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

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

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

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

Objectives This study investigated the subjective, embodied lived experience of individuals who had experienced psychosis, in addition to the interplay and impact of dominant psychiatric discourse on the meaning-making process. Constructions of psychosis deployed, experiential phenomena expressed, and therefore implications for subjectivity, selfhood, and meaning-making, were explored. Design A dual focus methodology combining Interpretative Phenomenological Analysis (IPA) and Foucauldian Discourse Analysis (FDA) was utilised to explore both language and experience. Despite arguments that combining IPA and FDA creates epistemological/ontological conflicts due to dissonant theoretical underpinnings, adoption of a critical realist position permitted an integration of these approaches. Method Four individuals with experience of both psychosis and accessing mental health services were interviewed. Focussing on both discourse and embodied lived experience, transcribed interviews were analysed using a dual focus of IPA and FDA simultaneously, followed by an integrative analysis. Results Individuals described a meaning-making crisis, affected by disorientating unusual perceptual experiences in a relational context. Themes emerged pertaining to loss, trust, agency and a fight for a meaningful existence, in both the embodied lived experience and socially constructed nature of reality. Dominant psychiatric discourse was experienced as generally limiting, with implications for levels of recovery and meaningful existence. Conclusion A combined methodological approach enabled a comprehensive understanding of the dynamic interaction between language and the situatedness of embodied experience, coexisting dynamically within our personal and social realities. Meaning-making, and participants developing their own personal meaning, were found to be fundamental in experiencing life as meaningful, thereby creating hope for the future. Recommendations for practice include prioritising the subjective lived experience of psychosis and acknowledging the socially constructed nature of our reality by creating a therapeutic encounter in which personal meaning can be made by drawing on a variety of culturally available discourses, rather than the imposition of meaning associated with dominant psychiatric discourse.

This thesis focusses on the issue of burnout in frontline ambulance workers. The first chapter presents a systematic review of quantitative research conducted with frontline ambulance workers, using the Maslach Burnout Inventory to identify the prevalence of burnout and factors associated with it. Fifteen papers were included in the review. A wide range of factors were identified and organised into five overarching concepts. Four of these were understood to be potential predictors of burnout: job demands, job resources, personal resources and individual factors. One factor group represented outcomes of burnout. The majority of studies used correlational analysis however, thus causality could not be asserted. Prevalence rates of burnout were estimated based on six of the studies included in the review, but could not be established definitively due to differences across studies in the use of the Maslach Burnout Inventory. The review raised further questions about the methodology typically used to assess burnout in ambulance workers. Chapter two presents a quantitative research study focused on the relationship between workplace violence, coping styles and burnout in frontline ambulance workers. Participants were recruited from four National Health Service Ambulance Trusts and their responses to questionnaire measures were compared. The findings revealed high levels of workplace violence and burnout symptomology. Dysfunctional coping styles mediated the relationship between workplace violence and both the emotional exhaustion and depersonalisation aspects of burnout. Findings were inconclusive regarding the utility of problem-focused and emotion-focused coping in the violence-burnout relationship. Results are discussed, and clinical and research implications are identified. The third chapter is the author's reflective account of conducting this research. The reflection presents an evaluation of the author's identity as both a researcher and clinician and the conflicts that arose during the research process. The relative strengths of different research methodologies are considered as part of this chapter.

This thesis explores the application and understanding of compassion. Chapter one examines the application of compassion through Compassion-based Interventions (CBIs) for parents. Chapter two investigates the understanding of compassion from the perspective of Mental Health Nursing Students (MHNSs). Chapter one is a systematic literature review investigating CBIs for parents. The aims were to evaluate the effectiveness of CBIs on psychological factors, examine qualitative themes and integrate quantitative and qualitative knowledge. Ten moderate to high quality studies published between 2018 and 2020 were evaluated using a mixed studies design (Pluye & Hong, 2014). Samples were small and biased, limiting the strength of conclusions. CBIs show promise for improving self-compassion in some mothers. More research is needed to strengthen other conclusions. Integration of quantitative and qualitative data suggests interventions with evidence of qualitative themes (sharing experiences, self-acceptance, reflecting on difficulties and hope and trust for the future) may yield more significant and larger effects than those without. Chapter two is a qualitative research study using Constructivist Grounded Theory (CGT) methodology to investigate MHNSs' understanding of compassion. Nine MHNSs were interviewed. Following CGT analysis, a theoretical model was constructed. Compassion was understood as an interrelated set of areas, namely "Pure concern for other"; Doing good, being good; Safe to learn; '"We're all in this together" and Care for self for others leading to a core concept of 'Connecting'. For MHNSs, compassion involves primarily connecting with their patients alongside connecting with values, their course and mentors, their cohort and tentatively with themselves. Chapter three is a first-person reflective account of the author's research experience. The account is shaped by the three systems of emotion regulation from Gilbert (2009). Personal and systemic factors affecting the author's threat, drive and soothe systems are discussed before concluding with a focus on the future.

Personal development (PD) groups are an expected and are assumed to be a necessary and beneficial part of counselling and psychotherapy training. These can take a varied and individualised form in training institutions, ranging in number of participants and facilitated by either member of teaching teams or by trainers external to the course. A qualitative study was designed to retrospectively explore 11 qualified counsellors' experiences of their PD groups in training and how they use these in their current client and training work. The participants took part in semi-structured interviews, and the interviews were analysed using Interpretative Phenomenological Analysis (IPA). The key findings indicate that experiences in PD groups can be psychologically traumatic, but if individuals are able to tolerate this, the experience can be processed into important learning for client and training work. The research suggests that the nature of experiential and emotional learning through PD group experiences emerges over a considerable period rather than at the time of the PD group work itself. Furthermore, self-understanding and insight, making connections to therapeutic and training work as a counsellor or psychotherapist, involves making meaning from these challenging experiences, enabling participants to use them in their clinical and training work. Recommendations for specialised training and support of group facilitators, and preparation for group participants, are made.

