Cochrane Databases, MEDLINE, EMBASE, Web of Science). Reference lists of two meta-analyses were checked for papers relevant to the prevalence of HI in adult prison populations. Results: Eight studies were included. They report HI prevalence in samples of prisoners of 25-86%. Quality was rated as low in seven (30-43%) and very-low in one (19%). One study reported upon disabilities associated with HI. Overall, these studies use a range of HI definitions, unrepresentative samples and do not use matched-controls. Conclusion: The prevalence of HI in prisoners remains unclear. This is linked to the low quality of study design and methods used. Service need is unclear because few studies consider whether disability has persisted after HI.

Developing a Scale for Assessing the Forensic Experience of Recovery: the SAFER questionnaire and Clinical Research Portfolio Abstract Background: A conceptual framework of recovery was developed through systematic identification of five key processes - Connectedness, hope/optimism, identity, meaning in life and empowerment (CHIME). There are increasing efforts to implement recovery focused interventions in forensic setting. To date there has not been a self-report recovery measure developed for this population. Aims: The primary aim was to develop a self-report recovery measure for forensic service-users, conceptually based on the Good Lives Model (GLM) of offender rehabilitation and the CHIME model of recovery. Secondary aims were to explore the concurrent validity, test-retest reliability and internal consistency of the measure. Method: The processes of recovery outlined in CHIME and the description of primary goods from the GLM were explored to identify overlapping constructs. When researchers reached a consensus on the connection between constructs, items for the questionnaire were developed. The questionnaire was titled SAFER (The Scale for Assessing the Forensic Experience of Recovery). A cross-sectional pilot study was devised to evaluate concurrent validity, test-retest reliability and internal consistency of the SAFER. Results: Forty-six forensic inpatients in low, medium and high secure facilities participated. Results show the SAFER had concurrent validity, good test-retest reliability and internal consistency. Conclusions: The findings offer preliminary evidence for the validity and reliability of the SAFER. Further, larger scale research is necessary to evaluate additional psychometric properties. Declaration of interest: none.

Background: People with psychosis display difficulties with autobiographical memory (AM). They also show poor awareness of deficits in cognitive ability; however, it is not yet known if this extends to awareness of deficits in AM. It is unclear if any awareness deficit is specific to AM or is part of a more general deficit in metacognitive ability. Alternatively, awareness deficits could be attributable to executive functioning problems. Deficits in these domains are also predicted to disrupt engagement in services. Aims: We aimed to test the degree to which patients were aware of deficits in AM and the extent to which this awareness, and their AM ability, were related to metacognitive ability. We also aimed to identify if AM for crime-related memories differed to that for general events and to study the impact of these factors on engagement in services. Methods: AM and metacognitive abilities were indexed using the AMI and the MAS-A. Awareness of AM abilities was operationalised as the discrepancy between self-ratings and actual performance. Cognitive functioning was also tested using a digit span, story recall, and ToPF. Staff members rated the service engagement of each participant using the SES. Results : Participants recalled recent events better than events from early adulthood or childhood. They judged that they were able to better recall offence histories than other life events. They exhibited a more impaired metacognitive ability than observed in a previous sample of healthy controls, and the results display a non-significant trend towards AM ability being related to metacognitive ability. Engagement was unrelated to metacognition or AM. Conclusions: We present preliminary evidence of an association between AM ability and metacognition; however, there are methodological limitations. This shows signs that there may be a benefit to conducting a larger sample size study in this area. It also allowed us to pilot and evaluate the methods, identifying ways in which research could be progressed in the future.

