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Aims: To explore the experiences of women from Black and Asian backgrounds, detained under the Mental Health Act (1983; 2007), on their journeys to accessing care for a First Episode Psychosis diagnosis. Background: Black and Minority Ethnic (BME) groups are sectioned under the Mental Health Act at significantly higher rates than White ethnic groups. BME groups are also more likely to be diagnosed with psychosis – a presentation primarily understood in services within the medical model of ‘mental illness’, and related to stereotypes of ‘dangerousness’. While quantitative research highlights the inequalities impacting Black men, BME women who show similar trends are often overlooked. Additionally, limited data exists about the lived experience of coercive pathways to psychosis care for these groups. Methodology: A critical realist research framework was used to qualitatively explore experiences of psychosis and services with Black and Asian women. Eight semi-structured interviews were conducted with women accessing Early Intervention for psychosis Services (EIS) and previously sectioned. Results: A thematic analysis identified three themes and six sub-themes: ‘Sense of Mistrust’; ‘Navigating Unsafe Systems’; and ‘Impact of Adversity’. Psychosis was characterised as feeling unable to trust others, and yourself. Initial interactions with services, particularly the police, were experienced as unfair, re-traumatising and potentially racialised. Trauma-informed and spiritual models to explain psychosis, felt neglected by services in favour of the medical model. However, social and psychological aspects of care offered by services, were described as unexpectedly helpful by the participants. Conclusion: It is proposed potentially unhelpful wider societal discourses, such as 'the Angry/Strong Black Woman', 'the Meek Asian Woman' and ‘psychosis is dangerous’ have an impact on experiences of accessing care for First Episode Psychosis. Recommendations discussed include: a systems-wide approach to tackling bias, acknowledging intersectionality, accommodating multiple beliefs in practice, and potential alternatives to detention under the Mental Health Act.

A paucity of research investigating men as a group has been in observed in the psychological literature, and researchers have further highlighted the need for psychologists to better understand and attend to men’s mental health needs. This study explored the help-seeking experiences of male victims of female-perpetrated domestic abuse. Patterns observed in the literature on men’s help-seeking behaviour have uncovered consistent under-utilisation of mental health resources, as well as the presence of gender role and masculinity-related issues in how mental health issues are perceived and responded to. Various internal and external barriers to help-seeking in male victims of female-perpetrated domestic abuse have also been observed. Review of the relevant theory and literature produced a rationale for exploring male domestic abuse victims using an indepth, qualitative approach. This UK-based study investigated the help-seeking experiences of eight research participants via semi-structured interviews. The resultant data were analysed using Interpretative Phenomenological Analysis (IPA), and produced five superordinate themes: ‘Blind spots’; ‘Reasons for pause’; ‘Vulnerability’; ‘Invalidation’; and ‘Finding help’. Findings were considered in the context of psychological theory and the current literature, with a focus on aspects of invisibility, masculinity and female privilege. The findings suggest that gender role-related tensions may be a salient issue in helpseeking for men abused by women, that representation of abused men in domestic abuse discourse needs to be increased, and that aspects of female privilege may be used against male victims by female abusers, which can have a detrimental impact on victims’ ability to access help. Clinical implications are discussed, which include the need to challenge stereotypes about domestic abuse, develop gender-informed interventions and harnessing positive aspects of masculinity in designing mental health interventions.

This research explored the challenges for commissioning services for Black men in Mental Health Services in the UK National Health Service (NHS). More specifically, the focus was on how commissioners conceptualised the structural and social issues in developing services for Black men with the aim of understanding how these issues might translate into service development. The context of commissioning was the focus of the study due to the influence this has on service provision and consequently on supporting the mental health of Black men. The study involved individual in-depth interviews with eight commissioners who had a role in commissioning adult NHS Mental Health Services. Interviews were analysed using thematic analysis drawing on an Intersectionality framework within a critical realist epistemology. Three main themes were identified, ‘Challenges to Commissioning Mental Health Services’, ‘Reframing Mental Health Services’ and ‘Black Men and Power Dynamics’. Key findings from the analysis highlighted various intersecting locations such as maleness, ‘race’, and social context in understanding factors that contribute to the mental health of Black men. These issues were drawn upon to discuss the constrains of service provisions available and explain why Black men were excluded from commissioning processes, leaving them with little power to influence decisions regarding mental health provisions. Based on the analysis, the limitations of current mental health provisions and processes involved in commissioning are discussed and considered in relation to supporting Black men’s mental health. This research indicates that more inclusion and support is required to empower Black men to be involved in commissioning processes in order to address some of the structural and social issues relevant to addressing mental health needs. The implications and suggestions are discussed in relation to considering ways that Clinical Psychologists in particular can facilitate this.

Violent or aggressive episodes are particularly prevalent in the emergency psychiatric settings (10%) often as a consequence to a variety of disorders ranging from the organic to mental disorders (i.e. Schizophrenia, Substance Use, etc.). While guidelines state patients should be calm in order to attain a diagnostic history, physical and laboratory tests before treatment is to be started, the violent episode presented often makes it impossible - ruining necessary history, physical and laboratory work as well as placing both staff and patients in a potentially harmful state. With this, rapid tranquilisation becomes both necessary and unavoidable. This thesis, the first of its kind in Lebanon and the Middle East, undergoes a pragmatic randomised controlled trial in Lebanon's only public psychiatry hospital. I begin with systematically defining 'what is aggression' specifically within the psychiatry emergency setting and the common disorders associated with it. I then conducted a systematic literature review of all known surveys examining both clinicians' opinions and practice on how aggressive episodes are treated. Following the survey of surveys, I proceeded to conduct a survey of both clinicians' opinions and what happens in practice in Lebanon's Psychiatric Hospital of the Cross. With the results and assistance from Cochrane Library, I conducted a systematic overview and updated reviews - both direct and indirect. While results did show a variety of treatments used in Lebanon have been tested in trials, Lebanon's main SOS treatment - the 'HPC' treatment has never been investigated within a trial and no reviews exist, although there is evidence it is used in practice. With this, I designed the trial protocol suited for Lebanese practice and with the University of Nottingham's ethics board and representatives of the Lebanese hospital, the trial commenced and ran to completion over a period of 10 months. A total of 100 patients were randomised with 48 in the HP group and 52 in the HPC group. Primary measures of outcomes were calm or tranquil at 20 minutes. Results showed no significant differences between both interventions with confidence intervals showing a slight preference towards the triple therapy when sampling size is adjusted. The thesis concludes with the difficulties of running such a trial within the region and the practical solutions to each problem presented.

Neuropsychiatric diseases such as schizophrenia can have profound impacts both on affected individuals and society more widely yet the neurobiology underlying these conditions is incompletely understood. Various environmental and genetic risk factors have been identified for these diseases which include rare deletions of the DLG2 gene, identified in multiple schizophrenia patients. DLG2 is known to encode a structural scaffolding protein within mature synapses; however, research presented here indicates protein expression earlier than previously appreciated and prior to synaptogenesis. To investigate a hypothesised role for DLG2 in early cortical neurogenesis and determine potential disease relevance, DLG2-/- and isogenic wild-type (WT) sister human embryonic stem cell (hESC) lines were differentiated into cortical excitatory neurons and characterised at multiple time points through various techniques, including RNA sequencing. These revealed novel roles for DLG2 during cortical development including the regulation of neural precursor cell (NPC) proliferation and adhesion to the extracellular matrix (ECM) as well as several biological progresses during neurogenesis responsible for the generation of neuronal subtype identity. DLG2-/- cultures produce more immature neurons characterised by deficits in morphology, migration, electrical properties and gene expression, including the cortical layer V marker CTIP2. Genes downregulated at day 30 of cortical differentiation, a time point corresponding to early neurogenesis, were enriched for schizophrenia common risk variants, linking DLG2 regulated biological processes in corticoneurogenesis with neuropsychiatric disease and potentially providing insight into the neurodevelopmental component of schizophrenia pathophysiology.