It is deeply rooted in the social consciousness that dangerousness in inherent in the mental disorder. Over recent years, few extremely violent crimes committed by individuals suffering from schizophrenia have had an adverse impact on public opinion enhancing the widespread social misconception. Considering there is limited research on crimes committed by offenders suffering from schizophrenia, the present study carried out in the interest of obtaining a better knowledge of schizophrenic offenders' criminal actions and the etiological factors associated to the expression and maintenance of the violent behaviour in such populations. The general purpose of the present study was to investigate the Criminal Narrative Experience of the Schizophrenic Offenders by the application of the Criminal Narrative Experience framework proposed for non mentally ill offenders (Ioannou, 2006); and further explore the emotional state of that population in terms of moral emotions, depression and suicidal ideation regarding the CNE of these offenders. This is the first study to examine the CNE framework solely in schizophrenic offenders and the first one to explore the emotional state in terms of the above mentioned aspects in combination to schizophrenic offenders during incarceration. A total of 64 schizophrenic offenders who have been found Not Guilty by Reason of Insanity and recruited from three Psychiatric Hospitals in Greece, were voluntary participated in the present study. All the participants completed the demographic questionnaires regarding their personal, psychiatric and criminal background and seven questionnaires regarding their Criminal Narrative Experience and their emotional state. The present research successfully implemented the Criminal Narrative Experiences model and revealed the internal motives and the emotional gratifications that lead to crime. The findings mirrored partially the findings of previous studies in non mentally and mentally ill populations. Specifically, the study identified three Criminal Narrative Experience themes the Displeased Victim, the Contradicted Revenger and the Pleased Hero. Furthermore, it was found that the most dominant criminal narrative experience was the Displeased Victim as the majority of the participants experienced negative emotions and felt as victims during the crimes they had committed. Last but not least, there were found differences between the three Criminal Narrative Experience themes in terms of their emotional state and there was found that the background characteristic of schizophrenic offenders do not play any significant role in the formation of their criminal experience.

From a broad perspective, clients' experiences of psychological therapies have been widely investigated. This has often focused on the experience of types of therapies and specific client groups, based on factors such as religion, mental disorder, gender, ethnicity, profession, and culture. However, within the realm of religiosity and spirituality, there appears to be a lack of research on Buddhist clients' therapeutic experiences, despite the vast amount of studies on the impact of implementing Buddhist principles into therapeutic modalities. For this reason, the aim of the current study is to capture, explore, and understand how Buddhist clients experience psychological therapy. This includes explorations into therapeutic relationships, treatment interventions, clients' relationships with Buddhism and its impacts on their experiences in therapy. A purposive sampling method was used to recruit seven self identified Buddhists who took part in semi-structured interviews. Findings were analysed using interpretative phenomenological analysis. This generated three master themes that provided insights into some of the factors that facilitated and inhibited the progress of therapy and the therapeutic relationship for Buddhist clients. The findings from this study add to existing knowledge of therapeutic experiences amongst religious and/or spiritual groups and provides new insights into how therapy can be helpful to clients with strong religious and/or spiritual beliefs and values, which at times may be in conflict with treatment interventions. The implications and future recommendations of this study for the field of counselling psychology, including the discussion of the importance of utilising R/S-specific interventions for this client group, relate well to therapists' training needs.

Objective Transdiagnostic web-based Acceptance and Commitment Therapy (ACT) interventions have been shown to be effective in improving mental health outcomes in university students in the USA (Levin, Haeger, & Cruz, 2019), Australia (Viskovich & Pakenham, 2018), and Finland (Rasanen, Lappalainen, Muotka, Tolvanen, & Lappalainen, 2016). However, these interventions have not yet been evaluated in the UK, where university students are experiencing a mental health crisis (The Insight Network, 2019). This study evaluated a transdiagnostic web-based ACT self-help intervention called LifeToolbox designed specifically for university students. Method A total of 112 undergraduate (22%) and postgraduate (78%) students attending university in the UK were randomised to the immediate treatment (ACT) or waiting-list control (WLC) condition with online self-report assessments at baseline and two further timepoints. A waitlist crossover design was used such that participants in the WLC condition transferred to the active arm following the second assessment. Primary outcomes assessed: academic distress, alcohol use, generalised anxiety, depression, eating concerns, hostility, self-compassion, social anxiety and overall distress. Processes assessed: cognitive defusion, mindful awareness, psychological inflexibility, valued living, and self-compassion. Results Overall results were mixed. However, relative to the waiting-list control group, participants receiving ACT significantly improved on mindful awareness, F(l, 55.70) = 19.14, p < .001, self-compassion, F(l, 56.47) = 6.63,p = .01, and social anxiety, F(l, 59.86) = 6.30, p = .02, in the intention-to-treat sample. Within-subjects analyses showed significant improvements on the combined mental health variables between the start and end of the course, F(l4, 26) = 4.20, p = .001, Pillai's V = .69, 11l = .69, on half of the primary outcomes (generalised anxiety, hostility, social anxiety, and overall distress) and on all ACT processes in the completer sample. All ACT processes mediated changes on one or more primary outcomes, with cognitive fusion being the most frequent mediator. Participants rated the program as 'excellent' on a standardised measure. Conclusions These preliminary findings suggest that web-based ACT self help programs merit more attention as a cost-effective and easily disseminated treatment platform for the promotion of mental health skills in university students.

