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

Individuals who are at high-risk of developing psychosis can experience distressing thoughts, feelings and behaviours. This can include hearing or seeing things that others cannot, having unusual beliefs or distrustful thoughts. These experiences can vary in terms of intensity, frequency and duration but are often reported as distressing. They are typically reported during late adolescence or early adulthood, when individuals may still be living at home with their family. They may impact on an individual's relationships with their family and how family members communicate with them. Research typically focuses on the outcomes for individuals, whilst the experiences of family members or other caregivers (family/carer) are often unknown. The research included: 1. What we know so far about the attitudes, behaviours and communication in the family environment. 2. Critical comments and controlling behaviours of family members (questionnaires completed by individuals and family/carers). 3. Individuals' and family/carers' depression and anxiety (self-report questionnaires), and individuals' symptoms (structured assessment). 4. Family/carers' experiences (interviews). Critical comments and controlling behaviours were found in this population. The more critical comments and controlling behaviours that individuals reported, the more likely that they would experience long-term depression and intensified unusual beliefs and experiences (psychotic symptoms). Family/carers may experience increased worry, emotional isolation and lack confidence in their caregiving role. The author discusses the mixed-methods approach as a strength of the research. A limitation is that the majority of participants were White British mothers, and therefore the results may be different in other cultures or socio-ethnic backgrounds. In summary, involving family/carers in sessions that focus on communication and relationships, as well as developing educational resources could have long-term benefits for service users, family members and services.

Background and objectives: Despite a large amount of literature on parents in academia, to date there has been limited empirical research into the area of returning to work after parental leave. This study is original in looking at this topic from the perspective of UK based academics. Given the stressors faced by parents who return to work after parental leave, it is important for counselling psychologists to look into this issue. Therefore, the overarching purpose of this study was to explore academic mothers and fathers' experiences of returning to work after parental leave in a research-intense University. Method and analyses: A qualitative design was employed to explore the experiences of returning to work after parental leave of fifteen academic parents across the whole institution. Semi-structured interviews were conducted, and the transcripts were analysed using the reflexive thematic analysis approach. Findings: Qualitative findings highlighted five themes within the data: 'Concerns about returning to work', 'Adjustments to new work patterns', 'Organisational factors influencing return to work', '(Perceived) division of childcare responsibilities' and 'Impact on career progression'. Conclusions: The key areas which influenced the experience of returning to work after parental leave were: the access to paid parental leave; the experience of flexibility that academic work entails and the negotiation of academic and parenthood identity and roles. Potential implications for counselling psychology and organisations, limitations and suggestions for further research are discussed.

Rationale: Evidence suggests that from early adolescence, girls and women experience greater rates of emotional symptoms and disorders, while recent evidence indicates increased emotional distress among adolescent girls. The current study set out to examine the factors and processes contributing to and mitigating emotional symptoms among early adolescent girls, with an emphasis on multiple risk exposure, and to explore how these phenomena are experienced. Methods: A pragmatic parallel mixed methods design was used. A quantitative strand included 8,327 girls aged 11-12 years, comprising both self-report and demographic data, and was analysed using structural equation modelling. A qualitative strand explored the lived experience of three girls aged 12 years, analysing accounts gathered through semi-structured interviews using interpretative phenomenological analysis. Quantitative Results: Results indicated four risk factors: Low academic attainment, special educational needs, low family income, and caregiving responsibilities. Exposure to a greater number of risk factors was associated with increased symptoms, though a latent risk construct incorporating both the nature and extent of multiple risk exposure showed the greatest predictive utility. Multiple risk effects were found to be associated with emotional symptoms entirely through indirect effects via components of stress appraisal processes. Family adult connection, school peer connection, and active engagement in home and school life were associated with lower levels of emotional symptoms. Family adult connection and school peer connection were found to be protective in relation to the effects of multiple risk exposure upon perceived stress components. Qualitative Findings: Four superordinate themes were developed: The experience of symptoms, which captures the ways participants conceptualised and experienced the thoughts and feelings associated with symptoms; internal grappling, which explores participants' conflict in understanding these symptoms in relation to themselves as well as the outer world; demands and control, which explores participants' experiences of persistent demands perceived to be beyond their control; and drawing on others, exploring the ways participants mapped out and drew on an emotional support network. Meta-Inferences: Quantitative and qualitative findings were integrated to develop three meta-inferences: (1) Emotional symptoms are embedded in daily life, (2) demands and stress can be psychologically overwhelming, and (3) close relationships are critical. The theoretical, methodological, and practical implications of findings are explored and directions for future research are discussed.

Reflecting teams have become one of the most common interventions in the area of systemic family therapy. Thorn (2008) surveyed 130 systemic family practitioners in the UK and found that 92% of respondents used reflecting teams for approximately one third of therapy time. However, the evidence base in this area is sparse and demonstrates many variations in practice (Biever & Gardner, 1995) as well as difficulties with the approach (Lever & Gmeiner, 2000). In addition, many psychologists, after completing doctoral training who work and specialise in the area of systemic practice using reflecting teams, receive little or no doctoral preparation to do so (Stanton, 2009). Reichelt & Skjerve (2013) in their study with trainee clinical psychologists using reflecting teams, found that participants expressed desires for supervisors to take on a more directive skills training in relation to using reflecting teams in systemic family therapy. Thus the present study explored firstly, how psychologists, with a prior experience in using reflecting teams in systemic family therapy, experience and make sense of using reflecting teams. As a secondary aim, this study explored how these psychologists experienced training in systemic family therapy. After seeking university ethical approval where consideration of ethical issues such as confidentiality and anonymity were detailed and measures to address these were put in place, after obtaining approval, data collection began. Five qualified psychologists based in the UK who had experienced working in systemic family therapy with reflecting teams, were invited to discuss their experiences of reflecting teams and training in systemic family therapy. Data was collected through semi structured interviews and analysed using Interpretative Phenomenological Analysis (IPA). Five superordinate themes were identified in the participants' narratives, these were: 'practising reflexivity', 'helpful discomfort', 'reflecting team roles', 'inspecting reflections' and 'creating something new and different'. Three superordinate themes, namely, 'helpful discomfort', 'reflecting team roles' and 'inspecting reflections' highlighted participants' experiences of the reflecting team as generating ideas on inter team dynamics. Subordinate themes such as 'team difficulties' and 'reflection protocols' revealed how participants' experiences of being in a team generated ideas related to the professional experience of other team members, role positions of reflecting team members, as well as implicit reflecting protocols. Subordinate themes named 'the reflecting team as helpful for learning' and 'new ways of thinking since training' shed light on the learning experience that reflecting teams facilitated providing a unique opportunity for live feedback. Implications of the study are discussed in relation to awareness of inter team dynamics occurring in the experience of using a reflecting team as well as the usefulness of the reflecting team for experiential learning. This research offers new and original insights for psychologists working in systemic family therapy, specifically how the experiences of using reflecting teams generated thoughts and ideas on inter team dynamics as well as the experiential learning and ongoing training that the experience of the reflecting team provides.

The aim of this thesis was to compare and contrast voice-hearing and meaning-making in Black clinical and Black Evangelical non-clinical voice-hearers. It is presented as three papers: (1) a thematic synthesis of the qualitative research of how religiosity and spirituality can positively impact people with psychosis; (2) an empirical qualitative study comparing and contrasting voice-hearing and meaning-making in Black clinical and Black Evangelical non-clinical voice-hearers; and (3) a paper presenting a critical appraisal and personal reflections on the research process. In the systematic review paper, 10 studies were identified that met the inclusion criteria. Whilst studies varied in quality, they were generally medium to high quality papers. A thematic synthesis identified three key themes: (1) religion and spirituality as a positive framework for understanding psychosis; (2) religious and/or spiritual practices for managing psychosis; (3) having faith instils hope for the future. These findings highlighted how religion and spirituality can be an important part of the lives of people living with psychosis. The second paper compared and contrasted voice-hearing and meaning-making in Black clinical and Black Evangelical non-clinical voice-hearers. Sixteen participants (eight clinical and eight non-clinical) engaged in interviews. A thematic analysis described three superordinate themes that described both groups' experiences: (1) nature of voices; (2) meaning-making and (3) the impact. These findings highlighted the similarities and differences between Black clinical and Black Evangelical non-clinical voice-hearers. The third paper provides further explanation of both papers, reasons for the decisions made and a critical appraisal of the work carried out, considering the wider context of clinical practice, theory and empirical evidence. Personal reflections on the research process as a whole are discussed.

Background: The scientist-practitioner (S-P) model is in the heart of the identity of clinical and counselling psychology. The framework was developed to facilitate the integration between science and clinical practice, as well as competence in both. However, the research that has focused on the scientist-practitioner identity of qualified psychologists is minimal, since the S-P has been treated as a model of training. Objective: The purpose of this study was to explore how experienced clinical and counselling psychologists relate to the scientist-practitioner model in their career. This topic was narrowed down to professionals working with psychological trauma. This professional area was selected as a substantial amount of research has contributed to its evidence base and development of clinical guidelines, making discussions about the implementation of research more transparent in the research interviews. Method: A single method qualitative design was employed. Thematic Analysis was used to analyse the 14 research interviews of 7 counselling psychologists and 7 clinical psychologists. Participants had a minimum of 2 years of work experience post-qualification and a collective average of 4.9 years of employment as qualified psychologists. Findings: The findings were conceptualised as a spectrum of epistemological and professional identities through which five superordinate themes emerged: The Scientist, the Aspiring Scientist, the Artist-Scientist, the Aspiring Artist, and the Artist. The study findings suggest that all participants identified as S-Ps, but their interpretations of the model and what constitutes science varied. Qualitative characteristics were identified to describe each theme. Professional issues and socio-political barriers to fully actualising the S-P were identified and discussed. Discussion: Patterns of more similar responses were observed when the participants shared a work setting, such as academia. The findings of this study lead to the further conceptualisation of the data portraying a philosopher-practitioner, instead of a scientist-practitioner. The stance of a philosopher-practitioner would be better at acknowledging and addressing the individual differences. If the artist-scientist spectrum is thought of as a critical realist-naïve realist spectrum, then the ontological and epistemological positioning of the participants would probably reflect their current role, worldview, and activities, as well as their interpretation of science.