Persistent depression is a debilitating health condition with a poor prognosis even in the context of current gold-standard pharmacological and psychological interventions. A better understanding of the mechanisms contributing to its maintenance is needed to facilitate the development of more targeted psychological interventions. Bayesian predictive processing models of depression propose that negative emotional and physiological outcomes arise in depressive illness as a result of disturbed interoceptive precision estimation in depressed individuals; however, evidence from the clinical and cognitive neuroscience literatures suggests the hypothesis that sensory precision is attenuated in persistent depression across sensory modalities in general. A series of studies was designed to index sensory precision across somatic and auditory modalities and to identify the level at which any disruption manifested in persistently-depressed participants relative to controls. Study 1 (Chapter 3) measured baseline signal discriminability under conditions of focused attention. Study 2 (Chapter 4) measured the impact of failures of voluntary attention on signal discriminability. Study 3 (Chapter 5) used a simulation approach to model sensory precision in the first two studies and to identify mechanisms which could successfully predict the data. Studies 4 (Chapter 6) and 5 (Chapter 7) measured attentional capture by task-irrelevant and predictive sensory cues respectively. Study 6 (Chapter 8) partially replicated Studies 4 and 5 and used the resulting data to estimate the group-level sensory precision and salience parameters of a predictive processing model of precision optimization. The results suggest that sensory precision is attenuated in persistent depression across sensory modalities, and that this attenuation results from disturbances of voluntary and involuntary attention rather than baseline perceptual sensitivity. Under conditions of voluntary attention, reduced sensory precision may result from efforts at resource conservation; and under conditions of involuntary attentional capture, it may be related to a loss of target discriminability and salience. Conversely, the bottom-up salience of somatic stimuli was uniquely enhanced among depressed participants and was predicted by high anxiety and by low interoceptive sensibility. These findings open up new avenues for investigation of the mechanisms underlying persistent forms of depression, and have direct implications for clinical practice with respect to psychological intervention.

Deprived socioeconomic circumstances can increase the likelihood of poor physical and mental health, outcomes transmissible to young people due to their reliance on parental socioeconomic resources. Interventions commonly target adolescent groups to minimise health inequalities, yet this age group is described as typically invisible in health inequalities research. There has been a dearth of research examining health inequalities in Northern Irish adolescents, and a narrative review of 69 studies identified that no previous research examining factors such as household overcrowding has been conducted in Northern Ireland. This thesis addresses this research gap by examining the impact of household deprivation, family circumstances, and housing and neighbourhood factors on adolescent health and wellbeing. This was achieved by linking the Northern Ireland Longitudinal Study (NILS) from the 2011 Census with multiple administrative datasets. A total of 52,501 NILS adolescents aged 11-18 – a representative 28% sample of the Northern Ireland population – comprised the core sample and were linked with their respective household members. Adolescent health and wellbeing outcomes were examined in four facets: physical, psychological, and cognitive and behavioural health conditions; disability; self-reported health; and prescription receipt for five medication types between 2011-2017. Household deprivation was frequently associated with health conditions, disability, and poor self-reported health. Family factors such as parental divorce and step-parent families related to poorer psychological health, and housing and neighbourhood factors such as overcrowding and neighbourhood deprivation were associated with poor self-reported health and disability respectively. While over one in six adolescents received an antidepressant prescription between 2011-2017, the research could come to no firm conclusions on the reasons behind this. The persisting relationship between household deprivation and poor adolescent wellbeing emphasises the need to minimise household poverty in Northern Ireland. Further research is required to explore the substantial increase in mental health medication receipt identified for Northern Irish adolescents.

Many young people experience mental health difficulties, which, if left untreated, can have detrimental effects into adulthood. Humanistic therapies are widely used for this population; however, evidence of their effectiveness is limited. Research on humanistic therapy with young people can be supported by the existence of validated, observer-rater adherence measures. Following a literature review, the most appropriate instrument for such a purpose was identified as the Barrett-Lennard Relationship Inventory (BLRI). This aims to measure Empathic Understanding, Congruence, Level of Regard, and Unconditionality of Regard. However, the psychometric properties of the BLRI have yet to be evaluated in young populations. Using 136 audio recordings of humanistic counselling with adolescents, the presence and level of the therapeutic core conditions were rated using the observer-rated BLRI Obs-40 (Version 3), and the psychometric properties of the scale were examined. Results of confirmatory factor analyses supported the original four-subscale dimensionality of the scale. Additionally, there was support for a model in which the first-order subscale factors loaded significantly on a single second-order factor of general ‘person-centeredness’. The internal consistency of the sub-scales and total score was high, and five-month test-retest reliability was satisfactory for total BLRI score. However, inter-rater reliability was found to be unsatisfactory across three independent raters using a sample of 50 recordings. The BLRI total score and subscales correlated strongly and significantly with the Person Centred and Experiential Psychotherapy Scale adapted for young people (PCEPS-YP) with the exception of the unconditionality subscale. Results suggest the BLRI Obs-40 (Version 3) can be used with young populations in training and research environments; however, rigorous training for raters is necessary to strengthen scale reliability and use as an observer-rated measure.

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.

Psychoanalytic psychotherapy is often thought of as a long-term treatment, however there is a rich history of short-term treatments in psychoanalysis and psychoanalytic psychotherapy. Short-Term Psychoanalytic Psychotherapy (STPP) was found to be as effective for the treatment of moderate to severe depression in adolescents aged 11-17 as CBT and a brief psychosocial intervention (BPI) (Goodyer et al, 2017), and the evidence base for time-limited psychoanalytic treatments with children and adolescents continues to grow. However, to the author’s knowledge there are no existing studies exploring child and adolescent psychotherapists’ experiences of offering short-term psychoanalytic treatments. The current study set out to investigate this topic by using qualitative data exploring child and adolescent psychotherapists’ experiences of offering STPP as part of a large randomized controlled trial (RCT), the IMPACT study, collected as part of the IMPACT: My Experience (IMPACT-ME) study (Midgley, Ansaldo & Target, 2014). Further qualitative data regarding the experiences of six child and adolescent psychotherapists offering STPP as part of everyday clinical practice was also collected, via a semi-structured interview developed from the interview used in the IMPACT-ME study. The two data sets were analysed using thematic analysis and interpretative phenomenological analysis, respectively. Child and adolescent psychotherapists offering STPP both within an RCT and everyday clinical practice reflected on their experiences of working with the time-limit, working with the STPP manual, and the roles of parent-work, supervision, and assessment. They also questioned: for which patients STPP might be a good fit; what STPP might be able to help with; how different STPP is from open-ended psychoanalytic psychotherapy, and how the profession might think about time and duration. They also reflected on the potential role of STPP in helping to manage resource and service-based pressures, and the influence an RCT might have on the experience of offering STPP. The experiences of the participants seem to suggest STPP could be helpful and valuable treatment option for children and adolescents with a range of mental health difficulties, and that STPP remained true to the core principles of psychoanalytic work. Interpretative ways of understanding the participants experiences are considered, along with the implications for the use of STPP within mental health services in the NHS.