This study examines the phenomenon of interoception – an individual’s perception or sense of their own body state (Pollatos, 2007) - and countertransference – the emotional experiences and reactions provoked in the therapist by a patient (Heimann, 1950). The study looks specifically at embodied countertransference – ‘the spontaneous arousal of physical feelings in the therapist ... ’ (Field, 1989: p.512). It employs theoretical and empirical research methods, both qualitative and quantitative, in order to capture something of the tension existing between empirical observation and the subjective emotional realm of feeling and intuition. The study explores links between interoceptive capacity and countertransference. Thirty-seven trainee child psychotherapists completed a qualitative countertransference questionnaire and Egan and Carr’s (2005) Body-Centred Countertransference Questionnaire. They performed an established interoceptive accuracy assessment (Heartbeat Counting (Schandry, 1981)) and completed a confidence measure pertaining to it. Data from the Heartbeat Counting task was used to generate a metacognitive measure of interoceptive awareness (Garfinkle et al, 2015). Empirical data pertaining to interoceptive capacity and body-centred countertransference were considered together, for the sample group as a whole and between training year groups, in order to explore the overarching research question: Is there a relationship between interoception and countertransference? Results: Interoceptive accuracy was not shown to increase with years of training in child psychotherapy. A statistically significant, non-linear, relationship between reported confidence on the interoceptive accuracy task and year of training was observed however; and interoceptive accuracy and reported confidence were also shown to be positively correlated. As a sample group, child psychotherapy trainees only approached ‘interoceptive awareness’. Embodied countertransference phenomena were universally reported, increasing in frequency with year of training to Year 3. In the qualitative research, countertransference emerges as a vital, albeit ‘opaque and disturbing’ tool, enabling the trainees to ‘go beyond words’ in their work with children and young people. A striking homogeneity was observed in participant responses, raising questions about the place for doubt and alternative perspectives upon a phenomenon much debated in psychoanalytic theory and the research literature. This a unique study contributing to the research literature in Child Psychotherapy. It highlights potential links between interoception and countertransference. Results may have implications for the training of Child Psychotherapists, in particular, to the attention that is paid to physical experiences. Further study of trainees and qualified psychotherapists may yield more connections between these two phenomena.

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

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

This qualitative research thesis looks to investigate the phenomenon of skin colour in the field of psychoanalytic child psychotherapy. This research is interested in why conversations around racialised skin colour appears to be a quiet aspect of psychoanalytic thinking and is known as an ‘under-researched area’. The thesis begins with a comprehensive literature review into how racialised skin colour has been understood in psychoanalytic and social psychological/sociological theory. Then explored are the experiences of psychoanalytic child psychotherapists with darker skin colour, as a point of entry to observing the culture around race within the profession. Employed is a unique mixed method design undertaking four semi structured interviews in combination with an autoethnographic narrative analysis. Investigated are the ways darker skin colour is experienced in the mind of the individual clinician, the interpersonal therapy space and professional discourse. Findings suggest psychoanalytic child psychotherapy must find ways to radically move away from (and with awareness) of traditionally psychoanalytic and politically affected race rhetoric, to develop a culture where trainees and qualified professionals feel safe to explore race with one another. This is imperative if the profession can offer young people and their families an authentic therapeutic experience, where novel, dynamic and developmentally valuable interpersonal moments are able to analyse the racial experience. This thesis provides essential thought and development of new ideas and considerations for psychoanalytic child psychotherapy thinking, practice and training.

This thesis is submitted in partial fulfilment of the requirement for the degree of Doctorate of Clinical Psychology (DClinPsy). It is a portfolio thesis and as such consists of two separate papers. The systematic review and empirical paper have been prepared in accordance with the author guidelines for the target journal, the Journal of Contextual Behaviour Science. Psychological Flexibility Psychological Flexibility is a person’s ability to maintain or change behaviour according to their goals or values, with an awareness of impacts on their situation and complete openness to ongoing thoughts and feelings. The construct of PF has been hypothesised to be a principal aspect of psychological health and mental well-being. PF is understood to reflect three dyadic sub-processes, referred to as open, aware and active. PF is a common target of contemporary cognitive and behavioural interventions for promoting psychological health, but this is most explicitly stated within Acceptance and Commitment Therapy (ACT). Paper 1: Systematic Literature Review The Avoidance and Fusion Questionnaire – Youth (AFQ-Y) is a process measure, designed to assess psychological inflexibility in young people. The AFQY8 (short-form) is increasingly being adopted for research and clinical use, but its psychometric properties are unexamined. The COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) is a set of explicit guidelines for the selection of process/outcome measures in both research and clinical use. The guidelines provide robust methodological criteria for undertaking systematic reviews of process/outcome measures and whilst examining the psychometric properties they also critically evaluate the quality of the evidence. Through the application of COSMIN methodology, the review provides a benchmark for the level of confidence that can be held by researchers and clinicians when selecting to use the AFQ-Y8. Paper 2: Empirical Paper Given its purported centrality to psychological health, it is important that validated measures of PF are available; however, no comprehensive measure of PF exists for use with an adolescent population. In order to comprehensively measure PF, there is a requirement to reliably measure the three dyadic sub-processes. The Comprehensive assessment of ACT (CompACT) is a validated process measure currently used with adults but has not been validated with an adolescent population. The empirical paper evaluates the construct validity of the CompACT in order to understand whether it is understood by an adolescent population i.e., whether item content is clear, relevant, and interpreted/responded to in terms of targeted meaning. To achieve this, two studies were undertaken. In study 1, cognitive interviewing was conducted with 36 students (11-18yrs), with analysis showing that adolescents found problems with all 23-items, specifically in the understanding stage, and predominantly lexical problems. Subsequent analysis generated an alternative pool of items with age-specific adaptations. In study 2, consultation was undertaken with 11 international experts (in PF and/or using ACT with adolescents) using a web-based survey tool. The outcome informed selection of a final set of 23 alternative items with confirmed construct relevance for gauging PF in an adolescent population. The overall outcome of study 1 and 2 is a revised comprehensive measure of PF, which requires psychometric validation.