Functional impairments, including global and social functioning, are reportedly prevalent in people who experience serious mental health problems (SMI), including people who receive diagnoses of psychosis, bipolar disorder and personality disorders. Impairments in functioning can have wide-reaching implications, both for the individual and for mental health professionals working with SMI. Given the impact on functional impairments on a person's mental health and well-being, it is important to explore potential psychological factors that might contrite to impairments in functioning to inform psychological assessment, formulation and intervention for people with SMI. Paper 1 presents a systematic literature review investigating the association between attachment and functioning for people who experience SMI. A comprehensive systematic search of the literature returned 10 empirical research studies. A critical appraisal of the studies was conducted whilst synthesising the findings. The findings were mixed: secure attachment was associated with better functioning, whilst an insecure attachment style was associated with impaired functioning in some studies but not in others reviewed. The studies were largely heterogeneous in terms of population, design and measures used. The findings are considered in relation to methodological limitations, clinical implications and recommendations for future research. Paper 2 is an original empirical study focusing specifically on the SMI population of psychosis. The study investigated the potential mediating role of insecure attachment and emotion recognition in the relationship between childhood trauma and social functioning. Sixty participants with psychosis were recruited to the study and completed measures of childhood trauma, attachment, emotion recognition and social functioning. Childhood trauma was associated with social functioning; however, neither insecure attachment nor emotion recognition mediated this relationship. The findings are discussed in light of methodological limitations and clinical implications are presented. Paper 3 provides a critical evaluation of the research process including reflections on decisions made regarding the design, methodology, recruitment process, and analysis of papers one and two. Personal reflections on conducting the research are also presented.

The aim of this thesis was to understand more about the potential applicability and utility of the Psychodynamic Interpersonal Therapy (PIT) model in chronic pain. The thesis is presented as three separate papers. In Paper One we present a narrative review setting out the theoretical and empirical case for PIT as a treatment in chronic pain. We describe the central tenets of the PIT model and present evidence demonstrating their applicability in chronic pain populations. The practical elements of the model are then described with reference to how they can be used to improve clinical outcomes in people with chronic pain. We conclude by comparing and contrasting PIT with other approaches to chronic pain and considering the clinical and empirical implications of the model. Paper Two is an empirical investigation examining the feasibility, acceptability, and safety of PIT as a treatment in chronic low back pain (CLBP) patients, and a preliminary evaluation regarding its efficacy as an approach. A case series of six sessions of PIT with eight participants with CLBP was conducted. An A-B replication design with multiple baseline and follow-up was used. Results suggest that PIT is feasible, acceptable and safe for use with CLBP; indicated by high attendance and adherence to treatment protocol, high satisfaction questionnaire ratings and no reported adverse events. Substantial improvements were observed for depression and to a lesser extent for interpersonal problems. Pain distress ratings were stable throughout. Clinical outcomes indicate that PIT may reduce depression and interpersonal difficulties in chronic pain. Finally, Paper Three is a critical reflection of the processes involved in conducting the project. This paper provides further detail on the methodology and decision making processes which took place within the research, alongside considering the strengths, limitations, and suggestions for future research. This paper concludes with personal reflections on the thesis project.

This thesis investigated the psychological factors associated with distress in the early stages of psychosis. The first chapter is a systematic review and meta-analysis of the literature assessing the comorbidity rates of both depression and anxiety in first-episode psychosis (FEP). Prevalence rates were shown be similar between depression and anxiety for included studies, suggesting that both anxiety and depression should be targeted for intervention, together with the psychotic symptoms. The second chapter is a secondary analysis of clinical trial data investigating the relationship between distress, severity and frequency of attenuated psychotic symptoms in individuals meeting ultra-high risk criteria for psychosis (UHR), both cross-sectionally and over time. A confirmatory factor analysis (CFA) and latent growth curve (LGC) models were applied to assess the study aims. The impact of cognitive behavioural therapy (CBT) on distress reduction over time by symptom was also assessed which did not significantly reduce distress compared with monitoring. Overall distress reduced over time, particularly in the first three months after presentation, although this was dependent on the type of psychotic symptom. The final chapter provides a critical appraisal of the previous chapters and overall research process. In conclusion, this thesis recommends that distress should be used as an outcome in future clinical research and as a clinical indicator to guide professional involvement.

Neuroinflammation and dysregulation of glutamate in schizophrenia A thesis submitted to the University of Manchester for the degree of Doctor of Philosophy in the Faculty of Biology, Medicine and Health by Catherine J Gregory, June 2019 Background: Schizophrenia is a mental illness with a lifetime prevalence of 7 in 1000 people. In some, symptoms can persist despite treatment with antipsychotic medication, leading to a poor quality of life. There has been a drive to better understand the pathophysiology behind schizophrenia, with the hope of developing more effective treatments. There is good evidence for a role of hypofunction of the glutamatergic N-methyl-D-aspartate receptor (NMDAR) in schizophrenia, as well as for a role of neuroinflammation. However, how these processes may vary across the illness duration and with antipsychotic exposure is unclear. In particular, how these processes may be linked is uncertain. There is emerging evidence that they may be linked via neuroinflammation-mediated activation of the kynurenine pathway of tryptophan degradation and the production of neuroactive metabolites such as the endogenous NMDAR antagonist kynurenic acid. However, no study to date has measured neuroinflammation and NMDAR hypofunction in the same patients. Methods: Patients with recent onset (n=20) and chronic (n=21) schizophrenia were recruited along with age- and sex-matched healthy controls (n=19). Positron emission tomography (PET) and the 18kDa translocator protein (TSPO) radioligand [11C]-(R)-PK11195 measured TSPO availability as an indication of microglial activation, a putative measure of neuroinflammation. 1H magnetic resonance spectroscopy (MRS) measured concentrations of glutamate, glutamine and gamma-aminobutyric acid (GABA) as an indication of NMDAR function, as well as myo-inositol, a putative glial marker. Results: In the first study of its kind, we found a positive correlation between TSPO availability and glutamate in antipsychotic-free patients with recent onset illness, which was not present in antipsychotic-exposed or chronic patients. We also found a reduction in TSPO availability in antipsychotic-free recent onset schizophrenia compared to controls but no difference in antipsychotic-exposed or chronic patients. We found no difference in glutamate, glutamine or GABA between recent onset or chronic schizophrenia and controls. We found a weak positive correlation between myo-inositol and TSPO availability in schizophrenia but no difference in myo-inositol concentration between patients and controls. Conclusions: Our results provide evidence for a link between TSPO availability and glutamate concentration in antipsychotic-free recent onset schizophrenia. This association appears to be moderated by antipsychotic medication. The lack of group differences in TSPO availability or glutamate suggest that significant neuroinflammation leading to glutamatergic dysfunction may only be present in a subset of schizophrenia, such as those with treatment resistance. Further investigation is needed in this cohort of patients. We also found preliminary evidence in support of a role for myo-inositol as a potential MR marker of microglia, but further confirmatory evidence is needed.

It is estimated that 793,000 people world-wide died from suicide in 2016. Suicide has a devastating effect on families, friends, workplaces, schools and communities, as well as an economic cost. Cognitive Behaviour Therapy (CBT) has been found to be an effective treatment for suicide prevention. Paper one provides contemporary evidence for the effectiveness of CBT for reducing suicide ideation and behaviour across the lifespan. A systematic review was conducted with twenty-five papers identified. Nineteen out of the 25 included papers concluded that interventions involving a substantial element of CBT lead to significant reductions in suicide outcomes. Clinical and theoretical implications are discussed. Paper two investigates how the main therapeutic components of CBT skills and therapeutic alliance may have a role in reducing suicide behaviour and its correlates. There was no evidence to suggest that the presence of increased key CBT skills or therapeutic alliance was related to improved suicide outcomes. However, there was evidence that CBT for suicide prevention improved outcomes with the highly selected sample. Future recommendations are discussed in line with study limitations. Paper three critically reflects on the journey of conducting a doctoral thesis. This paper provides the opportunity to consider more deeply the decision making processes involved and lessons learned.

Paper one provides a systematic review of the literature, which sought to identify measures of adult disorganised attachment and critically appraise the methodological quality relating to each psychometric property and the reported psychometric properties of the measures. The review further aimed to summarise and grade the overall quality of the evidence of each measurement property per instrument. Eighteen measures were identified from twenty-seven papers that met the eligibility criteria for this review. Measurement properties were promising for the Childhood Disorganisation and Role Reversal Scale, Psychological Treatment Inventory-Attachment Styles Scale, Attachment Style Questionnaire -Short Form and the Adult Attachment Interview. However, overall, due to limitations of the methodological quality of studies and inconsistent reporting of results, this review was not able to provide recommendations regarding the best instrument to use to measure adult disorganised attachment. This review identified a paucity of psychometrically robust measures of adult disorganised attachment, grounded in sound quality methodology. Paper two aimed to revise an existing measure of attachment in psychosis to include a self-report measure of disorganised attachment and to evaluate its psychometric properties within a clinical psychosis sample recruited online. Phase one of the study involved the generation of an item pool of disorganised attachment items. Content and face validity for the items was established through consultation with clinical and academic experts in the field and service user representatives with lived experience of psychosis. Phase two of the study involved the psychometric evaluation of the revised measure. The results provide an examination of a two and a three factor solution, analysed using exploratory factor analysis. Based on statistical and theoretical grounds, the three factor solution was the preferred solution and demonstrated good internal consistency and test-retest reliability. A disorganised factor was indicated in the three factor solution which demonstrated good construct validity through correlations with other measures of adult disorganised attachment and related constructs. Whilst results from this study are promising, they offer only preliminary evidence. The measure requires further psychometric investigation within another clinical psychosis sample in order to further evaluate its psychometric properties and confirm whether the preferred three factor solution reflects the structural dimensionality of the revised PAM measure. Finally, paper three provides a critical evaluation and reflection of the design, decision making process and clinical and research implications of papers one and two. Personal reflections of the overall research process are also presented.

The aim of this thesis was to explore empathy in adults, by examining its relationship with attachment and investigating whether it can be learnt via brief empathy training. The thesis is presented as three separate papers. Paper one is a systematic review of the literature on attachment and empathy, as measured by the Interpersonal Reactivity Index (Davis, 1980). The review highlights that attachment and empathy are both multi-dimensional concepts with more evidence existing for some relationships compared to others. There was more consistent support for a relationship between greater attachment avoidance and reduced cognitive and emotional empathy (perspective taking and empathic concern), than for attachment anxiety. Although more variable, there was still support for a relationship between greater attachment anxiety and emotional empathy, indicated by greater personal distress and lower empathic concern. However, further research is required to provide studies which allow statistical comparison of the relationship between attachment and empathy. Paper two is an empirical study investigating the effectiveness of a brief training package aimed at increasing empathy. There were no significant differences between participants randomly allocated to attend empathy training, compared to those allocated to a control group, on either a self-report or performance measure of empathy. However, attendance at training was high and those that attended rated it useful. Possible explanations and interpretations of the findings are discussed alongside suggestions for future research. Paper three is a critical reflection of the thesis research project and processes involved. This paper discusses the strengths and limitations of the research and provides further detail on the planning, methodology and decision making processes involved. The paper concludes with personal reflections on the overall thesis project.