Objective: There is a growing body of research which demonstrates positive effects of Acceptance and Commitment Therapy (ACT) on a diverse range of psychological disorders (e.g. chronic pain, depression, psychosis). Several reviews suggest that ACT may benefit people struggling to adjust to life following a Traumatic Brain Injury; however there are no published treatment trials using ACT with this group. The present study examined the feasibility of an intervention trial of ACT for people with severe Traumatic Brain Injury (TBI) treated in an inpatient rehabilitation centre. The findings informed recommendations made for the design and conduct of a larger study. Method: Mixed quantitative and qualitative methods were used including Focus Groups and questionnaire measures. Data were collected from patients and unit staff at multiple time points across three research sites. Focus Group data were analysed using thematic analysis in accord with best practice guidelines. Questionnaires and forms completed by the staff in order to establish application of inclusion/exclusion criteria and participant flow were analysed descriptively to get an indication of the acceptability of features of the study protocol. Results; Focus group findings indicated that due to cognitive deficits exhibited by participants, they perceived the ACT intervention as being too complex, and a number of amendments were suggested to support participants with cognitive deficits in future trials such as increasing repetition of key processes during intervention. Further suggestions were made in relation to future conduct of the study protocol such as revising the inclusion/exclusion criteria, family involvement in data collection, and provision of easy read materials to clients. Results indicated that participants had no issue with the randomisation design, there were no adverse events associated with the study protocol or intervention. Conclusions: Further piloting of the amended intervention protocol in line with recommendations made in this study is recommended prior to drawing any conclusion with regard the suitability and acceptable of ACT with people with a severe TBI in an inpatient facility. Further research should consider the amendments to the study protocol as recommended in this study.

Since its discovery over a decade ago, DISC1 has become one of the most promising candidate genes for Schizophrenia and associated chronic mental disorders. This notion has been supported by a wealth of evidence from genetic and biochemical studies. With multiple interacting partners, DISC1 acts as a scaffold protein, orchestrating vital signalling pathways that underpin neurodevelopment and signalling. While the aetiology of Schizophrenia is poorly understood, loss of DISC1 protein function remains one of the proposed disease mechanisms. Furthermore, its tendency to form aggregates is reminiscent of neurodegenerative illnesses such as Alzheimer’s and Parkinson’s disease. C-terminal truncation of DISC1 (TrDISC1) is known to decrease neurite outgrowth and number in the PC12 cell line, abolish protein interaction with proteins such as Ndel1 and also disrupt vital physiological process such as mitochondrial transport. However, very little is known about the underlying disease mechanism at the molecular level. In order to gain insight in to the role of DISC1 pathway in Schizophrenia and associated mental illnesses, I studied novel post translational modifications of DISC1. The main conclusion of my thesis is that these modifications affect DISC1 turnover and its scaffold function. The work described in this thesis has uncovered 2 novel post translational modifications and identified the E3 ligase involved in regulating DISC1 turn over. My work has also laid the foundation for the design and discovery of both peptide and non-peptide, small molecule inhibitors of the DISC1 and its cognate E3 ligase interaction. These inhibitors can serve as both pharmacological tools and for further investigation of the role of this novel interaction in DISC1 pathway and the vital physiological functions it is involved in. Furthermore, this work also indicates the feasibility of controlled and directed differentiation of patient specific iPS cells in to neurons, which act as a useful tool for disease modelling.

Charting the trans-Atlantic movement of ‘dynamic’ psychiatry from The Henry Phipps Psychiatric Clinic, Baltimore, to Gartnavel Mental Hospital, Glasgow, this thesis throws light upon the resultant ‘dynamic’ case note records, produced in Gartnavel during the 1920s. By undertaking an in-depth, qualitative analysis of Gartnavel’s case note records and corresponding archival materials, I explore the polemical question, posed, amongst others, by Foucault, of how psychiatry achieves its distinct status as a science of the individual. Foucault, most notably in Discipline and Power, ascribes to the psychiatric profession the power to fashion individual patient histories into cases, cases which simultaneously emphasise the individuality of a patient, while condensing, i.e. ‘fixing’ their identities that they may be constituted ‘an object for a branch of knowledge and a hold for a branch of power’. This thesis, while recognising the validity of this argument, explores how the clinical practices and philosophical outlook of dynamic psychiatry in the early twentieth century enabled both patient and psychiatrist to negotiate the construction of the psychiatric case note record, and consequently of patients’ individual identities. D. K. Henderson, physician superintendent of Gartnavel between 1921 and 1932, was one of the first, if not the first psychiatrist fully to incorporate dynamic principles into the working practices of a British mental hospital. Initiating methods of case note taking and staff meeting consultation (now integral components of modern day psychiatric practice) he transported the teachings of his mentor, the Swiss émigré psychiatrist Adolf Meyer, to the everyday clinical practices of Gartnavel. The dissemination of dynamic psychiatry through Henderson’s published works and medical teachings is recognised as having integrally shaped the practices of Scottish psychiatry in the twentieth century. However, the significance of the unpublished case note records, produced under his superintendence of Gartnavel during the 1920s, as sources of historical enquiry has gone largely unrecognised. A near-unique archive of ‘dynamic’ case note records is used in this thesis to reveal, what Roy Porter termed, a ‘history from below’ of clinical practices and examinatory processes. For as Henderson employed stenographers and clinical clerks to record verbatim and semi verbatim the dialogues that passed between patients and psychiatrists within staff meetings and mental examinations, I, as Porter himself aspired to, take as the focus of my research a history of the ‘two-way encounters between doctors and patients’. By employing an interdisciplinary research method, one that incorporates Foucauldian, literary, critical medical humanities, as well as more traditional forms of medical history scholarship, I establish a history of dynamic psychiatry set within clinical encounters. Engaging with current debate, evolving primarily within the interdisciplinary sphere of the medical humanities, I argue these records reveal a history of medical humanism, one in which both patients and psychiatrists actively shaped the history of twentieth century Scottish psychiatry.