This thesis comprises of two papers; a systematic review and an empirical study. The systematic review explored the effectiveness of group-based Acceptance and Commitment Therapy interventions for those with a diagnosed neurological condition. Individuals with a neurological condition have the lowest health related quality of life of any long-term health condition with around one quarter being diagnosed with a co-morbid mental health condition. Acceptance and commitment therapy (ACT) is effective for those with long-term health conditions with a growing evidence base. However, reviews of effectiveness in those with neurological conditions are lacking. The systematic review aimed to evaluate effectiveness and quality of studies of group-based ACT for adults with neurological conditions. Searches for peer-reviewed articles were carried out using Psych Info, Ovid MEDLINE and EMBASE. Two reviewers independently screened and rated all relevant studies. Twelve studies were included: eight were randomised controlled trials, one used a randomised design with repeated measures, one used a quasi-experimental design with pre-post measures and two used pre-post designs with no control group. The neurological conditions which were covered by the included studies were Multiple Sclerosis, Epilepsy, Fibromyalgia, Stroke and Chronic Headache. Interventions were targeted at a number of outcomes including Quality of Life, distress and the processes of ACT. The results of the review generally supported the finding that group-based ACT seems to be as effective as other active treatments and more effective than Treatment as Usual or Waiting list controls. Improvements as a result of ACT were found in all studies which examined the level of pain related disability, the impact of the neurological condition, frequency of seizures, secondary fatigue, and the core processes of ACT. The empirical paper was a qualitative study of a stroke specific self-management book. The study was thought to be beneficial to the evidence base for stroke as despite pressure to deliver psychological interventions to those who have experienced a stroke, there continues to be a lack of psychological resources available for this patient group. Depressive symptoms have also been found to be reduced in stroke survivors when they are provided with information post-stroke, thus emphasising the potential role for self-help resources in this area. The aim of the paper was therefore to gain insight into staff working within stroke services experiences of using a stroke specific self-management book in their practice. Interviews with fifteen staff members working within stroke services who had used the ‘Rebuilding your life after stroke’ (Morris et al., 2017) self-management book were conducted and analysed using a thematic analysis approach. Staff members varied in their role, training, age and length of service working with a stroke population. All participants appeared to believe that the book was a welcome addition to the resources available within stroke services. The book appeared to be considered as a form of peer support and was felt to be accessible from a practical point of view. Professional role and level of training appeared to influence the views of interviewees, how they used the book in practice and how user-friendly they felt certain ACT concepts were for themselves and the stroke survivors they work with. The main conclusion of the current study was that in general ‘Rebuilding your life after stroke’ (Morris et al, 2017) had been positively received and welcomed by those staff interviewed. All participants agreed that the book had in some way supplemented their practice with most remarking on the benefits of having such a resource available both for themselves and the stroke survivors they work with. The study did however find that staff without knowledge of psychological concepts such as ACT may find training around the book useful in order to gain the most benefit from it within their practice. This therefore outlines a potential role for psychologists within the area of staff training and upskilling of the workforce working within stroke services.

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

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

Some concerning statistics regarding mental health in young people have been reported in recent years, for example that globally, depression is one of the primary causes of illness amongst adolescents, with 50% of all mental health conditions appearing by the age of 14 (World Health Organisation (WHO), 2019). One particularly at-risk group is adolescents attending alternative provisions. Often considered the most challenging group of young people to work with, it is important that research aims to identify effective ways of supporting these pupils. The present study examined the impact of a six session Acceptance and Commitment Therapy (ACT) based intervention on the social and emotional wellbeing of pupils in year 11 accessing on-site alternative provision. Sessions were delivered by the researcher to an experimental group (n=4), with outcome measures compared to a control group who did not receive intervention (n=4). A mixed-methods design was employed, consisting of self-report and other-report questionnaires and semi-structured interviews. Two-way repeated measures Analysis of Variances (ANOVAs) were conducted and revealed no statistically significant interactions on any of the self-reported outcome measures except for the ‘Disruptive Behaviour’ scale of the Beck Youth Inventories 2nd Ed. between time and condition (BYI-2) F (1, 6) = 7.66, p = .03, ηp2 = 0.56. However, visual trends in the data indicated that pupils in the experimental condition experienced greater improvements on measures of wellbeing, psychological flexibility and behaviour compared to the control. Pupils in the experimental group also showed visual improvements across all outcomes measured by the Strengths and Difficulties Questionnaire (SDQ), completed by a member of staff. Thematic analysis of follow-up interviews with pupils in the experimental condition revealed six main themes of: SelfEvaluation, Motivation, Experience of Being an ‘SEBD’ (Social, Emotional and Behavioural Difficulties) Pupil, Interpretation of Programme Content, Engagement and Group Dynamics, along with 19 corresponding sub-themes. Four main themes were defined through a thematic analysis of a staff follow-up interview in the experimental condition: Changes to Pupils’ Behaviour, Changes to Pupils’ Engagement with Learning, Ideas for Future Delivery of Sessions and Additional Ideas to Support the Emotional Wellbeing of Pupils, comprised of 16 sub-themes. Threats to the internal validity of the data in this study are acknowledged, with preliminary findings being tentatively argued as evidence to support further research into this area. Recommendations based on the views of participants within the study are also discussed, including the importance of adapting materials to suit specific groups of pupils, and having sessions delivered by a member of staff.