Non-affective-psychosis tends to have a relapsing and remitting course. Relapses have profound adverse consequences for individuals and are costly to health services. Early signs interventions use timely prediction of relapse to prompt preventative action with the aim of averting, or lessening the impact of, relapse. The aim of this thesis was to investigate whether early signs interventions are efficacious and how they might be improved. To this end, existing studies testing early signs interventions were reviewed and four empirical studies were conducted. These studies examined the facilitators of, and barriers to, early signs interventions and tested whether adding 'basic symptoms' to conventional early signs and using smartphone technology to monitor these hypothesised predictors improves relapse prediction. Chapter 1 of the thesis outlines the importance of relapse prevention, provides background information about early signs, basic symptoms and symptom monitoring apps, and outlines the theoretical context of the thesis. Chapter 2 provides a detailed critical analysis of the methods used in the thesis and describes additional methods that were not covered in the five published PhD papers that are presented in Chapters 3 to 7. Findings from these papers are integrated with each other and with the wider literature in the discussion section of the thesis (Chapter 8), followed by an analysis of their theoretical, clinical and research implications. A systematic review of trials using early signs to target medication or psychosocial support (Chapter 3) showed that there is scope to further refine such interventions. Relapse rates were higher when targeted medication was used as an alternative to adequately dosed maintenance medication; although, not as high as when no medication was used. Targeted psychosocial interventions showed promise but there were insufficient studies of high enough quality to draw firm conclusions. To examine how early signs interventions might be improved, the thesis examined potential facilitators and barriers. Qualitative interviews with patients who had recently relapsed (Chapter 4) suggested that early signs monitoring may be easier for those who have the assistance of a family member or carer, an integrating recovery style, higher levels of insight and a good rapport with clinicians. Conversely, early signs monitoring may be more difficult for those with cognitive difficulties, low levels of literacy, a sealing over recovery style, a lack of insight, and high levels of residual psychotic symptoms. Some participants had encountered service-related barriers when attempting to seek help for an emerging relapse in the past; the capacity of a service to respond quickly to early signs is fundamental to a successful early signs intervention. With regard to relapse prediction, a systematised review of prospective cohort studies (Chapter 3) showed that conventional early signs have modest predictive validity and that studies using a wider variety of predictors and more frequent early signs assessments predicted relapse most accurately. Accordingly, the later PhD studies aimed to broaden the range of predictors (by adding basic symptoms) and to facilitate more frequent monitoring (using a smartphone app). The PhD findings supported the hypothesis that adding basic symptoms to conventional early signs improves relapse prediction. In retrospective interviews (Chapter 5), 74% of participants reported basic symptoms that began or increased in the three months before relapse. Prospective reports (Chapter 7), gathered using a smartphone app, showed that basic symptoms predicted increases in some psychotic symptoms items three weeks later, and that adding basic symptoms to early signs improved prediction in most cases. Prospective findings (Chapter 7) also indicated that using a smartphone app to assess early signs, basic symptoms and psychotic symptoms on a weekly basis was feasible and valid; qualitative interviews (Chapter 6) demonstrated that this method was largely acceptable to a sample with established psychosis. Therefore, app-facilitated assessment of these variables is recommended in future research; for example, a large-scale prospective cohort study or a trial of an early signs intervention incorporating both conventional early signs and basic symptoms.

This thesis focuses on acute mental health inpatient care settings within the UK, with a systematic review on factors influencing length of stay (LOS) and service users' experiences of care from admission to readmission. Paper One: Presents a systematic review, which aimed to synthesise and evaluate the research to date looking at predictors of length of stay in acute mental health inpatient care within the UK. Thirteen studies were identified for inclusion, exploring demographic, clinical, social, and provider level factors related to LOS. There was substantial variation in the factors examined in relation to LOS across studies, where consistency in findings across the factors investigated varied. However, older age, black and minority ethnic groups and involuntary admission were most consistently associated with increased LOS, and alcohol and substance misuse with a shorter LOS. Limitations of the literature and the review, and future clinical and research implications are discussed. Paper Two: Aimed to explore service users' experiences of care from admission to readmission to acute mental health inpatient care. The study used Interpretative Phenomenological Analysis (IPA) to gain an in-depth understanding of service users' experiences of care, including during admission, at discharge and follow-up care in the community and whether from their perspective this care met their needs. Participants' narratives highlighted inconsistencies in services abilities to meet their needs across the care pathway, which appeared to influence their need for readmission. Clinical implications and areas for future work are considered. Paper Three: Provides a critical reflection on the systematic review and empirical paper, including the planning, implementation, and interpretation during the research process, as well as clinical implications and areas for future research. Personal reflections on the research process are also provided.

The overall theme of the thesis is the investigation of fantasy-proneness and its relationship with non-clinical psychotic experiences. Firstly, a systematic literature review synthesised and critically appraised studies examining the relationship between fantasy-proneness and non-clinical psychotic experiences. The findings provided evidence of significant associations between fantasy-proneness and predisposition to psychotic-like experiences more generally, and/or the relationship between fantasy-proneness and predisposition to alterations in perception and thinking more specifically. The results are considered in relation to methodological limitations, clinical implications and recommendations for future research. Secondly, research was carried out to explore fantasy-proneness and dissociation as potential mediators in the relationship between childhood trauma and auditory hallucination-proneness, in a non-clinical sample. A serial mediation analysis indicated that childhood trauma has a significant indirect effect on auditory hallucination-proneness through fantasy-proneness and dissociation. This indirect effect remained significant when covariates, gender, age, ethnicity and paranoia, were controlled for. The findings are considered in relation to limitations of the study, possible clinical implications and recommendations for future research. Finally, a critical evaluation and reflection of the design, methodology, clinical implications and proposed future research is presented in the third paper. Personal reflections are presented on the whole research process.

Background: The development of a positive therapeutic alliance has been shown to be a strong determinant of treatment outcome in psychotherapy and evidence is emerging from a range of healthcare and medical disciplines to suggest that this construct may in fact be a variable component of treatment outcome, adherence and satisfaction. Although there is a surfeit of therapeutic alliance measures, these measures have yet to be validated with people with aphasia and evidence suggests that conceptualisations of the alliance, rooted in psychotherapy, do not encapsulate all of the characteristics of the construct relevant to specialisms such as rehabilitation and medicine. This thesis therefore, aimed to develop a theory-driven measure of the therapeutic alliance, which could then be used to determine whether the therapeutic alliance is a variable component of aphasia therapy in and of itself. Method: A systematic review and meta-ethnography was conducted to explore how stakeholders experience therapeutic alliances in stroke rehabilitation. Given the paucity of research in aphasia rehabilitation, two further empirical interview-based studies were conducted examining speech and language therapists (SLT) (n=22) and people with aphasias (PWA) (n=18) perceptions of therapeutic alliance construction and maintenance. Interviews were analysed through thematic analysis. A further Q methodological study examined which aspects of the therapeutic alliance were valued by people with aphasia. The theoretical understandings gained from these four studies informed the development of a robust therapeutic alliance measure, the Aphasia and Stroke Therapeutic Alliance Measure (A-STAM). The reliability and validity of the A-STAM were investigated with 34 therapist-patient dyads engaging in aphasia therapy following a stroke. Results: The findings from the meta-ethnography suggested that marked power imbalances between professionals and patients persist in stroke rehabilitation, despite professionals' attempts to redress this balance. Further qualitative insights demonstrated that SLTs employ multiple strategies to establish purposive alliances, with the aim of recognising personhood, sharing expectations and activating ownership. The findings revealed that SLT value judgements are implicitly intertwined into alliance development. For both SLTs and PWA therapeutic responsiveness to the situational and relational context was central to maintaining effective alliances. For PWA, goal congruence was dependent on listening to the PWA's narrative and identifying goals concordant with individual priorities. The findings from the Q study highlight considerable diversity in individual viewpoints; whereas some people valued acknowledgement and understanding, others prioritised challenge and direction. Preliminary findings suggest the therapeutic alliance measure (A-STAM) has good reliability and validity with a pilot sample. Conclusion: This thesis contributes to our theoretical understandings of this construct in aphasia rehabilitation and presents a novel measure of the therapeutic alliance which can be adopted in a clinical and research context to quantify this potential variable of change.

The first paper is the systematic review. Its aim is to review studies that provided information on the types of assistance sought by African-descended UK-based groups for mental-health difficulties. Four quantitative, four qualitative and two mixed-methods studies were included in the analysis. Findings, clinical implications and limitations are discussed. The second paper is the empirical study. It is a cross-sectional quantitative study which investigated associations between mental illness beliefs, perceived discrimination and attitudes towards accessing help from mental health services in an African-descended UKbased sample. Treatment control and illness coherence were the only significant individual predictors of attitudes towards help-seeking. Perceived discrimination did not moderate the relationship between mental illness perceptions and attitudes towards help-seeking. Clinical implications and limitations are discussed. The third paper is a critical appraisal of the research process and the two previous papers.

Paper 1 presents a systematic review on the evidence for the relationship between absorption and common mental health difficulties. A literature search was completed to identify empirical papers using the following electronic data bases: PsycINFO, MEDLINE, CINAHL and Web of Science. Twenty papers were identified that satisfied inclusion criteria for the review. Evidence supported a relationship between absorption and common mental health difficulties, suggesting absorption is a clinically relevant form of dissociation. Absorption was more strongly related to anxiety experiences across all anxiety disorders, which may potentially be due to a reduction in metacognitive awareness when absorbed. Paper 2 presents an experimental study investigating if state absorption has a causal impact on voice hearing. To explore this, we tested whether non-clinical, hallucination-prone individuals exposed to an absorption manipulation (n = 36) exhibited a significantly greater increase in auditory false alarms during a laboratory voice hearing task than a comparable group exposed to a relaxation control manipulation (n = 37). The absorption and relaxation conditions showed no increase in false alarms following manipulation. There was no significant difference in false alarm rates between participants in the absorption condition compared to the relaxation condition, when controlling for false alarms pre-manipulation. There was also no significant relationship between change in state absorption and change in false alarms from pre- to post-manipulation. This study indicates that absorption does not have a strong effect on voice hearing, however should be interpreted with caution due to limitations in the design and effect of manipulations. Paper 3 provides a critical appraisal of the systematic review, the empirical paper and the research process as a whole. Strengths and limitations of the presented research are discussed as well as future clinical and research implications.