Objective: The present study aimed to investigate the factors relating to mood and cognition which influence a person’s ability to participate in rehabilitation after Acquired Brain Injury (ABI). It was hypothesised that impairment in cognition, including specific impairment in executive functioning and depression would be associated with poorer engagement in rehabilitation. Method: Twenty-nine patients undergoing rehabilitation following stroke (89.7%) or TBI (10.3%) participated. Individuals recruited completed the Hospital Anxiety and Depression Scale as a measure of mood and an executive functioning test battery. Data collection occurred over a two week period as concurrent ratings of participation were gathered from physiotherapists and occupational therapists using the Pittsburgh Rehabilitation Participation Scale. Results: In support of the hypotheses, correlation analysis showed a significant positive correlation between participation in rehabilitation with executive functioning (p < .05) and a significant negative correlation between participation in rehabilitation and low mood (p < .05). No association was found between general cognitive ability, functional disability, time since injury, age, gender and participation.

Objectives: To investigate proof of concept, feasibility and efficacy of an online Cognitive Behavioural Therapy (CBT) intervention, modified to appeal to Christians who may be reluctant to access secular mental health services. Methods: 52 volunteers with Christian beliefs experiencing low mood or anxiety were recruited (median age=46.5, 25% male) to a pilot randomised waiting-list controlled trial of an online Spiritually-integrated CBT resource, with assessments at baseline, 8 weeks and 12 weeks. Primary outcome measures addressed mood, anxiety and general functioning. Results: No significant differences were found between groups on improvement of primary outcome measures, however there were non-significant trends in favour of those who had access to the course compared with waiting list control on all primary outcome measures. Conclusion: Online CBT targeted at religious groups may be an effective and practical means of promoting evidence-based psychological interventions to individuals who may not otherwise access them.

Objective: Every year, an estimated 10 million people suffer a traumatic brain injury (TBI; Hyder, Wunderlich, Puvanachandra, Gururaj, & Kobusingye, 2007). Refugees and asylum-seekers fleeing persecution have often experienced war and torture and are at a greater risk of TBI (Priebe & Esmaili, 1997). Following a TBI, cognitive, behavioural and psychosocial difficulties can significantly impact on independence (Cohen, 2001). This preliminary study investigated whether cognitive function is poorer in refugees and asylum-seekers who report a severe TBI, compared to those who do not. The study also compared cognitive performance in refugees and asylum-seekers attending mental health services with Western controls from normative data. Assessing the cognitive performance of this group against Western expectations is important, to inform the clinical work as well as UK asylum law and policy. Methods: The study employed a between-subjects design, comparing 14 refugees and asylum-seekers with a self-report of one or more severe TBIs and 11 without a history of TBI. Participants attended for one assessment session and completed the Colour Trails Test (CTT; D’Elia, Satz, Uchiyama, & White, 1996) as well as other cognitive tests. Where necessary, an interpreter was present. Results: Refugees and asylum-seekers who self-reported a history of severe TBI were not more cognitively impaired on the CTT than those without TBI. The combined groups performed significantly worse on the CTT compared to normative data. Conclusions: This preliminary study suggests that refugees and asylum-seekers attending mental health services are performing much poorer cognitively than healthy Western counterparts. This highlights the value of assessing cognition in this complex group, as on a case-by-case basis, results informed the practice of mental health clinicians and GPs. Furthermore, these results raise issues about the expectations placed on cognitively impaired individuals throughout the asylum process if these expectations are based on experience of cognitive function typical of that represented by Western norms. Additional research may instigate policy-makers to make adjustments to the asylum process to better acknowledge mental health and cognitive impairment.