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

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

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

Virtual Reality is an emerging technology with a variety of potential benefits in research, assessment and treatment. The ability to create and control the dynamic 3-dimensional environments within which behavioural responses can be measured and recorded, allows this technology to offer ways of psychological assessment that traditional methods may not be capable of providing. Although plenty of research has been carried out to explore the use of VR in psychology, little was done to further the understanding of the processes of VR design. Considering the potential possibilities of VR in the area of psychological treatments, it is necessary to investigate how VR applications can be designed to meet the needs of psychologists, researchers and end-users. To achieve this, the use of co-design approach is recommended. It is also important to provide stakeholders with the co-design pipeline and technical guidelines on how to create these applications. In the first stage of the research, a series of case studies for pain management and anxiety disorders were carried out to investigate the design opportunities and challenges in the development of mobile VR psychotherapy applications. This includes the description of the development and design process of VR applications, as well as the tools and techniques used for it. Specifically, a mobile VR application for pain management research, where I took part as a designer/developer, and another mobile VR application for anxiety disorders were developed. A study was conducted to examine the innovative use of mobile VR technology to deliver a form of cognitive bias training for anxiety disorder. Forty-two students high in trait anxiety completed one session of either virtual reality cognitive bias modification of interpretations training (VR-CBM-I) or standard CBM-I training for performance anxiety. Overall, the results showed that based on post-training, the VR-CMB-I training reduced perceived anxiety significantly more than the standard CBM-I training. Moreover, the increase in anxiety response in the VRCMB-I training condition after the stressor task was also significantly less when compared to the standard training. Thus, there was a significant increase in positive interpretations and a significant decrease in negative interpretations in both conditions after the training. The results from this stage allowed to identify some key co-design phases as well as techniques and components needed for a successful mobile VR application development. In the second stage of the research, the more advanced system was developed. The use of Multi-User Virtual Reality (MUVR) as a tool to offer effective intervention for representative users at high-risk of eating disorder (ED) was explored. Fourteen females deemed at high risk of ED completed one session of either MUVR intervention based on Acceptance and Commitment Therapy (ACT) or MUVR intervention based on Play Therapy (PT). The use of VR for remote psychotherapy was explored, and the impact of such intervention on both therapists and participants was observed. In addition, the design opportunities, pitfalls, and recommendations for future deployment in psychological interventions were presented. The findings from this thesis help extend the knowledge regarding the design, development and implementation of VR applications in psychotherapy. Contributions within the study can help psychologists, developers and researchers in identifying how these VR applications can be best designed and applied for psychological treatments. Additionally, these findings were formed into a set of 3 guidelines to aid developers and psychologists in creating better VR applications to facilitate psychological interventions.

Background: The health inequalities faced by people with intellectual disabilities (ID) are well documented, affecting both duration and quality of life. Painful health conditions can be difficult to recognise as many people with ID struggle to self-report their pain. Therefore it is important that accurate observational tools are available to support recognition and assessment of pain in people with ID. Aim: This thesis seeks to assess the use of currently available observational assessments of pain through meta-analytic methods, and then evaluates a more specialist observational tool designed to detect gastric pain. Meta-analysis: A comprehensive review of the literature found 62 distinct observational measures used in published research. The five most commonly used measures were assessed through a series of meta-analyses, synthesising correlations between observational and self-report measures of pain. Moderate correlations were found for all observational measures compared to self-report, though unacceptable levels of heterogeneity were also identified. Recommendations are made for use of the Face, Legs, Activity, Crying, Consolability scale. Empirical paper: The Gastric Distress Questionnaire (GDQ) is a parent report measure designed to screen for Gastro-oesophageal Reflux Disease (GORD), a painful health condition which is common in people with ID. Significant differences in GDQ scores were found between children with and without recent GORD. A clinical cut off is recommended for the use of the GDQ to screen for reflux. Behavioural observation by a naïve observer was not found to associate to GDQ scores provided by a parent, emphasising the importance of caregiver report in identifying GORD.

Introduction: Sarcoma is a rare form of cancer that is often misdiagnosed or diagnosed at an advanced stage. Surgery is the recommended first line treatment. Patients diagnosed with sarcoma report anxiety before surgery and a percentage of this patient population are at risk of psychological distress following surgery. The practice of prehabilitation has a growing evidence base for improving surgical outcomes for a range of cancers; however, it is yet to be demonstrated if prehabilitation for Sarcoma is feasible and offers benefit to sarcoma patients. The present study looks to investigate the feasibility of trialling a randomised control trial of psychological prehabilitation for Sarcoma patients. Method: A controlled pre-post study was designed, following a request from the sarcoma health care team at the local trust, reporting a need for care before surgery. Furthermore, previous research conducted by Tsimopoulou (2015) and Asfaw (2019), identified the need and benefits of prehabilitation in sarcoma patients. A one-hour intervention was created and offered to sarcoma patients, recruited to the study. Participants were randomised to either a control or experimental arm. Participants were asked to complete six questionnaires regarding their emotional and physical wellbeing. Following this, participants in the experimental arm received a psychological intervention with a trainee clinical psychologist prior to their surgery. The intervention was informed by Acceptance and Commitment Therapy and Compassion Focused Therapy. All participants then underwent surgery. Outcome measures were repeated at approximately four weeks after surgery. In addition to the formal outcome measures, the feasibility of the study was assessed in regard to the feasibility of recruitment, follow-up and randomisation, amongst other parameters. Results: Nine participants took part in the feasibility study. It was feasible and acceptable to randomise participants between conditions; however, participants completed follow up measures within differing timescales. A Cohen's D power calculation identified that for a randomised control trial to have sufficient power, one hundred and sixteen participants would need to be recruited. Finally, reliable change calculations highlighted the appropriateness of the chosen measures as they were found to be sensitive to changes in this population. 47 Discussion: The study indicated that it would be feasible to implement the psychological intervention as part of a randomised control trial of prehabilitation for sarcoma patients, with a number of modifications to the present design. Modifications include embedding the study within the service to utilise existing resources in order to increase both recruitment the controllability of the study. Furthermore, prehabilitation may only be indicated for a percentage of patients with Sarcoma therefore a pathway approach, where individuals are screened for vulnerabilities to psychological decline following surgery are identified, with other patients receiving treatment as usual. Volume II consists of five clinical practice reports. The first report presents the case of Margaery1, a 51-year old lady living with a diagnosis of schizophrenia presenting with intrusive thoughts. Two formulations are presented: A cognitive behavioural formulation of intrusive thoughts in the context of obsessive-compulsive disorder and a psychodynamic formulation are presented to understand the distress that Margaery experiences. The second report presents a service evaluation of staff members perceptions of the current pathway for clients diagnosed with emotionally unstable personality disorder in a local adult mental health community service. The third report presents the case of Alfred, a 65-year old man being treated in a local older adult inpatient ward, presenting with symptoms of a panic disorder. Alfred's distress is formulated within a cognitive behavioural therapy(CBT) formulation. A CBT intervention, including graded exposure, is then described and analysed using a single case A-B design. The fourth report describes the case of Daisy, a 26-year old female diagnosed with a mild learning disability, who presented with difficulties with interpersonal difficulties and health anxieties. A formulation informed by cognitive analytic therapy(CAT) is presented along with a CAT informed intervention. The final report describes the case of Jess, a 13-year old female presenting to a local child and adolescent mental health service with symptoms of generalised anxiety. Three formulations are presented: cognitive behavioural therapy, in addition to a systematic formulation and a psychodynamic formulation, which were used to reformulate the case are presented. The beginning of an anxiety management intervention is described, and the outcomes obtained during the time of intervention.