This thesis explored both parent and staff experiences of the implementation of parenting programmes using qualitative methodologies. The thesis consists of three papers: 1) a systematic literature review, 2) an empirical study and 3) a critical reflection of the research process. The systematic review (Paper 1) is a qualitative metasynthesis of parent's perceptions and experiences of parenting programmes. Twenty-six studies were included, spanning 17 years of parenting research in seven different countries and involving 822 parents. A thematic synthesis derived three main themes and nine subthemes: 1) a family's journey (prior to the parenting programme, outcomes and post-intervention), 2) aspects perceived to be important or valuable (group leader or facilitator, programme content and delivery and value of the group) and 3) challenges or difficulties (barriers to engagement or attendance, programme content and suggestions for improvement). Outcomes of parenting programmes included changes in the parent, alongside changes in the child and family more widely. The utility of parenting programmes as a means of early intervention were emphasised. In light of these findings, recommendations are made to improve provision of accessible, clinically and cost-effective interventions for parents striving to meet the challenges of their caregiving role. The empirical paper (Paper 2) explored staff implementation of a self-directed parenting intervention for parents with mental health difficulties. Triple P self-help workbooks were provided to existing front-line staff. Data were collected regarding workbook uptake and use. Semi-structured interviews with twelve practitioners explored their perspectives and experiences of implementation. Thematic analysis of interview data revealed practitioner concerns, views of the intervention and implementation issues. Whilst uptake and utilisation were varied, practitioners who did use the work reported positive outcomes. Findings were considered in relation to existing literature to make recommendations for overcoming barriers to implementation and facilitating a family-focused approach to meet the needs of parents with mental health difficulties and their children. Paper 3 provides a critical appraisal of the research process. The strengths and limitations of the work, the challenges faced and its contribution to this field of research are considered. The researchers' personal reflections on the process are offered.

This thesis comprises three papers and explores types of support to aid shared decision-making (SDM) and discontinuation of neuroleptic medication in the treatment of psychosis. Papers one and two have been prepared for submission in accordance with the journal guidelines. Paper one is a systematic literature review and meta-synthesis, synthesising the qualitative research concerning the use of SDM interventions for the treatment of psychosis. Using a systematic search strategy, 16 eligible studies were included in the meta-synthesis. Two superordinate themes emerged from the data: 'factors influencing the use of SDM interventions' and 'impact of using SDM interventions', with multiple sub-themes within each. Paper two is a three-stage Delphi method study exploring the types of support individuals with experience of psychosis desire when discontinuing neuroleptic medication. Three focus groups were undertaken to generate an 108-item questionnaire. Participants completed two rounds of the questionnaire in which they rated and then rerated statements based on level of importance. A total of 60 statements reached consensus as 'essential' or 'important' types of support. The findings showed that when discontinuing neuroleptics, individuals desire support from professionals, support networks and personal coping strategies. The clinical implications of the findings are discussed and ideas for future research suggested. Paper three is not written for publication and is a critical evaluation and reflection of the research process including the rationale for the research completed and methodological decisions made. Personal reflections on the experience of conducting a systematic literature review and an empirical Delphi study are also drawn upon as well as implications for future clinical practice.

Background: Paper I: Intensive Cognitive Behavioural Therapy (CBT) is an emerging intervention for psychological distress and mental health. There is no known review in this area in an adult population. Paper II: The InSPire programme was developed to deliver intensive cognitive behavioural suicide prevention (CBSP) therapy within a prison, to address barriers to long term engagement in previous psychological intervention studies (i.e. attrition). Aims Paper I systematically reviewed studies which have delivered intensive CBT within an adult population experiencing psychological distress. Paper II aimed to determine the feasibility of intensive CBSP in a prison, with individuals experiencing suicidal thoughts and behaviours. Methods: Paper I was a systematic review of 17 studies delivering intensive CBT across populations experiencing psychological distress associated with mental health, addiction, chronic pain and following a traumatic incident. Paper II was a feasibility case series with single baseline and single follow up. Thirteen individuals consented to the InSPire programme, delivering an intensive CBSP intervention within a three week period (five two-hourly sessions were offered). Outcome measures assessed suicidality (including thoughts of self-harm) and client satisfaction. Psychological mechanisms associated with suicide were measured, including perceived social support, emotional regulation and problem solving. Results: Paper I found promising results in the efficacy and feasibility of intensive CBT, particularly in the population experiencing distress associated with mental health difficulties. The review unearthed a number of recommendations for further research in this field. Paper II found the InSPire programme to be feasible, as determined by successful recruitment and retention across the study, including high participant satisfaction. The programme appeared to have an efficacious benefit for those who took part across all outcomes measured. Conclusions: Paper I highlights the promising feasibility and efficacy of intensive CBT, yet more rigorously designed studies (i.e. RCTs) must be conducted before firm conclusions can be drawn and prior to a future repeat review. Paper II highlighted the potential benefit of conducting intensive CBSP in prison. Given the limited generalisability of this study, a larger scale feasibility trial would now be warranted to determine more conclusive evidence. Paper III was a critical review paper appraising papers I and II. This included consideration of the methodological process, strengths and limitations, and considerations alongside further literature.

Demand for psychological treatment still far outstrips supply. Digital options for intervention are evolving rapidly. Software programs called relational agents use artificial intelligence to emulate conversation through text or speech. Relational agent interventions have been developed to treat a range of mental health problems, however, there is little consensus on whether this type of intervention is acceptable to clients or efficacious. Paper one systematically reviewed the literature on relational agent interventions in the treatment of mental health problems. The thirteen included studies were diverse in design and aimed to treat a broad range of mental health problems using an eclectic variety of therapeutic orientations and formats. Their potential to provide acceptable and efficacious mental health support without human therapist input appears promising. However, more robust study designs, comparison with existing or alternative intervention formats and clarity over their mechanisms of action is required to demonstrate and maximise efficacy and efficiency. It remains mostly unclear how psychological interventions achieve their effects and what it is about therapy that clients find helpful. A relational agent intervention called Manage Your Life Online (MYLO) emulates a transdiagnostic cognitive therapy called the Method of Levels (MOL). MOL arises from a theoretical approach called Perceptual Control Theory (PCT). The primary aim of Paper two was to explore participant experiences of the process of intervention with MYLO from a theory driven, PCT perspective. A multi-method approach was used to elucidate what people find helpful or hindering during intervention with MYLO. Fifteen participants with a variety of mental health related problems appeared to find MYLO acceptable. Consistent with core processes of psychological change according to PCT, questions which enabled free expression, increased awareness and novel insights were associated with helpfulness. In contrast, questions eliciting intense emotions, which were confusing or inappropriate or repetitive were unhelpful and associated with disengagement or loss of faith in the MYLO intervention. Findings provide insight into how to optimise the acceptability and efficiency of MYLO and support the transdiagnostic processes outlined in PCT. Critical appraisal of the processes and rationale for Papers one and two is conducted in Paper three alongside broader reflections on the contributions of both papers to the evidence base, implications for clinical practice and future research directions.

Psychological interventions that target the core processes which are proposed to maintain distress across diagnostic categories might have advantages over disorder-specific approaches for people experiencing first-episode psychosis (FEP). This thesis aimed to evaluate the feasibility and acceptability of a transdiagnostic cognitive therapy called Method of Levels (MOL) for people experiencing FEP, and to consider whether adaptations are needed to support its implementation into routine practice. MOL is designed to ameliorate distress, rather than reduce symptoms. A related aim, therefore, was to increase our understanding of the sources of distress for this population. The results of the thesis will be used to inform decision making about the suitability of MOL for further testing in a larger clinical trial. The thesis comprises three studies described over four papers: (i) a qualitative metasynthesis exploring sources of distress in FEP (Chapter 3); (ii) a feasibility randomised controlled trial (RCT) of MOL for FEP (Chapters 4 and 5); and (iii) a qualitative study exploring experiences of receiving MOL amongst people with FEP (Chapter 6). The metasynthesis is the first review to address the question of what causes distress in people experiencing FEP from a first-person perspective. Following a systematic review, findings from qualitative studies (n = 33) were synthesised using thematic analysis. Sources of distress for this population were found to be diverse and multifaceted. The results suggest that practitioners who pay attention to wider sources of distress will be experienced as more helpful by people experiencing FEP. Participants (n = 36) were successfully recruited to the RCT and randomised to one of two conditions: treatment as usual (TAU) or TAU plus MOL. Retention at final follow up was 97%, substantially higher than the 80% threshold pre-specified as a successful feasibility outcome. This was the first study of its kind and the results provide evidence that it is feasible to recruit and retain participants experiencing FEP in a trial of MOL, suggesting that it is suitable for further testing in a larger trial. It also provides preliminary evidence of MOL's acceptability for this population. A proportion of participants from the RCT (n = 12) were interviewed about their experience of receiving MOL. Results were analysed using thematic analysis. Four superordinate themes were identified: 'The therapist's approach'; 'I was in control'; 'Thinking and talking'; and 'Looking at problems from a different perspective'. Engaging with MOL was predominantly perceived to be a helpful experience. The study provides additional evidence of the acceptability of MOL for people experiencing FEP. This thesis makes a novel contribution to the literature on psychotherapeutic interventions for people experiencing first-episode psychosis and increases our general understanding of the lived experiences of this population.

This thesis was completed by Amanda Anderson and was submitted to the University of Manchester for the degree of Doctor of Clinical Psychology in the Faculty of Biology, Medical and Health on 24th May 2019. The thesis title is 'The experimental manipulation of auditory perceptual experiences: a systematic review and empirical study', and is comprised of three papers. Papers 1 and 2 have been prepared for submission to Frontiers in Psychiatry and Psychosis, respectively. Paper one was a review of 48 studies and aimed to identify and critique voice-hearing induction paradigms in order to guide future investigators in the design and evaluation of research in the voice-hearing field. Studies were organised into five groups based on the type of voice-hearing paradigm used. The quality of these paradigms was assessed, and their strengths and limitations evaluated, and recommendations for future studies made. Paper two aimed to explore the cognitive model of voice-hearing by using an analogue study to examine the effect of rumination on the frequency of voice-hearing, using a non-clinical sample of 106 participants. Participants completed baseline measures of trait rumination, hallucination proneness, mood and state negative affect, and were randomly allocated to a rumination or distraction group. A voice-hearing paradigm was used in which participants listened to an ambiguous stimulus and indicated when they believe they had heard a word. False alarms (the detection of a stimulus in the absence of one) were used as a proxy for voice-hearing, and false alarms and distress were compared between groups. The manipulation was successful (p = 0.007); however, the difference between the groups for total false alarms (p = 0.282) and distress (p = 0.387) was not statistically significant. Limitations of the study are discussed and recommendations made for future research in this field. Paper three provides a critical appraisal of the process of completing the review and experimental study, including personal reflections on the research process.

Associations between schizophrenia and violence are well-documented, but there is little epidemiological evidence concerning homicide perpetration risk in this patient population. Such information can inform risk management and help services to target specific interventions. This study utilised the National Confidential Inquiry into Homicide and Suicide by People with Mental Illness (NCISH) consecutive case series of all convicted homicide perpetrators in England & Wales and incorporated three interrelated studies: (i) nested case-control study of homicide by patients with schizophrenia, which compared male patients with schizophrenia who were convicted of homicide to matched control patients with schizophrenia who had not perpetrated homicide; (ii) case series of male patients who were diagnosed with schizophrenia and convicted of homicide compared to a randomly selected age-matched comparison group of male patients with schizophrenia who died by suicide; (iii) case series of convicted homicide perpetrators classified according to Hodgins' (2008) typologies of violent offenders with schizophrenia. The findings generated confirm the association between a diagnosis of schizophrenia and homicide and highlight heightened risk in the presence of co-morbid personality disorder, dual diagnosis, non-adherence with medication and disengagement with services.