Foods associated with a more favourable glycaemic response have been linked with cognitive benefits in acute settings in both the clinically healthy and those with type 2 diabetes. However, the current evidence is largely limited to examination of the effects of a single meal, particularly breakfast. Given that the daily human dietary pattern consists of multiple meals, the single meal paradigm fails to provide information about the glycaemic response and cognitive performance throughout the day. In addition, the glycaemic response following a meal has been shown to influence postprandial glycaemia and cognitive performance following a subsequent meal, which further illustrates the need to extend the current single meal investigation to a multiple meal testing paradigm. This thesis, therefore, aimed to investigate the relationship between the glycaemic response, cognitive performance and subjective mood across three consecutive meals in both clinically healthy and T2DM populations. Initially, two novel test meal profiles were designed using the glycaemic index concept with the aim of producing significantly different glycaemic profiles across the day; specifically, a Favourable (FGP) and Unfavourable (UGP) Glycaemic Profile. The two glycaemic conditions were then implemented in two randomised cross-over intervention studies in clinically healthy (n=40) and T2DM populations (n=25) to examine their effects on cognitive performance and subjective mood. Finally, a post-hoc analysis was performed to compare the glycaemic and cognitive outcome responses of the clinically healthy and T2DM populations. The FGP meals consistently produced a lower glycaemic response across the day in all samples. The clinically healthy population did not gain cognitive benefits from either condition, whereas the T2DM population displayed sustained cognitive performance during the FGP condition, particularly during the period after breakfast consumption. In addition, poor glucose regulators (defined via a glucose composite score) displayed worse cognitive performance than good glucose regulators within each population under an increased cognitive load. Finally, the glycaemic conditions had minimal impact on subjective mood. Taken together, these findings indicate that a more favourable glycaemic response profile over the course of several meals is associated with better cognitive performance in those with poorer glucose tolerance (i.e. T2DM) compared to an unfavourable glycaemic response profile. Longitudinal investigation of glycaemic control and cognitive performance in those with T2DM, using the multiple meal profiles developed in this thesis is suggested as future research. This would provide data on the extent, if any, of whether a long-term favourable glycaemic profile is associated with attenuation of cognitive impairment observed in those with T2DM.

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

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.

Patients with schizophrenia often display impairments in the expression of emotion and speech and those are observed in their facial behaviour. Such impairments present valuable information for the psychiatrists, as they can be used for diagnosis. However, behaviour analysis is subjective in clinical settings and time-consuming in research settings. In this thesis, our aim is to develop fully-automatic methodologies for a) quantifying patient’s facial behaviour, b) estimating symptom severity in schizophrenia, and c) determining whether the symptoms have improved or not by a given treatment. In the analysis, videos of professional-patient interviews of symptom assessment, that were recorded in realistic conditions, are used. This helps in moving from controlled contexts used in the literature to similar-to-real clinical settings. Firstly, an architecture is proposed for automatic facial expression analysis. The proposed architecture address the data imbalance and threshold selection problems in multilabel classification, and is trained using several datasets recorded in controlled environments. Then, the expression analysis is moved from the controlled environments to the recent in-the-wild settings, where VGG-16 networks are trained using 4 recent datasets captured in the wild. In-the-wild analysis helps in analyzing more patients and leads to better results in symptom estimation. Secondly, a deep learning approach is proposed for estimating expression-related symptoms of schizophrenia in two different assessment interviews, namely PANSS and CAINS. The proposed approach consists of Gaussian Mixture Model and Fisher Vector layers for extracting compact statistical features over the whole video interview. Experiments show promising results both on statistical analysis and symptom estimation. Finally, two methods are proposed for addressing directly the problem of treatment outcome estimation in schizophrenia – more specifically, are aimed at determining whether specific symptoms have improved or not by analysing jointly two videos of the same patient, one before and one after the treatment.

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

This is an explorative and qualitative research study that uses critical and reflexive ethnographic methods (Denzin and Lincoln, 2002). It explores the dance artist’s role in participative and somatic dance, recognising dance as a culturally constructed mode of human action (Buckland, 1999, p. 4). The dance artist is often under-represented and largely invisible in the dance-health literature. This study contributes to this gap in knowledge by exploring the embodied and intersubjective experiences of a group of independent dance artists practicing in a specific, creative, social, and cultural dance domain. Data was collected by adopting an ethnographic attitude of ‘being there’ (Geertz, 1988, p. 1) and embedding myself, as the researcher, in the field of study for a 12-month period. I engaged in a self-critical and self-conscious analysis (Etherington, 2004), thereby making explicit my orientations and assumptions as a researcher with a background in health care and occupational therapy. This is therefore an inter-disciplinary study exploring the potential transfer of knowledge between arts and health sectors. Data gathering methods included participant listening, observation and felt body experience to further understanding of the dance world experienced by this group of dance artists. Data was analysed using primarily ethnographic content (Glaser and Strauss, 1967), and some narrative thematic analysis (Riessman, 2003, 2008) of the dance artists’ partial life stories. The study findings suggest that social and intersubjective relations are key in this dance-health practice in enabling the dance artists, acting as Guides, to facilitate a heightened awareness of somatic and subjective lived body experience. The dance artists empower others to translate and find meaning, as they transition between different mind-body experiences. Corporeal learning and acculturation take place by participating in the creative dance practice, which both reflects and influences everyday life (Koff, 2005). This experience of embodied transformation is understood from the perspective of a salutogenic approach to health (Antonovsky, 1996) with an emphasis on capability, meaning and a sense of coherence. This is exemplified by a sense of congruence between the dance participants’ inner and outer physical experience (Blackburn and Price, 2007, p. 69). Essentially, the body is explored within a specific group of dance artists situated in a particular social and cultural dance-health setting. This doctoral research therefore seeks to bring embodiment before the sociological gaze (Crossley, 2007, p. 80) exploring the subjective and intersubjective lived body experience from a social perspective.

The research design combines specific qualitative methodologies with analysis of theoretical debate and empirical material. It is innovative, generating insights contributing to new knowledge in academia, policy and practice in this field. Key gaps in literature addressed include limited studies on; a) populations in the global south on mental health in humanitarian settings, b) majority populations (not combatants or victims of sexual violence), c) community approaches to war related suffering (notably religion) and, d) limited academic studies on such humanitarian interventions. Key findings indicate understanding of war related suffering as normal, linking the body, mind and spirit, with physical suffering paramount to psychological. Communities have their own approaches, mostly religion, considered as effective, relevant and appropriate. Advances in science reflected in the fields of alternative and integrative medicine support the ‘scientific’ value of such approaches. Finally, the inconsistency between community understandings and approaches and that of the global mental health responses is highlighted. Key recommendations include; incorporating valuing community approaches within humanitarian actor competencies; engaging policy makers, academics and practitioners in research around spirituality and mental health in humanitarian settings in the global south, encouraging reflection and debate on revisions to methodological approaches of engaging war affected communities, more research in this field, and finally more profound reflection on such global responses leading not just to change, but total transformation.

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.

Background: People with psychosis often experience social difficulties associated with key psychological processes, such as social anxiety, paranoia, interpersonal sensitivity and fear of negative evaluation. Virtual reality presents a unique opportunity to bring social environments into the therapy room. This study presents a development case-series of virtual-reality assisted cognitive behavioural therapy (VR-CBT) for people with first episode psychosis (FEP) who are experiencing social difficulties. Methods: Participants were recruited from two South London Early Intervention mental health teams for people experiencing a FEP. Participants received a course of 10 sessions of individual formulation-driven VR-CBT with a focus on improving social functioning. A novel VR environment and therapy package were piloted for the use of the assessment, formulation and treatment of social difficulties. The VR environment was used to conduct exposures, behavioural experiments and to practice coping strategies, which were then translated into the individuals’ real-life environments (e.g. at work, on public transport, in the gym etc). A psychometric assessment was conducted with each participant pre- and post-therapy. A feasibility assessment was conducted, regarding the process of recruitment and retention, required resources and barriers to implementation. To examine acceptability participants also provided qualitative feedback during and after their experiences, and completed an ‘unwanted effects’ questionnaire. Results: 11 participants were recruited to the study, which was above the target of 6-10. There was a 64% conversion rate from those who were approached to those who consented to participation. There was an 82% retention rate; although several participants therapy was somewhat affected by the Covid-19 pandemic and adjustments had to be made to their participation in the study. An assessment of study resources was completed and identified potential challenges for future implementation. Comparison of the pre- and post-therapy psychometric assessment scores revealed a reliable change on some of the assessed domains for all participants. Participants reported few or no unwanted effects and provided positive feedback about the inclusion of VR in the therapy. Conclusions: This study presents promising findings from an innovative VR-CBT package for people with FEP who are experiencing social difficulties. It appears to be feasible and acceptable to participants, and potential benefits were derived. However, a number of challenges to implementation were identified that should be carefully considered before further piloting or trailing is attempted. Therapist reflections on using the VR environment in therapy are also presented. The clinical implications and possible future directions for research are considered.