Background: Mindfulness Based Interventions (MBI's) have been adapted for workplace settings in recent years. Despite the large number of studies conducted exploring the efficacy of MBI's, previous research has yielded varied results, and the specific mechanisms by which MBCT leads to positive change remain unclear. There is very little qualitative research exploring employees' experiences of workplace MBCT interventions, or the impact of such interventions. If MBCT is to be considered as a workplace intervention, research must clarify the process underlying participant's use and experience, as well as the acceptability of such workplace interventions. Aim: The current study aims to • explore public sector employee's experiences and reflections of a brief MBCT intervention. • examine whether participants found the brief intervention useful and how participants used mindfulness. • explore any difficulties that participants encountered when practicing mindfulness. Methodology: Semi structured individual interviews were conducted with twelve participants. The data generated from the interviews was analysed using a thematic analysis approach. Additional quantitative data was collected, such as the Mindfulness Attention Awareness Scale (MAAS), and the General Health Questionnaire (GHQ-12). RESULTS The following four themes emerged from the twelve interviews: (1) effects of the mindfulness intervention, (2) implementation of mindfulness (3) sharing group experiences and disseminating mindfulness to others and (4) challenges of practice. Overall, most participants felt that they benefited from the intervention, there was an ability to reappraise life situations, increased acceptance, greater attention and awareness of actions, thoughts, and emotions, living more actively in the present moment, a calmer attitude, as well as improved sleep. However, quantitative data indicated lower mean scores of GHQ-12, but only small changes in the mindfulness mean scores post intervention. Participants that attended the intervention integrated mindfulness practice in a variety of ways, some participants integrated formal structured practice within their daily routines, other participants chose to use mindfulness as and when they felt it was required, such as when they needed to relax, or were required to deal with a difficult situation. Finally, some participants integrated mindfulness into their day to day activities and focused less on formal meditation. The intervention was not without challenges, participants noted the difficulty in finding the time to practice, maintaining focus while practising, applying mindfulness within the workplace and sometimes in the home environments also, and issues with course logistics. Implications for the role of brief MBCT as a workplace intervention are discussed. Recommendations: This study contributes to the field of mindfulness in the workplace in three distinct ways: it offers an insight into the applicability and challenges of mindfulness workplace interventions including the flexibility of mindfulness techniques, it offers an exploration of the role relationships and peer support can offer within a brief MBCT intervention, and it also demonstrates an insight into the role of appraisals in participants who have engaged in a brief MBCT workplace intervention, and helped uncover areas to be explored in future studies. If there is an understanding of the mechanisms by which MBCT can be useful in the workplace, and what outcomes it may present then this is useful information for model development for such workplace interventions. Future workplace mindfulness research should explore the fidelity of MBCT interventions, the role that group dynamics, barriers and facilitators to practice can have on intervention outcomes. Future research should also focus on addressing the barriers to practice and establishing the longer-term effects of MBCT interventions.

Volume I consists of a systematic literature review, empirical research paper, and public dissemination document. The systematic review of Instagram and eating disorder (ED) psychopathology found that content viewed on Instagram, rather than overall Instagram consumption, may reflect individuals ED psychopathology. However, further research displaying greater internal and external reliability is required before a comprehensive consensus of findings can be achieved and used to inform the development of targeted online public health campaigns or interventions. The research paper presents a study exploring the associations between Instagram, body image, and orthorexia nervosa (ON), an alleged ED that is characterised by a preoccupation with consuming healthy and pure foods. Instagram usage may be an important factor to consider in treatment and prevention efforts. The public dissemination document provides an accessible overview of the review and research paper. Volume II consists of five Clinical Practice Reports (CPRs). CPR I presents a Cognitive-Behavioural and Systemic formulation of a 15-year-old female with anxiety. CPR II presents a case study of a Cognitive Behavioural treatment intervention for a 12-year-old female with anxiety. CPR III presents a single-case research design to assess the effects of Exposure Response Prevention with a 15-year-old male with OCD. CPR IV presents a service evaluation of the Formulation Training Programme in an Older Adult’s Service. CPR V presents a presentation abstract for a case study of a 30-year-old male with chronic Intestinal Failure using the Cognitive Behavioural Therapy model for depression.

In recent years, theoretical and empirical research interest in Acceptance and Commitment Therapy (ACT) as a parent intervention has grown. There is now a need to synthesise emerging empirical findings. A systematic review of published studies investigating ACT as a parent intervention was undertaken via PsycINFO, MEDLINE, CINAHL, Scopus, the Cochrane library and the Association for Contextual Behavioural Science databases. Using inclusion criteria and a quality assessment, 14 outcome studies were identified for evaluation using a narrative synthesis. The majority of studies investigated ACT for parents of children with physical health or neurodevelopmental conditions. The findings, based on heterogeneous studies including a small number of randomised controlled trials, suggest that ACT-based parent interventions may have positive benefits on parenting style and behaviours, parenting-specific psychological flexibility and general psychological flexibility. It is concluded that ACT holds promise as a parent intervention, and its potential to benefit both parents and their children are discussed. Recommendations for future research are made, in particular for further studies in a broader range of contexts.