Background and objective: Common factors theory proposes that clients make significant contributions to psychosocial change processes and outcomes in psychological therapy. However, the client factors concept contains such a wide range of client activities, characteristics and extratherapeutic circumstances that without some form of structural logic, it is difficult to understand how clients contribute to change processes, or how counselling psychology theory might be shaped to work with the most potent client factors. Using first-hand participant experience and published peer-reviewed psychotherapy outcomes research, this study sets out to identify client factors associated with psychosocial change and non-change, and to organise them into a conceptual framework. Method: A deductive qualitative 'hierarchy of abstraction' concept analysis method is used to interpret and organise data from nine participant interviews and 68 research studies. Graphic frameworks derived from each data source are compared, then combined into a single reconstructed concept framework. Findings: The resulting conceptual hierarchy model presents client factors associated with change and non-change over four levels of abstraction. The detail of experience is located at the least abstract elemental and categorical levels of change-related activity and inactivity; then abstracted to stages of change and non-change; then further abstracted to two broad client factors. In this provisional model, the first of these factors is client use of available social support resources, which inspires and reinforces the second factor, which is reflective and experiential learning. Inadequate social support is implicated in the learning and experiential stagnation associated with non-change. The adequacy of the reconstructed concept is assessed against seven criteria; and by comparing its fit with two social learning theories. Conclusion and implications: In view of the importance of reflective and experiential learning in this conceptual model, social learning theory is proposed as relevant for informing future developments in counselling psychology theory and research. In this model, the term 'social learning factors' more accurately points to the potentially major constellation of wider client and extratherapeutic social contributions to therapy outcomes currently indicated by 'client factors' in common factors theory.

Evidence addressing the impact and bidirectional influence of being a parent and experiencing psychosis is relatively sparse, and often fails to adopt a strengths based approach. The purpose of this thesis was to combine multifaceted evidence bases, examine approaches to intervention and give a voice to parents experiencing serious mental illness (SMI). Throughout this thesis, a multi-method approach was utilised. This included reviewing a complex evidence base and conducting cross-sectional, longitudinal and qualitative research. Currently, there is a paucity of research investigating the role of parental emotion and cognition and how parenting interventions (PIs) can be perceived and utilised by families. To address this, Chapter 1 provided an in-depth narrative review of the literature regarding expressed emotion (EE), attributions, parenting and mental health. Following this, chapter 2 describes the methodological approaches employed within each study. Next, Chapter 3 (Empirical study one) reports the findings from the first study to explore EE and attributions with parents experiencing psychosis (PEP) (n = 20) and parents with no SMI history (n = 20). This was conducted due to the debilitating nature of psychosis and the interference it can cause for social, emotional and psychological functioning. Being a parent is both a risk and protective factor for mental health; however, up to 50% of parents experiencing SMI lose custody of their children. It was therefore important to explore and understand how the family environment (as evidenced by EE) and potentially dysfunctional interpretations and beliefs (attributions) impact the parent-child relationship or parenting capabilities. Greater awareness and insight into the relationship between mental health, child-blaming attributions, hopelessness, criticism, warmth and positive remarks offers insight into intervention approaches. To encourage the development of appropriate and optimum parenting support, the use of an existing PI with PEP was explored using a case series methodology (chapter 4; Empirical study two). This is the first study to employ the 10 week self-directed variant of the Triple P - Positive Parenting Programme with PEP (N = 10). The PI was offered in a supportive capacity using a weekly case series approach with three and six month follow-up. The PI provided structured guidance on strategies and skills that could enhance parenting. Exploring the acceptability and feasibility of the PI helped to understand the factors driving motivation, attrition and retention in the PI. The findings contribute to the evidence base concerning parenting and psychosis, and show that a self-directed PI with support can lead to positive outcomes. Clinically significant levels of change were reported across measures of mental health, well-being, self-efficacy, parenting and parent-child interaction. All parents reported improvements; parents who ended the PI early also demonstrated similar levels of improvement compared to those completing all 10 weeks. The PI appeared to build on parents' awareness of their mental health and the connections SMI can have with parenting. This study aimed to lay the foundations for future work offering appropriate PI for those experiencing SMI. Reported within Chapter 5 (Empirical study three) is an Interpretative Phenomenological Analysis (IPA) exploring the use of the guided self-help PI for PEP (N = 5). During parents' reflections, their perceptions of change, empowerment, passion and pride following the PI were discussed. Finally, Chapter 6 presents a general discussion encompassing this programme of work and provides suggestions for future work.

This thesis provides a detailed exploration on the experiences of women with postpartum psychosis and those of their family members. The thesis consists of three papers: 1) a systematic literature review, 2) an empirical study, and 3) a critical evaluation and reflection on the research process. The systematic literature review (Paper 1) is a metasynthesis of qualitative research investigating the experiences of women with postpartum psychosis and family members, with emphasis on the processes perceived to be involved in recovery. Fifteen studies, capturing the views of 103 women and 42 family members were identified for inclusion. Thirteen subthemes and four main themes were identified: 1) Experiencing the unspeakable, 2) Loss and disruption, 3) Realigning old self and new self and 4) Social context. The findings offer new insight into the unique experience of postpartum psychosis and demonstrates that recovery does not follow a linear path. Key areas for service development and further research opportunities are highlighted. The empirical study (Paper 2) attempted to expand the findings from the systematic literature review by investigating the psychological experiences, needs and preferences of women recovering from postpartum psychosis and family members. Thirteen women and eight family members were interviewed and their data analysed using thematic analysis. Twelve subthemes were organised around three main themes: 1) Seeking safety and containment, 2) Recognising and responding to the psychological impact and 3) Planning for the future. The outcomes highlighted the complexity and longevity of recovery. A number of psychological needs were reported, which could be partly met through psychological intervention. Further research is needed to develop, implement and evaluate interventions. The critical evaluation and reflection chapter (Paper 3) provides an overview and appraisal of the research process, including reflections on decision making and lessons learned. It provides a final overview of the clinical implications highlighted within paper one and two. The paper highlights the importance of qualitative investigation to capture the depth of individual experience and inform the development of complex interventions. The paper concludes that postpartum psychosis is a complex and multifaceted experience, in which a range of needs and intervention must be considered and further exploration is necessary to improve clinical practice.

This thesis explores attitudes and decisions around engagement with mental health services of individuals in the Middle East. Paper 1 examined the attitudes towards mental health interventions of individuals living in the Middle East by systematically reviewing the literature. Thirteen quantitative studies were included and the findings synthesized using a narrative approach. The findings indicated that over half of all individuals in most studies considered seeking mental health treatment and that they would seek support first and foremost from their family and friends. Stigma was consistently found to negatively impact on attitudes towards mental health interventions. Other factors that impact on attitudes were also discussed and clinical implications highlighted. Paper 2 was an empirical study which focused on families displaced by the Syrian conflict who have resettled in the UK. Four mothers' decision-making process to engage in a parenting group was explored in-depth using Interpretative Phenomenological Analysis. The aim was to gain an understanding of their subjective experience with regard to facilitators and barriers to engagement. The themes that emerged appeared to suggest a lack of connection, and yet wanting to connect with others. The sharing of experiences within a group setting were important to the women. They expressed uncertainty and had concerns about control within the group. Another theme was related to wanting help but feeling that services did not understand and accommodate their needs on a practical level. The data also highlighted a sense of abandonment by services on an emotional level. The mothers also reflected on feeling stuck which appeared to be a motivator to decide to take part in the parenting group. The intervention booklet was predominantly perceived positively. However, some of the mothers highlighted difficulties around implementation. These findings were discussed in light of existing literature and clinical implications included. Paper 3 is a critical appraisal of the systematic review and qualitative study and offers reflections on the research processes.

Criteria have been developed to identify individuals at ultra-high risk (UHR) of developing a psychotic disorder. Many UHR young people exhibit marked and persistent impairments in social and occupational functioning, regardless of symptomatic remission or transition to full-threshold psychotic disorder. In this thesis, I sought to identify factors that drive and sustain functional impairment in this group. The aim was to identify risk factors for poor functional outcome in this population. This in turn could potentially help to inform interventions. In Paper 1, I conducted a systematic review of factors associated with functional deficits in the UHR population. This was the first systematic review examining this issue. The review identified negative symptoms, disorganisation and neurocognitive deficits as robust predictors of poor outcome. I also identified areas that had been little studied, including the effect of childhood trauma, social cognitive dysfunction and the drivers of poor “real world” outcomes such as long term unemployment. Exposure to childhood trauma is common among the UHR group. I provided an extended rationale for examining its association with functioning in Paper 2, citing a range of literature linking exposure to trauma to functional deficits in people with severe mental illnesses. I then analysed which of a range of clinical and sociodemographic variables at baseline, including trauma, were the strongest predictors of long-term functioning in a large UHR cohort (Paper 3). Only childhood trauma and transition to psychosis were significant independent predictors of poor long-term functioning in the multivariate analyses. Paper 4 is the first study to investigate the long-term unemployment rate and baseline predictors of employment status at follow-up in an UHR cohort. After 2-13 years (mean = 7), 23% of the sample was not in employment, education or training. Childhood trauma and the duration of untreated illness at baseline were significant independent predictors of employment status at follow-up. Paper 5 identified a cross-sectional association between performance on a theory of mind task and a measure of global functioning that remained significant after controlling for negative symptoms and stress in multivariate analyses. Finally, in Paper 6 I reported the findings of a qualitative study that I conducted with twenty UHR service-users. Participants reported a range of impairments in their social and occupational functioning which they attributed to a combination of clinical, cognitive and psychological factors. This included negative symptoms, cognitive deficits and adverse childhood experiences, as well as variables which had been largely unexplored previously, such as self-stigmatising attitudes and dysfunctional metacognitive beliefs, providing new targets for future research. Based on these findings, the quantitative analyses and my literature review, I propose a model that attempts to explain how these variables interact to drive and sustain functional impairment in the UHR group. This thesis provides new insights into factors that underlie functional deficits in the UHR group. I end the thesis with a discussion of these findings and their clinical implications, consider the strengths and limitations of this work and identify areas for future research.