Objectives: The use of formulation in teams is becoming increasingly established. Yet, research into this area is still limited. This study set out to explore team formulation from multiple perspectives in the context of an early intervention first episode psychosis service. Method: A social constructionist version of grounded theory was used to explore experiences of team formulation and care of fifteen participants (clinical psychologists, other multidisciplinary team members, and service-users), using semi-structured interviews. A phased approach to data collection and analysis facilitated theoretical sampling and triangulation. Transcripts were subjected to line-by-line and focused coding to support the development of categories grounded in the data. Results: An emerging model of team formulation arose from the data, comprised of two levels - ‘value and function’ and ‘processes’ - that were interrelated and made up of sub-themes. ‘Value and function’ of team formulation ultimately was to improve engagement and care for service-users at risk of arrested recovery. This was seen to be facilitated by ‘constructing understanding’ and ‘broadening perspectives’, resulting in ‘flexibility, consistency and empathy’ that allowed for person-centred care planning and the establishment of better relationships with service-users. Team formulation involved and required staff to ‘negotiate roles’ and ‘manage uncertainty’. The data indicated the importance of a system or space that promotes the development of mutuality of meaning and shared understanding. Conclusions: This study indicated the systemic value of team formulation in supporting people who have difficulties engaging with services and staff working with them. The emerging model derived provides a meaningful departure point to develop a more comprehensive theory of team formulation that could provide a foundation for improving, developing and disseminating this practice.

Objectives: 1) To gain an in-depth understanding of fathers’ experiences of having their preterm infant hospitalised in a Scottish Neonatal Intensive Care Unit, and 2) to develop a clearer understanding of fathers’ support needs. Methods: Six fathers of infants cared for in a Scottish Neonatal Intensive Care Unit completed semi-structured interviews about their experiences. Interpretative Phenomenological Analysis was used to identify themes emerging from these interviews. Results: Six overarching themes were identified: 1) adjusting to the demands of the situation, 2) relationships with staff, 3) technology: a divided opinion, 4) becoming a father, 5) emotional reactions, and 6) adaptive responses. Conclusion: This study offers an in-depth understanding of fathers’ experiences of having their preterm infant cared for in a Scottish Neonatal Intensive Care Unit, and has helped to develop a clearer understanding of fathers’ support needs. Findings: (1) validate the relevance of the constructs of support outlined within an existing conceptual model of parents’ support needs (the Nurse Parent Support Model) for fathers in the NICU, (2) justify modifications to the existing model to incorporate additional forms of support which are not currently included, and (3) indicate how this revised model could be implemented in clinical practice to inform the provision of Family Centred Care and thus promote parent and infant wellbeing.

Research suggests that the roots of psychopathy are evident in youth. Studies have consistently shown psychopathy to be associated with a myriad of adverse outcomes including violence and antisocial behaviour. Thus, the early identification of psychopathic traits may facilitate early intervention and risk management strategies. A diagnosis of psychopathy has important clinical and legal implications. Thus, it is crucial that measures used to assess psychopathy are valid and reliable. This study investigated the inter-rater reliability (IRR) of the Psychopathy Checklist Youth Version (PCL: YV). Several studies have highlighted sources of rater bias with adult measures of psychopathy, amongst other measures. Therefore, this study also addressed whether IRR was associated with the rater’s professional characteristics or the severity of cases presented. Six case vignettes were developed (two with low, two with moderate and two with high levels of psychopathic traits). These were rated by experts in the field. Nineteen multidisciplinary health professionals recruited from relevant services participated in this study. All participants attended training on the PCL: YV and then rated the case vignettes using the PCL: YV and completed a Staff Information Questionnaire. This study found high IRR overall for the PCL: YV. However, lower IRR was obtained for particular items (“Impulsivity”, “Poor anger control”, “Early behaviour problems”) and the moderate cases. The rater’s professional characteristics were not found to influence IRR. Potential explanations for these findings are discussed followed by recommendations for future research.