This thesis is comprised of two volumes. Volume I consists of the research component whilst Volume II comprises the written clinical component based on work completed during training. Volume I is comprised of a systematic meta-analysis, an empirical research paper and a press release. The meta-analysis reviews literature that investigated the impact of cognitive behavioural approaches on distress for those with a first or early episode psychosis. No main significant effect was found but, a significant effect was found within non-specialised services. The empirical research paper used interpretative phenomenological analysis to explore how visual hallucinations are experienced and made sense of within a schizophrenia spectrum diagnosis. Five superordinate themes were identified: ‘It’s not only a visual experience’, ‘Agency’, ‘Role of others, ‘Coming to know the experience’ and ‘Creating a narrative’. Volume II is comprised of five clinical practice reports (CPRs). CPR1 presents the formulation of a young person with low self-esteem from both a cognitive behavioural and psychodynamic perspective. CPR2 is a service evaluation exploring staff experiences of discharging families within the service framework of the Choice and Partnership Approach. CPR3 is a single case experimental design assessing the effectiveness of a behavioural intervention with a young boy with learning disabilities. CPR4 is a case study of an 81-year-old woman with anxiety who received cognitive-behavioural therapy. An abstract summarising CPR5, a clinical presentation of a young man with first episode psychosis who received psychodynamic therapy is presented.

Transcranial direct current stimulation (tDCS) has enjoyed something of a renaissance in neuroscientific research, however, this has not been accompanied by a commensurate increase in our understanding of its neurobiological mechanisms. At present, there remains a large explanatory gap between the stimulation effects on cells in in vivo or in vitro studies and the wide variety of behavioural findings in human studies. Consequently, tDCS research is currently confronted with a wide variety of conceptual and methodological challenges that have hampered the development of mature rationales for its use in healthy and clinical populations. This thesis aimed to address some of these challenges by combining data from behavioural and neuroimaging experiments with findings from individualised models of tDCS-induced electric fields. Experiments focused on the visual system, using relatively simple paradigms based on pattern-reversing checkerboards and the detection of achromatic dot stimuli to investigate stimulation effects on visual processing, The role of inter-individual variability – both in baseline sensory performance and in head anatomy – received particular attention in the design of studies. In the second chapter of the thesis, the question of suitable current waveforms for doubleblind, sham-controlled tDCS studies is discussed. The third chapter investigates the role of electrode montage in eliciting tDCS effects on contrast detection at central and peripheral visual field locations. In Chapters 4 and 5, inter-individual differences in anatomy are quantified using computational modelling of electric fields and neuroimaging methods. Work presented in Chapter 6 explores the feasibility of acquiring concurrent tDCS-NIRS-MEG data. Together, results from these studies suggest that the large parameter space for designing and interpreting human tDCS experiments calls for a broad range of methodological advances in future tDCS research.

Volume I contains three research papers. Firstly a systematic review was conducted to investigate the effectiveness of rehabilitation strategies for improving navigation in people with acquired brain injuries (ABI). Secondly, a mixed within and between-subjects experiment was conducted to explore differences in Virtual Reality route learning in people with traumatic brain injury (TBI) compared to a matched control group in relation to landmark type (proximal and distal) and navigation strategies (egocentric and allocentric). Finally, a public dissemination document provides an overview of both the systematic review and empirical paper in a manner suitable for dissemination to relevant stakeholders. The results of the systematic review indicated that there is much variation in the compensatory rehabilitation strategies used to help people with ABI successfully navigate. Compensatory rehabilitation strategies were broadly categorised according to whether they were person-oriented, environmentally-oriented or hybrid approaches. Overall, the conclusions that could be generated was limited by poor methodological quality and thus, more robust research is needed on this topic before an evidence-based navigation rehabilitation strategy can be used in clinical practice. Suggestions as to promising areas for future research are given. Findings from the experimental Virtual Reality route learning study suggested that people with TBI are impaired at route learning using distal landmarks compared to a neurologically-healthy control group. As navigation using distal landmarks has been associated with an allocentric ‘mental map’ strategy using the hippocampus, it is possible that the participants with TBI in this study were impaired at route learning using distal landmarks due to an inability to use their hippocampi to build up a mental map of space. However, as both groups of participants reported using an egocentric ‘associative’ strategy to learn both types of landmark routes, this association needs further exploration.

This thesis was submitted in partial fulfilment of the requirements for the degree of Doctor of Clinical Psychology at the University of Birmingham. Volume One presents three research papers. The first paper is a meta-analysis of the relationship between moral distress and burnout in healthcare professionals. The second paper consist of a research paper which utilises Interpretative Phenomenological Analysis to explore how nursing staff working in a psychiatric intensive care unit experience the therapeutic relationship in the context of using physical restraint. The final paper is a public dissemination document which summarises the literature review and research paper. Volume Two consists of five clinical practice reports (CPRs) completed over the course of the training. CPR One presents a case formulation from a cognitive behavioural and psychodynamic perspective. CPR Two is a service evaluation investigating the needs of young adults transitioning from child services to an adult learning disability team. CPR Three consists of a single-case experimental design to evaluate the effectiveness of a cognitive-behavioural intervention for a male experiencing health anxiety. CPR Four presents a case study of a female experiencing intrusive thoughts and compulsions. Finally, an abstract of an oral case presentation (CPR Five) is included in this thesis.

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

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

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

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

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

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

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

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

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

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

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

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

Background: Typically referred to as delusions, unusual beliefs are commonly regarded as symptoms of a psychotic disorder, requiring treatment. Drawing on the Hearing Voices Network’s approach to voice-hearing, peer support groups for unusual beliefs aim at providing mutually supportive environments where members can share their experiences and support eachother. Despite the growth of an active network of unusual beliefs peer support groups, to date, there has been no research in this area. Aims: The present study aimed at exploring participants’ experiences of attending peer support groups for paranoid and unusual beliefs and the impact of group participation, as perceived by members. Methods: The study adopted a qualitative research design. Individual semi-structured interviews were conducted with 11 participants and data were thematically analysed. Results: Four themes were developed from the data: (1) ‘In search of an ‘oasis’’, reflects the safety and acceptance that the group afforded, as well as situations during which some of the very components that rendered the group a safe and accepting haven, seemed to be jeopardised; (2) ‘Choice means something different here’, explores the ways in which the group enabled participants to reclaim a sense of agency and control which was often either denied or was unavailable in other contexts; (3) ‘This is peer support,not therapy’, captures the group’s non-clinical character and the ways in which participants’ accounts questioned dominant assumptions about the nature of unusual beliefs; and (4) ‘From the ‘I’ to the ‘We’’, explores the sense of community that the group forged for participants. Discussion: This is the first study to explore the Hearing Voices Network approach to unusual beliefs. The implications of the study for the user-led network as well as for clinicians supporting people with distressing or overwhelming beliefs are discussed and suggestions for future research are offered.