Background: Although many people report benign, psychotic-like or unusual experiences (UEs) which do not cause distress, rates of reported suicidal ideation and suicide attempts are elevated across the psychosis continuum. Recent research investigating potential risk factors for self-injurious thoughts and behaviours (SITBs) has focussed on the individual contribution of UEs. Whilst there is substantial evidence linking UEs to SITBs, there are inconsistent findings regarding the direction of associations and the role of other factors such as co-occurring mental health difficulties in clinic-based populations. Method: Searches were conducted across three electronic databases: Embase, PsycINFO and PubMed. The reference lists of included studies were also screened for any additional papers. Best practice guidelines for conducting systematic reviews were adhered to and a quality assessment was performed. No studies were removed on the grounds of quality, but this was noted where study findings were integrated and described.

Background: Cognitive models of psychosis propose that coping responses to psychotic experiences (PEs) play an important role in the development of need-for-care. One limitation of the existing literature on coping with PEs is that studies focus primarily on clinical groups, and comparisons are usually made to healthy groups without PEs. Individuals with persistent PEs who do not experience distress or impairment are also highly pertinent to understanding factors that protect from need-for-care in the context of PEs. We therefore aimed to identify and summarise literature exploring the coping responses of healthy individuals with PEs. Methods: We systematically reviewed quantitative, qualitative and mixed methods studies exploring coping either solely in nonclinical individuals with persistent PEs or studies comparing these individuals with a clinical group. Results. Seventeen studies met the inclusion criteria. Most studies met the majority of quality criteria as assessed by the Mixed Methods Appraisal Tool (MMAT; Hong et al.,2018). Findings indicated that PEs are responded to with different types of engagement in the clinical and nonclinical groups. Safety seeking behaviours were more commonly reported by clinical individuals, with less consistent findings for distraction. More neutral/mindful types of responding were found to be more commonly associated with nonclinical group membership. For reappraisal,findings were inconclusive. The differing methods of measuring coping across studies were a key limitation of the existing literature, and this may account for some inconclusive findings. Conclusions: Unlike previous findings on symptomatic coping styles suggesting that engaging and getting involved in the content of PEs is maladaptive, this review suggests that it is possible to engage with PEs in a healthy way, from a relative position of control. Disengaging response styles are likely to be more helpful from a position of acceptance of experiences rather than resistance/avoidance. It is likely that group differences in perceived controllability, perceived threat, and phenomenology of PEs play a role in determining how an individual responds and whether engaging or disengaging from PEs is helpful. Future research should focus on developing a clear and comprehensive taxonomy of coping to capture the complex nature of responding across the psychosis continuum.

Background: Carer criticism, of all expressed emotion (EE) elements, has been linked most consistently with poorer clinical outcomes for patients transdiagnostically. Patient perception of carer criticism (perceived criticism) has been found to predict poorer outcomes across several disorders. The Perceived Criticism Measure (PCM) has featured predominantly in the literature. Despite the bidirectional effects of caregiving relationships on patient and caregiver outcomes,to date, there are no systematic reviews investigating the role of perceived criticism (PC) in both patient and carer outcomes in severe mental health conditions. Objectives: This review aimed to systematically synthesise the evidence available in relation to the role of PC in patient and carer outcomes in severe mental disorders as well as bridge the gap in current knowledge of existing PC measures. Method: A systematic review (Prospero ID: CRD42019122820) was conducted in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Four databases (EMBASE, Medline and PsycINFO through OVIDSP and Web of Science) were searched, identifying literature focusing on the role of PC in patient and carer outcomes across severe mental disorders. For the purpose of this review, schizophrenia and related disorders, non-organic psychosis, bipolar disorder, anxiety disorders (including panic disorder, obsessive compulsive disorder, post-traumatic stress disorder, generalised anxiety disorder, social anxiety disorder or agoraphobia), eating disorders (including anorexia, bulimia or binge eating disorder) and depression were included under the severe mental illness (SMI) umbrella. The quality of the reviewed studies was evaluated using an adapted version of the “Quality Assessment Tool for Quantitative Studies” developed by the Effective Public Health Practice Project (EPHPP).

Background: Childhood onset mental health difficulties are known to be associated with later mental health disorders and worse prognoses in adulthood. Individuals who develop schizophrenia present from childhood onwards with cognitive deficits, psychotic-like experiences (PLEs), and internalising and externalising problems. People with a diagnosis of a schizophrenia spectrum disorder (SSD) are also more likely than people without this diagnosis to engage in aggressive behaviour towards others. This systematic review examines the evidence base investigating associations between childhood externalising problems (EP) and later psychotic symptoms. Methods: Searches were conducted on Ovid (Medline and Psychinfo), Pubmed and Scopus. PRISMA best practice guidelines for conducting systematic literature reviews were followed. Data was extracted from pre-defined items and assessed using a quality rating scale.

Systematic Literature Review: Twenty-six articles investigating the psychological experiences of boarding students were identified and subjected to a systematic analysis. Some studies indicated that boarders experience higher levels of psychological distress (especially soon after boarding transition), experience greater incidences of bullying victimisation, engage in more bullying perpetration, and may be at a higher risk of presenting with eating disorder psychopathology. However, other results reported general parity between wellbeing outcomes for boarders and non-boarders, or modest benefits for boarders measures of wellbeing and personality characteristics. Analysis highlighted the lack of research conducted in UK boarding schools, and the need for further research with extended follow-ups. Limitations of the literature and recommendations for professional practice and future research are discussed. Research Paper: Thematic analysis was used to explore the experiences of male ex-boarders who had identified experiences of difficulties in relationships. Three superordinate themes were presented: Disempowerment depicted how participants felt powerless or controlled by others, and the impact this had in later relationships; Suppressing aspects of self and personality related to how participants described hiding emotions or parts of their personality to ‘get by', and how these strategies presented in adulthood; and A process of recovery was concerned with how participants sought ways to ‘recover' from their experiences. Findings were discussed in relation to existing theory and literature and highlighted the importance for educational and care institutions to recognise ideological powers, as well as the use of therapeutic interventions that are underpinned by theories of attachment.

Treatment fidelity concerns whether therapy is implemented as intended and an important aspect of treatment fidelity is therapist competence. Therapist competence scales are a popular method of assessing whether therapy is competently delivered, however these scales vary in their development and evaluation, and in their resulting reliability and validity. This thesis presents a review of therapist competence scales and an empirical study that investigated a new therapist competence scale for Compassion Focused Therapy. Systematic Literature Review: The systematic literature review explored the development and psychometric evaluation of therapist competence scales for cognitive and cognitive-behavioural therapies. Four databases were searched, and thirteen papers were included in the review. The standard of papers was assessed using a bespoke quality appraisal tool and results were narratively synthesised. There was little consensus about the methods that should be used to develop and evaluate competence scales and it was concluded that researchers might use multiple methods of assessing competence rather than rely on competence scales alone. Empirical Research Project: A mixed-methods approach was used to explore the psychometric properties and expert feedback of the Compassion-Focused Therapy Therapist Rating Scale (CFT-TCRS; Horwood et al., 2019). CFT experts watched clips of simulated CFT and used the CFT-TCRS to assign competence ratings before engaging in a semi-structured interview. Inter-rater reliability between participants was ‘good'. Content analysis of the expert feedback provided a number of useful suggestions to improve the scale. Once amended the CFT-TCRS may become a useful tool for clinical practice, therapist training and continued research into aspects of treatment fidelity in CFT.