Background: Electroconvulsive therapy (ECT) is prescribed in cases of severe and treatment resistant depression. Its efficacy in reducing depressive symptoms is well established, but due to uncertainty regarding its impact on cognitive functioning, remains one of the most controversial treatments in psychiatry. The experiences of patients undergoing ECT are rarely examined, and studies that have investigated this are generally conducted with younger adults using quantitative methods that may obscure the expression of complex attitudes. Aims: The present study investigates older adults’ experiences of ECT in Scotland using a qualitative methodology. Methods: Four older adults (over 65 years of age) who had experienced ECT within the last five years were interviewed. Interpretative Phenomenological Analysis (IPA) was used to explore participants’ experiences of ECT. Results: Three superordinate themes emerged from the data: experience of depression, power and control, and changing beliefs about ECT. Conclusions: Recommendations are made for clinicians and healthcare providers. 1) Information about ECT should be provided in an oral format on a one to one basis, 2) medical professionals should be alert to the possibility of coercion, 3) action should be taken to reduce anticipatory anxiety regarding ECT’s potential impact and 4) meeting patients for up to two sessions after undergoing ECT may be beneficial. These recommendations can be used to contribute to existing improvements in delivery of care and treatment for older adults receiving ECT.

Background: Acceptance and Commitment Therapy (ACT) aims to help individuals live a life congruent to their values by cultivating psychological flexibility (PF); the ability to respond to experiences with acceptance and creativity. Concurrently, Compassion Focused Therapy (CFT) addresses the role of self-attacking cognitions on psychological difficulties. Recent work suggests that integrating aspects of CFT into an ACT approach (i.e. developing a person’s PF to self-attacking thoughts through self-compassion) may offer additional therapeutic value. There remains no assessment of this specific therapeutic process. Aims: The project aimed to develop and validate a new scale to assess flexibility of responses to self-critical thoughts (FoReST). Methods: Factor Analysis was used to explore factor structure of the FoReST in a convenience sample of 253 adults. Construct validity was explored by comparing FoReST with measures of similar constructs (PF, self-compassion, self-criticism) and potentially related outcomes (anxiety, depression, quality of life). Findings: Alternative 2-factor (‘unworkable action’ and ‘avoidance’) and 1-factor (‘unworkable action’) versions of the FoReST showed high concurrent validity with similar measures, good predictive validity for mental health and wellbeing outcomes and good internal consistency. The relative strengths and weaknesses of both versions are discussed. Recommendations: Findings indicate that the FoReST may offer a useful clinical and research tool for emerging forms of ACT for people high in self-criticism. Future research will be required to confirm the factor structure of the FoReST, confirm concurrent, predictive validity, test-retest reliability, and validate the scale in relevant clinical populations.

Background: Many studies have found little relationship between performance on traditional neuropsychological tests and measures of everyday functioning in people with brain injury. Computerised assessment measures incorporating more complex and life like scenarios may provide greater accuracy and ecological validity. The aim of this study was to investigate the ability of a computerised measure of executive function to assess planning and prospective memory deficits in a sample of people with brain injury when compared to questionnaire and traditional neuropsychological measures. Methods: Twenty-two individuals with acquired brain injury completed a computerised multiple errands test (C-MET), questionnaire measures of everyday difficulties (e.g. Dysexecutive Questionnaire; DEX) and traditional measures of executive functions including the Zoo Map test and The Stockings of Cambridge (SOC). Exploratory analysis compared relationships between performance on planning and prospective memory subcomponents of the C-MET with the other measures of executive function included in this study. Further analysis compared performance of the brain injury group with data from a sample of 46 healthy controls collected as part of a normative study. Results: C-MET was positively correlated with both the Zoo Map and Stocking of Cambridge tests. Compared with a sample of healthy controls, the brain injury group performed significantly worse on C-MET planning and PM measures and the Zoo Map test. Performance on C-MET Planning and PM and self-rated questionnaire measures were significantly correlated, but contrary to hypotheses, better performance on C-MET was associated with increased reports of difficulty in daily life. Conclusions: Results of this study offer support for the construct validity of C-MET as a measure of executive functioning. However the C-MET’s ability to distinguish between PM and Planning constructs and to predict difficulties that individuals with brain injury experience in everyday life was not supported.