Current conflict across the world has led to unprecedented displacement of people. Research has captured the wide-ranging consequences of displacement on health and emotional wellbeing, identifying that refugees and asylum seekers require help and support in many areas of their lives. One of the resources available to them in the UKis psychodynamic psychotherapy. This study was the first of its kind to explore the experience of psychodynamic psychotherapy from the perspective of refugee and asylum seeker clients, and therapists working with those populations. Using a qualitative design, nine participants shared their experiences of psychodynamic psychotherapy in semi-structured interviews. The thematic analysis identified six themes to describe participants' experiences of psychodynamic psychotherapy within a distinct service context. The findings emphasise the unique experiences of clients and therapists, and the different starting points and needs that clients have at the beginning of therapy. Psychodynamic psychotherapy within the service under study is viewed positively by participants but also used flexibly. It is adapted through the modification of the therapeutic frame, joint working with other professionals and an active role in supporting needs including immigration and integration. Specific elements of the psychodynamic model that are helpful for refugees and asylum seekers are identified along with clinical and research recommendations.

Adolescent refugees may endure multiple adversities, experiencing pain and suffering and occasionally more severe psychological distress or psychopathology as a response to their circumstance. At the same time, they may prove incredibly resilient or develop positively exactly because of these adversities, what Papadopoulos (2007) calls adversity-activated development (AAD). This study explores adolescent refugees' responses to their predicament and the factors contributing to them. The data was collected by semi-structured interviews with 17 refugee adolescents (age range = 14-19) living in Greece and the UK. The thematic analysis of the research data corroborates the three different categories of responses to refugee adversities, i.e. negative, resilient and positive ones, according to the Adversity Grid (Papadopoulos, 2007). This is the first time that a research using the Adversity Grid has been applied to refugee adolescents, adding to the existing body of research on the Grid as well as on adolescent refugees. The analysis also confirmed a series of intrapersonal, interpersonal and sociopolitical factors that interweave adolescents' attribution of meaning and affect their responses to adversity. In addition to these variables, adolescence-specific characteristics, protective influences and vulnerabilities, which interact to synthesise the specificity of the position of the adolescent refugee, are presented as contributing factors to their responses. Refugee adolescents undergo multiple transitions and dealing with them seems to have positive implications for some and negative for others. Adolescence-specific tasks, including identity building and individuation also appear to create both negative and positive conditions that affected the research participants' responses to adversities, depending on whether they perceived the refugee experience as an extra burden challenging these tasks or as an opportunity for growing into strong, mature, independent beings. Moreover, adolescence-normative characteristics, including omnipotence and narcissism, appear to buffer some of the participants against the negative effects of refugeedom, while they result in deeper vulnerability for others. These results highlight the research participants' uniqueness and the complexity of their experiences and responses, indicating that the detrimental effects of the refugee experience and the manifestation of resilience and AAD are not mutually exclusive.

In recent years, there has been an increased interest in families who raise children that express themselves in gender diverse ways alongside a dramatic increase in the number of referrals to clinics. Research on the experiences of parents is, however, very limited. Furthermore,gender diversity in very young children (i.e. pre-pubertal) raises many emotionally, ethically and morally charged dilemmas, which parents often seek help for. Learning about the experiences of supporting a child during social transition alongside professional help, may help to inform future clinical practice and enable families to be supported in a way they find most helpful. Ten parents (six mothers, four fathers) of pre-pubertal children who expressed themselves in gender diverse ways, and had socially transitioned, were recruited through a specialist gender clinic. Each parent participated in a face-to-face interview where they were asked about their experiences of raising their child while receiving help from professionals. Adopting a Constructivist Grounded Theory methodology, data were analysed through an iterative process of constant comparison, leading to the construction of a substantive theoretical model grounded in the data. The category of "Transition‟ captured the essence of parents‟ experiences. It represents the time during which the parents did, or did not support the child through moving away from their assigned gender to the desired one; firstly on their own, and gradually with the support of friends, their community and professionals. The resultant model explicates the dynamic and relational process of "Transition‟ as the core category which is directly influenced by, and influencing, many other factors. The model is considered in relation to extant literature and implications for clinical practice and future research are discussed.

Genograms are a graphic representation of the composition and structure of a person's family members, relationships, systemic patterns and influences over at least three generations (McGoldrick, Gerson & Petry, 2008). Genograms can include objective family information such as births and deaths, as well as subjective information such as relational dynamics and family patterns, and use symbols to represent these (McGoldrick et al., 2008). The genogram is a tool, which is frequently used in systemic family therapy and has been gaining popularity in other professional fields since 1985, including psychology professions (McGoldrick et al., 2008). Training in the use of genograms is now included as part of many educational psychology professional doctorate training courses. However, there is currently very little published research literature in relation to the use of genograms in educational psychology practice. This research was a small-scale, qualitative study, which sought to explore educational psychologists' perceived strengths and limitations of using genograms in their practice. Seven semi-structured interviews were conducted to gather the views of educational psychologists working for a traded service in an inner-London borough. Nine key themes were inductively identified using thematic analysis (Braun & Clarke, 2006), in relation to the perceived strengths and limitations of using genograms in educational psychology practice including: engaging clients and building rapport; accessibility; information gathering and assessment; case formulation; using the genogram as a therapeutic tool; specific areas of need; ethical considerations; knowledge, training and experience; and, systemic considerations in current educational psychology professional context. The research also identified that educational psychologists were using genograms across many areas of their practice including; consultation, assessment, interventions, supervision, multi- professional work and critical incident response. Implications for educational psychology practice are discussed and future directions for research are outlined.