The mental health of children and young people has received a lot of attention from researchers and news media in recent years. It is recognised that exposure to stressful events is one of the strongest determinants of psychopathology. Significant distress experienced in childhood in particular may increase the vulnerability to experiencing mental health problems later in life. Literature Review: The aim of the review was to explore the literature examining the exposure to adversity among university students in the UK. A total of 29 papers met the inclusion criteria and were synthesised narratively. The prevalence rates of childhood trauma ranged from 26% to 56.2%. The rates of exposure to lifetime adversity ranged from 39% to 88.6%. The findings of this review suggest that a substantial proportion of university students in the UK have been exposed to some form of adversity at some point of their live. There is also evidence that there is a link between adversity exposure and symptoms of psychological distress However, varied definitions and assessment measures used in those papers led to complications in interpretation of these results. Empirical project: The study investigated the levels of anxiety, depression, resilience, and life satisfaction among pupils attending boarding schools in the UK. A total of 243 participants (94 boarders, 149 day students) from seven boarding schools, completed a set of online questionnaires. The study found possible differences in the levels of psychological distress between boarders and day students, with boarders faring worse on mental health. However, complexities in this relatively small data set, in particular the effects of gender on well-being variables in the context of unequal proportions of males and females in the boarding and day samples, mean that these results should be interpreted with caution.

Literature Review: A systematic review of 11 research papers explored the experiences of clients and therapists using a reflecting team in family therapy. The findings of these studies were synthesised using meta-ethnography. Three themes were identified which explored the experience of reflecting teams; unusual and strange; unique conversations and therapeutic environment. These themes highlighted that the process of using a team was different to what was expected, but that it could be helpful when people were made to feel safe and understood. It suggested that reflecting teams are an effective and helpful approach within family and couples therapy. Extra considerations should be taken to ensure that clients feel able to engage with the process, avoiding it from becoming overwhelming and unhelpful. Research Report: As child and adolescent mental health services often provide family therapy to teenagers and their families, this research aimed to explore their experiences of the team. Four young people aged between 12 to 18 were recruited from a family therapy service. They took part in semi structured interviews which were then subject to Interpretative Phenomenological Analysis. Three themes were identified relating to Feeling exposed, Process of Change and Ambivalence. The presence of the team and mirror was uncomfortable but did allow a change for young people voices to be heard. The process of change included factors recognised by young people, such as the presence of the team themselves, how they brought differences together. Ambivalence about making changes was related to their perspective of who was responsible to change, and how they were motivated to do things differently.

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

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

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

Background: Schizotypy has been described as a vulnerability factor to the development of schizophrenia-spectrum disorders with its three dimensions: positive, negative and disorganised, being associated to different patterns of symptoms and impairments. Digital technologies (DTs) have proved to be viable and accepted tools for assessing, treating and preventing a wide range of mental health disorders across both clinical and non-clinical populations. This review is focused on the use of DT in the assessment and research of any characteristics in high schizotypy in non-clinical individuals. Method: A systematic review was carried out across four online databases: PsyINFO, Embase, Ovid and Web of science. The search yielded 5,784 articles, after screening, seven studies met eligibility criteria, with the quality assessment conducted for each of them. Results: The seven studies included examined a total of 407 participants (156 males, 251 females). The number of participants in each study ranged from 24 to 117. The review illustrated the feasibility and safety of a wide range of DTs in assessing and researching a breadth of characteristics in healthy adult individuals including screening for schizotypy personality traits. The EPHPP tool was used to assess the studies’ qualities. All studies received a global rate of ‘weak’. Conclusions: Limited preliminary data suggest that DTs are viable assessment and research tools in schizotypy healthy populations. The review highlights the presence of insufficient information about the use of DTs to directly assess schizotypy. Suggestions for future research and areas that needs further exploration are discussed.

"Illness perceptions and outcomes in psychosis and bipolar: a systematic review". Introduction: Psychosis and bipolar are associated with significant negative impacts for individuals. Psychological and psychosocial interventions are recommended treatments, however engagement in mixed and there is limited understanding about mechanisms of effectiveness and predictors of outcomes. Illness perceptions have been extensively studied in a physical health context and found to be predictive of treatment engagement and outcomes. Evidence suggests that illness perceptions in psychosis and bipolar may show the same relationships, and thus form a potentially important treatment target. It is therefore important to better understand these complex relationships. Aim: To examine the relationships between illness perceptions and outcomes in psychosis and bipolar, including the direction of these relationships. Outcomes of interest included distress, wellbeing, quality of life, functioning, positive psychosis symptoms, engagement, and change over time in illness perceptions. Method: A comprehensive literature search of MEDLINE, EMBASE, and PsycINFO databases, returned 2573 references for screening. Inclusion and exclusion criteria were used to screen titles and abstracts, followed by full texts. References lists of included papers were also scanned resulting in a total of 33 included studies from 32 papers. Data extracted included details of participants, study design, illness perception and outcomes measures, and findings. A narrative synthesis was completed. Results: Included studies varied in design, measurement of illness perceptions and outcomes, methodological quality, and inconsistency in findings which limits the specificity of conclusions. However, overall the studies demonstrated that more positive or adaptive illness perceptions were associated with better outcomes, including psychological distress, wellbeing, quality of life, functioning, positive symptoms, and engagement in CBTp or psychoeducation interventions. However, as these findings were largely from cross-sectional analyses, causal inferences are limited to findings from only a few longitudinal studies demonstrating variation in stability of illness perceptions over time without specific interventions and that perceptions of control and loss could improve during CBT and psychoeducation interventions. Conclusion: Further intervention studies are needed to provide more evidence on the potential for changeability of illness perceptions and importantly to understand whether, and, if so, how, in the psychological treatment of psychosis and bipolar, change in illness perceptions is related to outcomes. "The role of illness perceptions on engagement and psychological outcomes in Cognitive Behavioural Therapy for Psychosis (CBTp)". Introduction: Illness perceptions are important mechanisms of engagement and change in physical health interventions and emerging evidence suggests they may play a similar role in psychological therapies, including the cognitive behavioural interventions recommended for psychosis and bipolar (CBTp). The limited number of CBTp studies to date that have investigated the role of illness perceptions have demonstrated that CBTp can improve illness perceptions and that this may relate to some outcomes. This relationship needs to be further understood to ascertain the potential to improve outcomes and effectiveness of treatment by specifically targeting illness perceptions in therapy. Aim: The present studied aimed to further understand the relationships between change in dimensions of illness perceptions and outcomes in CBTp, including the direction of these relationships. Method: A prospective cohort design was utilised with data collected as part of routine care across three time points: pre-therapy, mid-therapy and post-therapy. A modified version of the Brief Illness Perceptions Questionnaire (BIPQ) assessed ten dimensions of illness perceptions and the CORE-10 assessed levels of distress. Engagement was dichotomised as attending five or more therapy sessions (engaged) or ≤ 4 sessions (did not engage). Cross Lagged Panel Models (CLPM) were used to assess causal relationships between separate dimensions of illness perceptions and levels of distress during therapy. Results: Two dimensions of illness perceptions predicted engagement in therapy. Those who in engaged in therapy (n = 305) had perceptions of less personal control over their mental health problems but higher perceptions that talking therapy would be helpful than those who did not engage (n = 305). The subsample (n = 248) of participants with sufficient data to be included in CLPM analyses showed that, during therapy, illness perceptions predicted change in levels of distress, for perceptions of symptom identity and that changing the way you think or do things can improve mental health. Levels of distress predicted change in illness perceptions across six dimensions including: consequences, personal control, identity, concern, coherence, emotional response, changing the way you think or do things can improve mental health, and looking at things differently as helpful. No causal effects were found for either perceptions of timeline or treatment control with levels of distress in either direction. Conclusion: These findings suggest a strong causal role for distress on illness perceptions which has been neglected in previous research. Findings are potentially supportive of the possibility of incorporating explicit illness perception interventions into CBTp, but highlight the need for further controlled, longitudinal studies.