Physical exercise is widely accepted as having a plethora of physical and psychological benefits for the general population, including weight management, cardio-metabolic risk reduction, mood improvement and cognitive enhancement. This broad spectrum of beneficial effects has led to considerable research interest into how exercise may be applied with clinical care and treatment of people with severe mental illnesses, such as schizophrenia. Indeed, exercise interventions have been found to improve outcomes in people with schizophrenia, perhaps through providing effective adjunctive treatment for the various physical and mental health issues which are not resolved (or even worsened) by antipsychotic treatment. Exercise may be particularly useful when implemented in the early stages of schizophrenia, i.e. first-episode psychosis (FEP), in order to prevent obesity and cardiometabolic diseases from arising, and facilitate psychosocial recovery before enduring disability takes hold. However, the feasibility and effectiveness of exercise in this population is not well understood. In this thesis, I combine both meta-analytic and experimental methods to examine the effectiveness of physical exercise as an adjunctive treatment for the symptoms and cognitive dysfunction associated with psychotic disorders, and to investigate the feasibility of using individualised exercise training as an intervention in FEP. Furthermore, using both qualitative and quantitative data sources, I investigate the factors which may influence the effectiveness of exercise interventions for people with psychotic disorders, and explore motivations and barriers towards physical activity in this patient group. My investigations show that exercise can be used to target unmet treatment needs in FEP (i.e. improving negative symptoms and cognition), which may facilitate early recovery. However, results also indicate that exercise effectiveness is ultimately dependent upon participants achieving and maintaining sufficient weekly amounts of activity, therefore emphasizing the importance of developing acceptable interventions. I further show, using both qualitative and quantitative data sources, that social support and autonomy are critical factors determining exercise adherence - with individualised exercise training presenting an effective method for fulfilling these requirements, and promoting exercise engagement in FEP. I conclude by commenting on developments within the literature, identifying outstanding questions and discussing the clinical implications of the evidence to date, along with proposing a novel and potentially feasible system for providing exercise treatments to people with FEP, in order to improve physical health and facilitate recovery.

Children of parents with psychosis are more likely to have emotional and behavioural problems, and problems with relationships. Emotional Overinvolvement (EOI) is a way of measuring how a parent or caregiver thinks and feels about their child. In adulthood it has been shown that EOI can be related to mental health difficulties. The aim of this thesis was to review existing research on how EOI could relate to social and emotional problems in children, and to explore whether the way in which EOI influences children is similar in families of parents who have a psychosis diagnosis compared with parents without a psychosis diagnosis.

This thesis aimed to explore neuroleptic medication discontinuation, with particular focus on aspects relevant to clinicians. Papers 1 and 2 have been prepared for submission to journals and are in line with journal requirements. To ensure consistency throughout this thesis some minor formatting and stylistic changes have been made. Paper 1 is a systematic review aiming to examine and synthesise evidence on the relationship between the therapeutic alliance and neuroleptic medication adherence in individuals with experience of psychosis. Eighteen empirical papers were identified for inclusion in this review, seventeen of which reported positive associations between therapeutic alliance and neuroleptic adherence. However, further research using high quality designs and advanced statistical methods are required before it is possible to conclude the true extent and potential mediators of the relationship between alliance and adherence. Paper 2 utilised grounded theory method to examine clinicians' perspectives of decision-making concerning neuroleptic medication discontinuation. Twelve in-depth interviews were completed with Psychiatrists and Mental Health Nurses and a theoretical model was developed depicting a complex process of decision-making for clinicians working with service-users wishing to discontinue neuroleptics. The process of making decisions about neuroleptic discontinuation was found to be subjective and dependent on clinicians' previous experiences and judgements regarding potential risk factors. The clinical and research implications are discussed with reference to existing literature. Paper 3 provides a critical appraisal and reflective account of papers 1 and 2 and was not written for publication. This includes evaluation of the research area, methodological decisions, strengths and weaknesses, implications for future research and practice and personal reflections of the research process.

This thesis consists of a systematic review and a research study which sought to explore the factors involved in leading to distress, and in facilitating recovery, following a diagnosis of bipolar disorder. It comprises three standalone papers. Both papers one and two have been prepared for submission in accordance with the relevant journal guidelines. These guidelines have been adhered to as much as possible, with some additional material presented and extended descriptions for the purpose of the thesis. Paper one is a meta-synthesis of qualitative literature from studies in which people with a diagnosis of bipolar disorder discuss factors that they experience as distressing. Four electronic databases were systematically searched. Twenty-four studies were included within the review. Quality appraisals were conducted on each of the included papers to assist in providing context. The methodological approach of thematic synthesis was used to extract and analyse the data. Seven analytical themes to describe aspects that were experienced as distressing, emerged from the synthesis. Themes of stigma and fear of relapse appeared to crosscut themes of diagnosis, loss, uncertainty, threat and relationships. The review findings and limitations are discussed in relation to the existing literature. Paper two is a qualitative empirical study in which the factors and processes involved with facilitating recovery following a previous diagnosis of bipolar disorder were explored. Twelve individuals from international locations were recruited and interviewed. A diagnostic assessment was used to confirm that participants had previously met the criteria for a diagnosis of bipolar disorder. A constructivist approach to grounded theory analysis highlighted ten categories from the data. These included support as a foundational factor for the recovery process. Other categories such as believing things can change and not giving up, as well as becoming the director of your own life, were identified. A diagrammatic model was produced to represent these categories and the suggested relationships between them. This theoretical model is discussed with example quotations. Findings supported and extended on previous literature, the clinical implications of which are discussed. Paper three is not intended for publication and is an overall critical review of the research process. This paper discusses the rationales, and the strengths and limitations, of both papers. Discussion in regards to key decision points and the considered alternatives are also provided. The approaches to interviewing and the qualitative analysis across both studies are reviewed with consideration of researcher reflexivity. Paper three also includes personal reflections and implications of the research drawn from both papers.

Paper 1, prepared according to guidelines for the Journal of Psychosomatic Research, is a systematic review of the literature exploring the relationship between negative expectancy effects and negative trait affect. A total of 18 articles satisfied inclusion criteria for the review. Studies were critically appraised and a narrative synthesis was used to make sense of the findings. The relationship between negative expectancy and negative affectivity was found to be highly variable across the studies. Several possible factors pertaining to this variability were explored, including methodological variations in the generation and reporting of negative expectancy effects. The findings are discussed in relation to theoretical models of expectancy, with suggestions for future direction of studies being made and clinical implications explored. Paper 2, prepared according to guidelines for The Journal of Pain, reports an experimental study which was conducted to explore the role of emotional focus on the magnitude of expectancy effects. Thirty-four healthy volunteers took part in an experimental task, involving a series of trials in which visual cues presented the likelihood of either receiving a low or high level of painful electrical stimulation. For some of the trials, the cues presented did not match the stimulation applied. Therefore, participants received levels of pain intensity that were unexpectedly higher (positive) or lower (negative) than anticipated. During this task, focus of attention was either directed to emotional state or sensory-perceptual information. Results showed that overall this cue- evoked paradigm was effective in manipulating expectancy. However, there were no significant differences in responses to negative expectancy effects observed between the emotion- and sensory-focused conditions. Several conclusions were drawn from these results and are discussed in relation to theories of expectancy and pain. Paper 3 is a critical reflection and considers additional issues that have arisen throughout Papers 1 and 2. The systematic review and empirical study are critically appraised and methodological, theoretical and clinical implications are discussed. Strengths and limitations of the presented research are discussed throughout.

A broad range of adverse experiences during childhood have been associated with psychological distress and mental health difficulties in adulthood. This thesis aims to further knowledge in this area by exploring the role of different types of childhood experiences in the development of psychiatric disorders characterised by unstable affect in adulthood. Paper 1 focuses on the role of a range of adverse childhood experiences as risk factors for the development of borderline personality disorder (BPD). The paper presents a systematic review and meta-analysis of the available literature exploring the prevalence of childhood adversity in individuals diagnosed with BPD compared to non-clinical and clinical control groups. Findings revealed that individuals diagnosed with BPD are significantly more likely to report experiences of childhood adversity compared to both non-clinical groups and individuals with other psychiatric diagnoses. Limitations of the available literature and clinical implications of these findings are discussed. Paper 2 considers the potential role of early responses to emotion from primary caregivers in the development of conflicting appraisals that drive shifts in affect characteristic of Bipolar Disorder. The paper presents the development of a new measure to explore the consistency of responses to emotion from primary caregivers during childhood. This was achieved through the use of cognitive interviews to develop and refine an initial pool of items, followed by the administration of the new measure using an online sample of 70 individuals with mood disorders. This measure demonstrated good internal consistency and concurrent validity. Implications and avenues for further development are discussed. Paper 3 is not intended for publication and provides a critical appraisal of the process of undertaking the body of work contained in this thesis. In this paper the strengths and limitations of this body of work are considered with the aim of reflecting on the research process as a whole to inform future research and clinical practice.

BACKGROUND: Psychosis is a devastating psychiatric condition that consists of abnormal thinking and perceptions. In the majority of adult psychotic illnesses, a cause is neither sought nor identified, despite mounting reports describing autoimmune and inherited metabolic disorders that cause psychosis. Established and emerging therapies in many of these diseases can improve the overall treatment outcome, especially when initiated early. Niemann-Pick disease type C is one of the inborn errors of metabolism that can present with psychosis in adulthood and can go undetected for many years. The measurement of the plasma cholestane-3Î2,5α,6Î2-triol levels is a recently discovered reliable and cost-effective method for detecting Niemann-Pick disease type C cases. Whereas the levels of the enzymatically formed oxysterols are understandably affected by medication that interferes with the cytochrome P450 enzymes, it is not known if the levels of the non-enzymatically formed oxysterols, such as the cholestane-3Î2,5α,6Î2-triol, are modified by medication like antipsychotics. HYPOTHESIS: Firstly, we hypothesised that the occurrence of autoimmune and inherited metabolic causes of psychosis is greater than clinicians currently believe, and secondly, that the cholestane-3Î2,5α,6Î2-triol test utilised in detecting Niemann-Pick disease type C is affected by antipsychotic usage. OBJECTIVES: The primary study aim was to establish the prevalence of several autoimmune disorders (systemic lupus erythematosus, Hashimoto encephalitis, encephalitis due to N-methyl-D-aspartate receptor antibodies, voltage-gated potassium channel antibodies and glutamic acid decarboxylase antibodies) and inborn errors of metabolism (Niemann-Pick disease type C, adrenoleukodystrophy, Wilson disease, metachromatic leukodystrophy, α-mannosidosis, Fabry disease, Gaucher disease, GM2-gangliosidosis, homocystinuria and other amino acid disorders) in patients with psychosis admitted to a psychiatric unit. The secondary aim of the study was to determine whether the antipsychotics affect the oxysterol test’s utility in detecting Niemann-Pick disease type C cases. METHODS: This observational, cross-sectional study had 2 arms: The Screening Tests and The Oxysterol Assay. We performed several blood tests and neurological examination in 93 patients with psychosis recruited to The Screening Tests, and we measured the cholestane-3Î2,5α,6Î2-triol levels in 194 patients recruited to The Oxysterol Assay. Data regarding antipsychotic use, and possible confounders, including age, gender, BMI, statin use, smoking, and psychosis, were collected for The Oxysterol Assay. The analysis for The Screening Tests was performed using Excel and for The Oxysterol Assay using SPSS. RESULTS: Fifteen patients out of 93 (16.1%) had significantly abnormal autoimmune and metabolic results. However, no positive diagnosis of an autoimmune or inherited metabolic disorder was made to date, as tests to confirm the diagnoses were not included in the study. We found that the antipsychotic medication does not alter the cholestane-3Î2,5α,6Î2-triol’ utility as a detecting tool in Niemann-Pick disease type C. Our study showed, for the first time, a statistically significant (p=0.005) positive correlation between age and the cholestane-3Î2,5α,6Î2-triol levels: they increase by 0.141 + 0.049 ng/ml with every year (95% CI 0.044 - 0.238). The presence of conditions that have an overpowering effect on the cholestane-3Î2,5α,6Î2-triol levels, such as Niemann-Pick disease type C or hepatic disease, possibly shadowed the age impact in previous studies. CONCLUSIONS: Further research to establish the prevalence of organic causes of psychosis is still needed and, based on our findings, researchers can now estimate more precisely the funding required to answer this crucial question. The cholestane-3Î2,5α,6Î2-triol tool to detect Niemann-Pick disease type C can be reliably used in patients who receive antipsychotics. We welcome further investigation on the age-dependence mechanism of the cholestane-3Î2,5α,6Î2-triol levels.