Evidence of neuroanatomical abnormalities in subjects with a recent first episode of psychosis (FEP) has been heterogeneous, possibly due to the increased risk of false positives and heterogeneous findings associated with small samples that dominate the literature. In addition, the clinical impact of such findings has been limited. Machine learning promises to overcome this limitation, however, initial attempts to identify FEP have yielded inconsistent results. Within this movement, deep learning has recently emerged as a promising approach in areas such as visual and speech recognition, as well as other areas of medicine. Its ability to capture highly abstract and complex interactions may be useful to capture the characteristic subtle and widespread neuroanatomical changes of FEP. The overarching aim of this doctoral thesis was to investigate neuroanatomical abnormalities in FEP at the individual level in a mega-analytic approach. Structural Magnetic Resonance Imaging (sMRI) data was collated from five independent studies, totalling 1074 participants. FEP and healthy controls (HC) were first compared using voxel-based morphometry in a large-scale megaanalysis. This was followed by a thorough review of the current evidence for deep learning in psychiatric and neurologic neuroimaging. A deep neural network, along with other wellestablished methods for comparison, were then used to classify FEP and HC at each site separately to test for the reproducibility of findings. Finally, a deep neural network was used to classify the two groups in a large-scale mega-analysis. Collectively, results revealed a pattern of fronto-temporal-insular changes identified both at group and individual level. Deep neural networks performed better than traditional machine learning approaches, albeit by a small margin. However, performances were lower than expected overall, ranging between 50 and 70%. Upon interpreting these results, I was able to show evidence for publication bias, suggesting that initial studies may have been over-optimistic. Consist with this, the large-scale deep learning analysis suggested that the reliable classification of FEP based on neuroanatomical data may be around 60%. In light of these results, future studies should continue the pursuit for larger samples combined with multimodal approaches to build more reliable and informative models.

Background: Existing reviews of trauma and psychosis have identified a relationship between childhood emotional abuse (CEA) and psychosis, but have not distinguished between different types of CEA. Thus, further investigation is needed. This systematic review aimed to explore the relationship between caregiver antipathy in childhood (i.e. criticism, hostility, coldness or rejection shown by parent figures towards the child) and psychosis diagnosis/symptoms. Method: Five databases were searched and studies were evaluated against inclusion/exclusion criteria. The relevant data was extracted and a narrative synthesis of key findings was completed. Estimates of effect size for antipathy-psychosis associations were calculated using standardised conventions. Assessment of study quality was undertaken using the Effective Public Health Practice Project (EPHPP) Quality Assessment Tool for Quantitative Studies. Results: Fourteen papers met all inclusion criteria. Twelve studies found significant associations between caregiver antipathy and psychosis and two did not. There was evidence that adults with schizophrenia-spectrum diagnosis reported more severe caregiver antipathy in childhood than non-clinical controls. In addition, caregiver antipathy was associated with more severe psychosis symptoms. Most studies received weak or moderate overall quality ratings. Conclusions: This is the first review to focus on investigating the relationship between caregiver antipathy and psychosis. The variability in study methods and quality makes it difficult to draw firm conclusions about the nature and strength of these associations. Further studies using more robust methodological and statistical procedures are required to consolidate the emerging evidence.

This thesis is derived from my own experience that: When I am sane, I am an atheist, but when I am Mad, I am driven by the Hand of God. From this paradoxical position I hypothesise a non-binary Intersection of Madness, Mental Disorder and Acute Religious Experiences. To establish and develop this Intersection I explore the way Madness, Mental Disorder and Acute Religious Experiences have been constructed and how they do and do not construct their referent realities. I explore the interrelation of these ideas showing how these have been addressed, but also remain undertheorised in the Academic disciplines of Psychiatry and Religious Studies. This thesis draws on my experiences but also an extensive bibliography of over six hundred texts split evenly between the sciences and the humanities. I introduce three innovations: 1.) Mad Studies: This approach privileges the voices of those who have experience of Madness. By applying this approach to both Psychiatry and Religious Studies for the first time, traditional models of understanding can be redescribed. 2.) Acute Religious Experiences: I conceptualise these as a distinct category which is competent to address species wide behaviours, in the same way that the categories of ritual or worship are not limited by particular instances. I propose that Acute Religious Experiences as a category is competent to address the full diversity of instances of extreme experiences articulated by humans in ‘religious’ terms. 3.) Disruption: DSM-5 (APA 2013), the dominant psychiatric text, introduces Disruption as a new approach to cultural relativism. I theorise Disruption as a placeholder for the Intersection of Madness, Mental Illness and Acute Religious Experiences. The work of Part II is to develop and establish my theoretical approach. I draw on historical understandings only insofar as they provide context and expose the antecedents on which contemporary understandings of these terms have been constructed. The concern of this thesis is always with the existential states of Disruption and developing my argument that understanding these at the Intersection of Madness, Mental Disorder and Acute Religious Experiences provides new insight and understanding. Part III sets out three very different applications, based on the previous work of theory development: 1.) A critique of contemporary psychiatric research into Religion from a Mad Studies point of view. 2.) An Autoethnographic account of one of my own experiences of Disruption in South India in 1985 and 3.) A radical re-description of the life of the Historical Jesus which becomes possible as a result of my Mad Studies point of view. As the result of the work of this thesis I am able to demonstrate that the non-binary Intersection of Madness, Mental Illness and Acute Religious Experiences provides immediate advantages and also new directions for the Academic disciplines of Psychiatry and Religious Studies and these are set out in my conclusions.

Language interpreters are pivotal in ensuring equal access to psychological therapy for refugees and asylum seekers in the United Kingdom. However, historical conceptualisations of interpreters as ‘invisible’ in therapy appear to have contributed to a lack of research in this setting. The current study sets out to explore interpreters’ experiences of therapy with refugees and the professional support they need in this setting. Eleven interpreters participated in semi-structured interviews, which were then analysed using Thematic Analysis. Three overarching themes were identified: What is my Role?; Emotionally Connected vs Detached; and Current Context vs Aspiration. Results highlight participants’ experiences of an ambiguous and complex role and of a unique setting that poses technical and emotional challenges; interpreters' conceptualisation of their preferred support; the experienced precarity of an unregulated and poorly recognised profession; and the personal growth being an interpreter brings about. This study has clinical and policy implications, such as organisations’ obligations to offer specialised, multi-modal support to interpreters and the urgency of granting interpreting protection of title.

Background. Cognitive Behavioural Analysis System of Psychotherapy (CBASP) has been developed to treat individuals affected by persistent depressive disorder (PDD). There is a growing number of empirical studies to suggest that CBASP is effective in treating chronically depressed population. Taking into account these findings as well as the chronic and debilitating nature of persistent depression, it can be invaluable, when planning treatment, to understand the factors contributing to and maintaining this condition, as well as mechanisms of change involved in CBASP. Purpose. A systematic review aimed to establish the quality of evidence indicating the effectiveness of CBASP when addressing difficulties with interpersonal functioning which are believed to be causing and maintaining depressive symptoms according to the theory of persistent depression developed by McCullough (2000). McCullough hypothesised that childhood trauma leads to an impairment in the cognitive-emotional development, which then leads to interpersonal difficulties that result in depressive symptoms. An empirical study aimed to identify the strength of the relationships between different constructs in the theoretical foundations of CBASP. Methods. A systematic literature search was conducted identifying research reporting the effects of CBASP intervention on interpersonal functioning in the clinical samples affected by PDD or depression of chronic nature but not meeting all the criteria for PDD. The search yielded nine papers which met inclusion and exclusion criteria. The Effective Public Health Practice Project quality assessment tool was employed to assess the quality of the included studies. In order to collect data for empirical study, a cross-sectional design was used. Clinicians working in the mental health teams in the local board were asked to identify adult patients on their caseloads who were affected by PDD. The clinicians were then invited to introduce the study to these patients and, if the patient showed an interest, offer them a questionnaire pack to read at home. Thirty-two patients with PDD completed and returned a set of questionnaires measuring childhood trauma, pre-operational functioning/reflective functioning, interpersonal difficulties, and depressive symptoms. A series of multiple regression analyses were used to analyse the results. Results. The systematic review provided evidence supporting the hypothesis that CBASP intervention leads to an improvement in the area of interpersonal functioning. The majority of the assessed studies demonstrated the improvements on the measures of interpersonal functioning, while all of the studies showed reductions in depressive symptoms. The methodological quality of the studies has been evaluated to be of good or very good standard which strengthened the reliability and validity of the results. Findings from the empirical study, somewhat surprisingly, failed to demonstrate the hypothesised association between childhood trauma, pre-operational thinking, interpersonal difficulties and the severity of depression. Childhood adversity, pre-operational thinking and interpersonal difficulties did not predict the severity of depressive symptoms. The relationship between childhood trauma and interpersonal functioning, as well as interpersonal functioning and depression, did not reach statistical significance, even when the subscale of the Inventory of Interpersonal Problems (Horowitz, Alden, Wiggins, & Pincus, 2000) measuring a hostile submissive interpersonal style associated with persistent depression, was entered into the model. Discussion. The findings from the first chapter of this thesis provide evidence suggesting that CBASP intervention leads to an improvement in the area of interpersonal functioning and reduction in depressive symptomatology. Importantly, the review's results demonstrated that while the assessed studies were primarily of good quality, more studies investigating specific mechanisms of change involved in the CBASP intervention are needed. The analyses which were part of the empirical study revealed the lack of associations between the constructs used by McCullough in his theory of persistent depression. While it is possible that the relationships between the discussed constructs are weaker than previously established, there have been a number of methodological limitations, such as a potentially unrepresentative sample and its small size, which might have contributed to the absence of predicted effects.

Background: Currently, up to 20% of young people worldwide have a diagnosable mental health condition, and an even greater proportion have subclinical symptoms and/or are at risk of developing difficulties. Universal approaches to treatment, prevention, and the promotion of positive wellbeing for youth are of growing interest. Method: A systematic review and meta-analysis was conducted to determine the effectiveness of third wave cognitive behavioural therapies (CBT) for children and adolescents. Therapies reviewed were transdiagnostic and applicable across the continuum from ill-health to thriving. An empirical study explored the feasibility of a randomised controlled trial (RCT) for a psychologically-based mindset intervention, incorporating constructs from third wave CBT, as a universal promotive mental health tool in UK educational settings. Results: Thirty RCTs across clinical and non-clinical settings were included in the meta-analysis. When all studies were included, behavioural difficulties/externalising problems (g=-.67), third wave processes (g=.67), and wellbeing/flourishing (g=.65) yielded significant effects. When analysing only studies rated moderate-high quality, significant effects were found for emotional symptoms/internalising problems (g=-0.34), interference from difficulties (g=-0.82), third wave processes (g=0.53), wellbeing/flourishing (g=0.51), and quality of life (g=0.49). Behavioural difficulties/externalising problems ceased to be significant, while physical health/pain was consistently non-significant. The empirical study suggested that the mindset intervention and research design were feasible. Minimum recruitment targets were met (N=80). Student feedback was positive and participants appeared to understand the intervention content. Data were indicative of possible intervention effects for primary outcomes of personality mindset and psychological flexibility. Secondary outcomes of self-compassion, self-esteem, low mood, and anxiety also yielded some promising results. Maintenance was difficult to evaluate due to sample attrition. Conclusions: Third wave CBT and psychological mindset interventions may be applicable to improve mental health and/or promote thriving among young people. There were notable limitations to both papers. Implications and directions for future research were discussed.

Background: This portfolio contains a systematic review and two empirical projects in the clinical field of psychosis. The aim of the systematic review was to narratively synthesise the effectiveness of psychological treatments for amotivation as a key negative symptom. The first empirical project aimed to explore possible selves theory with regards to individuals with psychosis and significant functional difficulties, as a possible motivational factor influencing functional recovery. The second empirical project aimed to explore whether Social Recovery Cognitive Behavioural Therapy (SRCBT) had an impact on possible selves and whether any change mediated functional recovery. Methods: The systematic review included all psychological and psychosocial interventions for amotivation in psychosis, with focus on the most reliable measures of amotivation. The empirical projects included secondary analyses of data collected from the Improving Social Recovery in Psychosis project, where 77 individuals with psychosis and particularly low functioning were recruited. Results: In the systematic review, conclusions regarding efficacy of interventions could not be drawn, due to the limited number of studies and mixed results. In the first empirical paper, Possible selves in people with psychosis and particularly poor functioning were found to have low specificity, balance and enmeshment, but relatively high optimism. Possible selves were not associated with functional outcomes in this population. Equally, in the second empirical paper, SRCBT was not found to have an impact on possible selves. Conclusions: Ongoing research is required to explore novel treatments for amotivation in psychosis, particularly utilising outcome measures which give sufficient weight to amotivation as a construct. Whilst motivational theories suggest that possible selves were an important motivational construct impacting on functioning, perhaps change in possible selves is not necessary for behaviour change to occur. Future research is implicated with regards to whether possible selves are subject to change once behavioural changes are consolidated following therapy.

Context: Prevalence rates of severe mental illnesses (SMI) such as psychosis differ between ethnic groups disproportionately. Disparities also exist when exploring access and outcomes to psychological therapies based on ethnicity. The literature suggests that individuals from ethnic minority groups with SMI are less likely to be offered a psychology therapy. Methods: The broad aim of the thesis was to explore the effectiveness and accessibility of psychological therapies for ethnic minority groups who experience a SMI. A systematic review explored the effectiveness of psychological therapies for ethnic minority groups who experienced a SMI. Secondly, an empirical paper investigated whether sociodemographic factors, including ethnicity, influenced the offer and uptake of psychological therapies in a sample of service users who experienced first episode psychosis. Results: Our systematic review included nine studies for analysis, with seven reporting significant improvements in SMI symptom severity. Seven studies made cultural adaptations which led to a reduction in SMI symptom severity compared to treatment as usual. However the quality and risk of bias varied between studies, reducing the strength of the findings. In our empirical paper we found that service users in ‘White Other’ and ‘Other’ ethnic minority groups were less likely to be offered a psychological therapy compared to the white British reference group (‘White other’ OR = .48, CI .26 – .89, p = .04, ‘Other’ OR = .38, CI .17- .87, p = .02). Presenting to Early Intervention Services increased the likelihood being offered a psychological therapy. Conclusions: Our evidence highlights that whilst psychological therapies may be useful for ethnic minority groups with SMI, the availability is mixed depending on the service accessed. Future research is needed to explore the frequency and use of culturally adapted therapies in clinical settings. Research is needed that allows comparisons to be made between culturally adapted and standard therapies.

Understanding how the genetic risk factor Disrupted-in-schizophrenia 1 contributes to neuropsychiatric disorders will help direct therapeutic efforts. Disc1 functions in neurogenesis and neuronal migration. Defects in early neurodevelopment are thought to be a contributing factor in neuropsychiatric disorders. Our group previously demonstrated that ENU-generated disc1Y472X/Y472X mutants have alterations in hypothalamic development from 2 days post fertilisation. Critically, behaviours relating to the hypothalamic-pituitary-interrenal (HPI) axis such as stress responses were also perturbed in larvae and adult. Here, we generated a novel disc1exon6/exon6 CRISPR knockout line with a frameshift mutation closer to the human translocation breakpoint. Following mutant validation, we characterised previously identified hypothalamic markers and found altered expression of retinal homeobox 3 and steroidogenic factor 1 (sf-1/ff1b). In addition, we identified increased expression of oxytocin in the developing hypothalamus. Behaviourally, a decrease in feeding and hunting behaviour was observed in both disc1Y472X/Y472X and CRISPR-generated disc1exon6/exon6mutant larvae. Sleep regulation was altered in disc1Y472X/Y472X only. Conversely, only disc1exon6/exon6mutants had maladaptive responses to acoustic and light stimuli as larvae, and to a novel environment as adults. These behaviours are associated with hypothalamic function and relevant to neuropsychiatric comorbidities such as eating disorders, insomnia, and anxiety. Using immunostaining for phosphorylated ERK as a measure of neuronal activity, we noted that loss of disc1 led to significant increases and decreases in neuronal activity in different neuronal populations in 7 dpf larvae. Regions of interest (ROIs) with increased activity included the forebrain and cerebellum, while ROIs with decreased activity included hypothalamic and connected regions. Finally, GSK-3ß inhibition during a critical time window normalised ff1b expression in disc1Y472X/Y472X mutant embryos, with later effects on neuronal activity and feeding behaviour at larval stages. This study demonstrates the validity of zebrafish in neuropsychiatric disease research and characterises novel neurodevelopmental and hypothalamus-associated behavioural functions of disc1.