This thesis was focussed around the perspectives of service providers on the access to mental healthcare and parenting interventions for refugees from the Middle East. Paper 1 includes a meta-synthesis of primary qualitative research relating to service provider perspectives on refugees from the Middle East accessing mental healthcare in the context of displacement and resettlement. Paper 2 provides an empirical study which utilised a Thematic Analysis approach to analyse interviews that were done with service providers on perspectives on a Conversation Group for refugee families and complexities that would need to be taken into consideration for its implementation in resettlement contexts. The paper 3 comprises of the researcher's insights and critical reflection on the process of conducting this research and with a focus on explaining decisions made and implications of the research.

Paper one is a meta-synthesis of qualitative literature exploring the views of service users and carers/family members regarding their experiences of engaging with EIS. Following a standardised approach, four databases were searched and a sample of 14 papers were identified. Using an inductive thematic analysis (ITA) approach, within a critical realist epistemological framework, three main themes were identified: the importance of a personal relationship with an EIS staff member, the impact of this relationship and the consideration of life after EIS. The results highlighted the importance of service users and/or carers/family members building and maintaining a strong therapeutic bond with at least one member of EIS staff. Paper two is a qualitative study investigating service users' experiences of transitioning from EIS. Semi-structured interviews were completed with 15 participants who had either been discharged to primary care or to Community Mental Health Teams (CMHTs) and analysed, again using ITA, adopting a critical realist stance. Analysis identified five main themes: feeling ready for discharge, relationships and trust, planning for discharge, expectations of future care and the safety net of early intervention. The results and discussions offer practical implications and recommendations for services. Paper three provides a critical reflection of the research process. It includes reflections on the methodological approaches used, strengths, limitations and implications of the findings for research and clinical practice.

Understanding of the cognitive mechanisms of psychopathology in adults has contributed to the development of promising advances in treatment. There remains a dearth of similar evidence in child and adolescent psychopathology. There are calls to bridge developmental and clinical approaches to research and a move to consider the applicability of adult models of psychopathology. This thesis explores the contribution of two related aspects of cognitive function that represent core components of the Self-Regulatory Executive Function (S-REF) model of adult psychopathology (Wells, 2009) in child and adolescent populations: executive function (EF) and meta-cognition. Paper one systematically reviews the evidence that EF assessed at or before 5 years is associated with symptoms of internalizing psychopathology to test for prospective associations and determine which dimensions of EF are most predictive of symptoms. Fourteen studies that included 3428 participants used longitudinal multi-panel designs and administered a performance measure of EF at or before 5 years. Statistics from tests of association between EF and a subsequently administered measure of internalizing psychopathology were examined. Overall, poorer performance on EF measures was associated with increased risk for internalizing problems, particularly anxiety. Measures of complex response inhibition such as the day/night task most consistently demonstrated significant association with psychopathology. However, the direction of effects varied as a function of child temperament and parenting experiences. Higher levels of response inhibition were associated with increased risk for psychopathology in children with temperamental vulnerability and experience of over-controlling parenting. The ability to flexibly shift attention was protective in similar contexts. The reviewed evidence indicates that measures of EF in early childhood could indicate risk for internalizing problems. Response inhibition and attention shifting may provide a target for early intervention. Future research should select, assess and report on specific EF components in relation to outcomes. Meta-cognitive beliefs (MCB) - implicit and explicit beliefs about cognition have been associated with psychopathology in adults and adolescents (Sun et al.,2018). Paper two aimed to test the independent contribution of MCB over and above theory of mind (ToM) to psychopathology in a high-risk adolescent sample. We assessed MCB in 41 adopted adolescents who were participating in a longitudinal study of outcomes in adoption. ToM was assessed during middle childhood and parents reported on child psychopathology during middle childhood and again in adolescence. We found no association between MCB and ToM. MCB but not ToM were positively correlated with psychopathology. Furthermore, adolescent reports of dysfunctional MCB were significantly positively associated with parent reported internalizing psychopathology independent of ToM, demographics and language. There was no linear association between MCB, ToM and extent of early maltreatment or adversity. This is consistent with previous studies of ToM and suggests that future research should focus on alternative aetiological mechanisms (e.g., emotion socialization). Findings suggest that the S-REF model of psychopathology may provide a useful framework for understanding the mechanisms of internalizing disorder in adolescent maltreated populations, which has important theoretical and clinical implications. Paper three provides an overview of the theoretical underpinnings of the thesis, methodological strengths and weaknesses of each paper and the implications of the findings for theory and clinical practice.

Thesis Abstract This thesis forms part of the examination for the Doctor of Clinical Psychology (ClinPsyD) in the Faculty of Biology, Medicine and Health (School of Health Sciences) at The University of Manchester. The aim of the thesis was to explore the parenting experiences of refugees both across the refugee journey and in resettlement contexts. Paper one is a meta-synthesis of qualitative literature exploring parenting experiences for refugees in the resettlement context. Following a standardised approach, six databases were searched and a final sample of 15 papers identified. Using a constructivist approach to interpret the data, five core concepts were identified. The refugee parenting experience in resettlement was conceptualised in terms of a dynamic interplay between resettlement challenges and protective/promotive factors with the concept of support relevant to both aspects. The results highlighted the multiple complexities that refugees must parent through in the resettlement context. Paper two presents a constructivist grounded theory study of the parenting process for Syrian refugee parents who have fled conflict and eventually arrived in the UK. Semi-structured interviews with six health professionals and six refugee parents were conducted and analysed using the constant comparison method, along with the analysis of secondary data, contextual information and theoretical memos. The theory conceptualised the refugee parenting experience as a process of resilient parenting in recovery, with narratives and language as a key mechanism. The results highlighted a recovery process for parents that begins early in the refugee journey and the importance of positive coping factors that can be built on as part of tailored support. Paper three provides a critical reflection of the research process. It includes reflections on the methodological approaches used, strengths, limitations and implications of the findings for research and clinical practice.

The aim of this thesis was to explore the relationships between worry, rumination, psychotic symptoms and sleep disturbance. The thesis is presented as three papers; a systematic literature review, an empirical study and a critical appraisal. The systematic literature review in paper one gathered findings from clinical studies on the role of worry and rumination in psychosis. Robust evidence was found for a positive association between worry and persecutory delusions but not auditory hallucinations. Little evidence was found for a relationship between rumination and persecutory delusions or auditory hallucinations, yet conclusions remained tentative due to the limited number of studies in this area. The empirical study in paper two used experience sampling methodology (ESM) to investigate the relationship between objective, actigraphy defined, sleep disturbance and next-day worry, rumination and psychotic symptoms in people experiencing psychosis. Sleep disturbance did not predict worry, rumination or psychotic symptoms. Worry and rumination predicted concurrent auditory hallucinations and worry additionally predicted concurrent persecutory delusions. Effect estimates were small, as was the sample size, meaning the findings must be interpreted with caution. The critical appraisal in paper three evaluates and reflects upon the entire research process for both the literature review and empirical study. Strengths and weaknesses of the research are considered as well as implications for theory, clinical practice and future research.

This thesis aimed to explore interventions and nurse-patient relationships in acute mental health inpatient settings. Three separate papers are presented in this thesis: a systematic literature review, an empirical paper and a critical evaluation of the first two papers. Paper 1- This systematic review aimed to investigate clinically trialled psychosocial interventions for patients admitted to inpatient settings; and to identify which were effective at improving quality of life, symptoms or patient functioning. Eighteen were identified, fifteen studies showed a statistically significant positive impact on at least one outcome. Seven intervention categories (animal assisted therapy, music therapy, progressive muscle relaxation, education-based interventions, talking therapies, training-based interventions and cognitive remediation) and at least one study in each category was found to be effective. Methodological quality was generally low, and the small number of available RCTs makes it difficult to draw definitive conclusions. Further research is required of psychosocial interventions for acute mental health inpatient wards which use more rigorous methods of testing and reporting trials. Paper 2-To explore patient social functioning and nurse distress in relation to nurse-patient alliance, emotional regulation and attachment style in acute mental health inpatient wards. Patient anxious attachment style was significantly associated with difficulties in regulating emotions. Patient social behaviour was predicted by emotion regulation, attachment and alliance, but was not predicted by nurse emotion regulation, nurse attachment style or nurse-rated alliance. Nurse distress was associated with nurse emotion regulation, nurse anxious attachment and nurse-rated alliance, these factors also predicted nurse distress. Paper 3-The aim of the critical evaluation is to provide a critical appraisal of the design, implementation and interpretation of the findings for Papers 1 and 2. Strengths and challenges for both papers are discussed, and personal reflections about the thesis process are included.

The aim of this thesis was to explore the relationship between therapeutic alliance and suicidality. Three separate papers are presented: a systematic literature review, an empirical paper and a critical appraisal of the first two papers. Paper one, the systematic review, explored the relationship between therapeutic alliance and suicidality in existing research. Twelve papers were found which met the inclusion criteria: patients aged 18 or over, used a validated measure of alliance and explored the relationship between alliance and suicidality. Findings indicated that self-harm and suicidal thoughts are negatively associated with alliance measured from the patients' perspective: the higher the alliance, the lower the frequency or severity of self-harm and suicidal thoughts reported. There was less evidence for a relationship between alliance and suicidal attempts, possibly due to the infrequency of suicide attempts in the studies reviewed. Further research is also required to explore the relationship between suicidality and alliance rated by professionals or observers. Paper two, the empirical research, explored the relationships between therapeutic alliance, suicidality, defeat and entrapment in patients on a mental health ward. Alliance was explored between patients and nurses from both perspectives. Both patients' and nurses' perspectives of the patients' suicidality was also explored. Defeat, entrapment and suicidality were strongly correlated. Nurse-rated bond alliance and patient-rated external entrapment were also related, however, no other significant relationships were found between alliance and either defeat, entrapment or suicidality. Paper three, the critical appraisal, provides the reader with reflections on the methodology of both papers and the challenges completing the two research papers. Clinical implications and suggestions for future research are also presented.

This thesis aimed to explore the construct of stigma and its relationship with experiences of psychosis. In particular, it sought to investigate the role of assessment, lived experience, and therapeutic response to stigma, with those who experience psychosis. To achieve these objectives multiple methods were utilised including qualitative interviews, cross-sectional and longitudinal methods, systematic narrative synthesis and meta-analysis, and a feasibility randomised controlled trial. Chapter one provides a review of the stigma literature applied to people who experience psychosis. Chapter two provides an overview of the methodology utilised in this thesis and outlines the six academic papers which comprise the bulk of this thesis. Chapter three (Study 1) describes a systematic narrative synthesis and meta-analysis of psychosocial interventions for internalised stigma in psychosis. This review identified that no current trials of psychosocial intervention improved internalised stigma, but low-quality evidence limited the conclusions drawn. Further research examining psychosocial interventions is required. Chapter four (Study 2; n=79) outlines the development of semi-structured interview measure of stigma (SIMS) in psychosis. A reliable, valid and clinically relevant measure of stigma was developed specifically for people who experience psychosis. Chapter five (Study 3; n=25) outlines a qualitative exploration of stigma experiences with psychiatric inpatients who experience psychosis. This study identified three superordinate themes of 'stigmatising social environments and networks', 'stigmatised person with psychosis', and 'stigma interactions'. Chapter six (Study 4; n=79), explored relationships between stigma and psychological factors in psychosis. It identified that internalised shame and self-esteem were significant mediators between the relationships of experienced and perceived stigma with depression, hopelessness and recovery. Based on the evidence examined in chapters one to six, chapter seven (Study 5) outlined an integrative cognitive model of internalised stigma in psychosis. Chapter eight (Study 6), based on the model described in chapter seven, describes a feasibility randomised controlled trial (n=30) that was conducted examining the efficacy and acceptability of a brief internalised stigma CBT intervention, comparing it to a psychoeducational intervention, with acute inpatients who experience psychosis. The intervention was shown to be feasible and acceptable but a larger definitive trial is required. Finally chapter nine outlines an overall discussion and reflections on the previous chapters.

Bipolar disorder carries an ultra-high risk for the experience of suicidal thoughts and behaviours. Up to 80% of people who experience bipolar disorder will experience suicidal ideation during their lifetime and 50% will attempt to end their life on at least one occasion. Psychological theoretical models of suicide hypothesise that perceptions of social support play a significant role in the pathways underlying suicidal ideation and behaviour. However, there is a paucity of theoretically-motivated, scientific studies which investigate the relationship between perceived social support and suicidality in bipolar disorder. Empirical research examining the nature of this complex relationship, as well elucidating as the psychological mechanisms which underlie the relationship, are important for three reasons, (1) to refine theoretical models of suicide and ascertain whether they are applicable to individuals with bipolar disorder, (2) to identify potential psychosocial markers for suicide risk in bipolar disorder, and (3) to explore potential target areas for suicide-preventative psychological interventions. A series of five studies were designed to investigate the following key areas, (1) the ways in which social support-related constructs lead to, worsen and protect against the development of suicidal ideation and suicide attempts in bipolar disorder, (2) whether perceptions of defeat and entrapment, two theoretically-motivated constructs, underlie the development of prospective suicidal ideation in bipolar disorder, (3) the relationship between negative appraisals of social support, defeat, entrapment and suicidal ideation in bipolar disorder; iv.) the role of positive and negative appraisals of bipolar-relevant experiences in the pathways underlying perceived social support and suicidal ideation. These studies were informed by the first systematic literature review of the role of psychological and social factors in the suicidal thoughts and acts of people who experience bipolar disorder. A sixth study explored experiences of suicide research participation from the perspective of individuals with bipolar disorder. Qualitative findings highlighted that negative social experiences and a perceived lack of understanding from key members of social networks triggered suicidal thoughts. Perceived burdensomeness and the reinforcement of negative self-appraisals by others increased the severity suicidal thoughts and facilitated suicidal behaviour. However, considering the potential impact of participants' own suicide upon others was an important protective factor against suicidal behaviour. Similarly, reflecting on past positive social experiences fostered feelings of hope for the future and protected against the worsening of suicidal thoughts. Longitudinal quantitative studies supported the hypothesis that defeat and entrapment underlie prospective suicidal ideation in bipolar disorder. A longitudinal study also highlighted the existence of an indirect pathway, whereby negative perceptions of social support led to heightened defeat, entrapment and suicidal ideation. Moderated mediation was used to demonstrate that extreme and personal appraisals of depression moderated the relationship between defeat and suicidal ideation in bipolar disorder. Findings supported a socio-cognitive model of suicidal ideation and behaviour, the Schematic Appraisals Model of Suicide (SAMS; Johnson et al., 2008). Clinical and theoretical implications are discussed throughout.

This thesis investigated the application of the Self-Regulatory Executive Function (S-REF) model (Wells & Matthews, 1994, 1996) to distressing experiences of psychosis. A multi-method approach tested a series of hypotheses derived from the S-REF model. The methods included systematic review, meta-analysis, cross-sectional and experimental designs. Statistical methods examined relationships between metacognitive beliefs, coping strategies, positive symptoms and distress. Chapter 1 provides a general introduction to psychosis and metacognition, and outlines the aims and objectives of the thesis. Chapter 2 provides an overview of the methods used in subsequent studies and presents a detailed rationale for the choice of design and analysis. Chapters 3 and 4 (study 1 and 2) present the findings of two systematic reviews and meta-analyses. The reviews reflect two fundamental aspects of the S-REF model (metacognitive beliefs and unhelpful coping strategies) and summarise the current empirical position of research in each area respectively. Study 1 revealed a high level of similarity between metacognitive beliefs endorsed by people with psychosis and people with emotional disorder. Study 2 revealed several plausible links between unhelpful coping strategies, experiences of psychosis and negative affect. The reviews identified areas that require further investigation and guided the development of the subsequent studies. Chapter 5 (study 3) examines the relationships between metacognitive beliefs, positive symptoms and negative affect in a clinical sample. The results showed that metacognitive beliefs predict negative affect over and above the topological characteristics of positive symptoms. The findings highlight the influence of metacognitive beliefs in negative affective states when the contribution of psychotic symptoms is controlled. In a similar design, chapter 6 (study 4) examines the relationships between unhelpful coping strategies and positive and negative outcomes in a clinical sample. The results revealed that coping strategies did not predict positive symptoms, negative affect, quality of life or recovery. However, metacognitive beliefs emerged as consistent and unique predictors of these variables when the comorbidities were controlled. The findings further highlight the influence of metacognitive beliefs on subjective wellbeing. Chapters 7 and 8 examine the relationship between metacognitive beliefs, paranoia and negative affect. Chapter 7 (study 5) tested whether experimental manipulation of negative metacognitive beliefs could increase paranoid intrusions and negative affect. The study utilised a fake-EEG paradigm, whereby metacognitive beliefs were manipulated with the suggestion that detection of a paranoid thought by the EEG would result in a loud noise. The findings were not statistically significant, but demonstrated the manipulations worked and the experimental paradigm is feasible. Chapter 8 (study 6) explored the combined role of cognition (i.e. schemas) and metacognition in non-clinical paranoia. The findings suggest that schemas predict paranoia frequency whilst metacognitive beliefs moderate distress. This thesis has extended current research by demonstrating novel links between metacognition and negative affect in the context of experiences of psychosis. The findings have relevance for psychological approaches as they support the investigation of both cognitive and metacognitive factors. The findings also have relevance for psychological intervention as they support the consideration of metacognitive approaches.

This thesis explored the impact of causal beliefs on treatment outcome and stigma in people who have experience of psychosis. A multi-method approach was utilised. Chapter 1 provides a background to the thesis and an overview of current findings and this is followed by a review of the methodologies in Chapter 2. Study one (Chapter 3) provides a systematic review and narrative of current research on this topic. This identified a distinct lack of research within this area of study and highlighted mixed findings in relation to the importance of causal beliefs on treatment outcome. Study two (Chapter 4) used qualitative interviews to examine factors that influenced the development and maintenance of causal beliefs using a thematic approach. This identified a number of themes, including the role of information processing and affect. Study three (Chapter 5) explored the opinions about the cause of psychosis in a group of clinicians and the relationship between these beliefs and opinions about the helpfulness of treatment. Clinicians who endorsed psychosocial causes viewed CBT as more helpful, whilst clinicians with biogenetic beliefs were more likely to believe medication would be helpful. Study four (Chapter six) explored the causal beliefs of a large group of service-users and how these beliefs were related to perceptions about the helpfulness of treatment and the treatment accessed. This study found that service-users endorsed a number of different causes but preferred a psychosocial model overall. Only a small number of significant relationships between beliefs and treatment were identified. Study five (Chapter 7) utilised an experimental design to examine the impact of two explanatory models (biogenetic vs. psychosocial) on internalised and external stigma in people experiencing psychosis. Results indicated a significant reduction in internalised stigma in both groups. Only those in the psychosocial group observed a reduction of external stigma. Study six (chapter 8) explored the relationship between causal beliefs and different aspects of treatment (perceptions, adherence, outcome) with individuals participating in an RCT. Psychosocial beliefs were associated with a belief that therapy would be helpful, whilst biogenetic beliefs were associated with a belief that medication would be helpful. No relationships were identified between beliefs and adherence with medication or engagement with therapy or treatment outcome. This thesis has provided an overview of current causal beliefs in a large group of service-users and clinicians. These suggest that both groups endorse a multi-factorial model, but prefer psychosocial explanations. Some relationships were found between beliefs and treatment, in particularly in relation to opinions about the helpfulness of treatment. This suggests that beliefs may influence attitudes in a meaningful way. However, beliefs were found not to influence treatment adherence, engagement or perceptions about the helpfulness of different treatment options. Finally, the experimental study identified some interesting relationships between beliefs and the different domains of stigma, suggesting that aetiological information influences internalised stigma and external stigma differentially. The clinical and research implications of this are discussed.