Learning is an active process, continuously developing throughout one’s lifetime. Social media platforms offer a unique opportunity for learning to occur, bringing forth independent and collective learning opportunities for individuals of all ages. This study employed an online social media platform to harness informal learning and cultivate a community of practice within a group of psychiatric mental health nurses. The aims were twofold. It was envisioned that by using a social media platform, the participants could access informal learning opportunities. The second aim anticipated that a community of practice could be cultivated as the social media platform would offer a medium for support. I sought to explore the experiences of this group of psychiatric mental health nurses by understanding the social processes they encountered in forming part of the study. Thus, I adopted a constructivist grounded theory approach to understand their experience. A total of 28 psychiatric mental health nurses opted to take part and it was agreed that Facebook would be the medium for this study. The participants had a positive experience when adopting a Facebook page for informal learning. However, an unexpected finding was that a community of practice failed to form. It transpired that the study was performed within the organisation where the participants were employed despite the initial intention to conduct the study independently of any institution. A multitude of organisational issues arose which impacted the cohesiveness of the group, leaving all the participants of this study demotivated. These factors together with perceptions of lack of professionalism amongst nurses hindered staff from cultivating a community of practice. It was concluded that emphasis needs to be placed on raising the profile of psychiatric mental health nurses. This can be achieved by emphasizing continuous professional education. It is also suggested that organisations focus on adopting contemporary leadership styles to enhance working relationships whilst further research is carried out in this area.

Introduction: Smartphones have become the primary device for accessing the online world. The potential for smartphone use to become problematic is increasingly recognised, with students at particular risk due to their high usage and reliance. There is limited research evaluating interventions for problematic smartphone use. The present research aimed to develop and evaluate a digital intervention for problematic smartphone use in the student population. Method: A mixed-methods case series design was used to evaluate the acceptability and impact of the intervention for ten participants. The intervention included: goal setting, personalised feedback, mindfulness and behavioural suggestions. Participants were asked to complete self-report measures of problematic phone use, online dependency, mindfulness, wellbeing, psychological distress, sleep and self-determination. Participants’ phone use and sleep were also measured directly. Results: The results provide evidence for the intervention package reducing problematic smartphone use, although there was no observable impact on overall screen time. There was some evidence of positive influences upon online dependency, mindfulness, wellbeing, and sleep. No particular component of the intervention seemed more effective than the others. Discussion: The findings suggest that the intervention package is both effective and acceptable to students wishing to better manage their problematic smartphone use.

The aim of this research study was to investigate whether the Brief Addiction Therapist Scale (BATS) (Crosby, 2018), a transtheoretical fidelity measure, is associated with therapeutic outcome. The BATS evaluates therapists’ routine delivery of psychotherapies widely used in the treatment of alcohol and drug use problems. The current research conducted a secondary analysis of existing randomised controlled trial (RCT) data. Digital recordings of Motivational Enhancement Therapy (MET) sessions that were recorded as part of the original United Kingdom Alcohol Treatment Trial (UKATT Team, 2005) were observed and therapists were rated using the BATS. Multilevel statistical procedures in which the therapists were treated as a random factor were conducted in order to examine whether the BATS scores could predict therapy outcome. The results showed that the therapist BATS scores did not predict clients’ outcome of therapy. However, the analysis suggested that the BATS scores explain some of the therapist variance in outcomes. The findings of this thesis provide further support for the real-world application of the BATS.

This research explores the association between authentic leadership and workplace wellbeing and how the variable of attachment insecurity mediates this relationship amongst Clinical Psychologists working in the NHS. A total of 207 participants, who were employed as Clinical Psychologists working in the NHS, completed an online survey. The online survey collected demographic information and data through self-reported outcome measures. The demographic information included: age, gender, ethnicity, length of time qualified, relationship to their leader, the job role of their leader and NHS employment. The self-reported measures quantified authentic leadership, workplace attachment style and workplace wellbeing. A correlational and regression analysis was used to assess the relationship between authentic leadership and workplace wellbeing and whether this relationship was mediated by the variable of attachment style (avoidance and anxiety). The results showed that the majority of participants identified their leader as fellow Clinical Psychologists and that those leaders often had multiple roles and responsibilities. The findings illustrated that there was a significant positive correlation between authentic leadership and workplace wellbeing. Attachment anxiety was shown to negatively correlate with both authentic leadership and workplace wellbeing. Similarly, attachment anxiety was also seen to indirectly influence the relationship between authentic leadership and wellbeing at work. However, attachment avoidance was found to not be associated with wellbeing and leadership to the same degree as attachment anxiety. This research highlights that it is important for an individual who experiences attachment anxiety at work to have an authentic leader as this can improve their workplace wellbeing. The strengths and limitations of this research are presented. Implications for clinical practice are discussed alongside suggested directions for future research.

Introduction: Understanding and protecting the well-being of university students is of increasing importance to universities and support services. Problematic digital technology use has been associated with poorer student well-being internationally, but little is known about this relationship in the UK university student population. The current research investigated whether digital technology use and well-being are associated in the UK student population, which factors of well-being are important to this relationship and how they are associated with digital technology use. Method: Students from the University of Leeds (n = 544) completed an online survey composed of standardised measures of factors relating to psychological well-being, mental health, physical health and problematic digital technology use. Nine models were analysed using structural equation modelling. Theoretical relationships between well-being and digital technology use and moderating effects of basic psychological need satisfaction, social support and mental health were assessed, as well as the goodness of fit for each model. Results: The superior model, 5.0, hypothesised that greater problematic digital technology use would be associated with lower well-being. Mental health and basic psychological need satisfaction were hypothesised to moderate this relationship. In model 5.0, digital technology use was significantly negatively associated with well-being (β = -0.16, p < .01). Basic psychological need satisfaction did not moderate the relationship. Mental health moderated the relationship and was significantly negatively associated with well-being (β = -0.90, p < .001) and significantly positively associated with digital technology use (β = 0.26, p < .001). Discussion: Digital technology use is related to well-being in the UK university student population. Students with mental health difficulties are more likely to have a problematic relationship with digital technology and for their use of digital technology to negatively impact on their well-being. It is recommended that universities work to increase awareness of the impact of problematic technology use on well-being and its relationship with mental health difficulties.

Psychiatric nurses are considered the most vulnerable healthcare workers in terms of encountering violence, and this trend is rising. Violence in the workplace poses a threat to the physical, emotional and psychological wellbeing of nursing staff, and in particular those working in mental health settings. This study explores how patient violence is experienced by qualified nurses employed in one inpatient psychiatric unit in the Kingdom of Saudi Arabia, paying attention to the short and long term effects and strategies that could better enable nurses to prevent, minimise and/or address workplace violence. As male and female patients and nurses are segregated in Saudi healthcare settings, this study focuses on female patient violence against female nurses. A qualitative descriptive approach was chosen to provide the philosophical foundation of this work. A purposive sample was used to recruit nine participants working in inpatient settings in one hospital in the KSA. The inclusion criteria required participants to; be a licensed registered nurse, be employed during the past decade in acute psychiatric units for female adult inpatients, and have experience of patient violence in one form or another. Data was collected using semi-structured, face-to-face interviews and participants were asked to complete a short demographic questionnaire. Data were analysed using thematic analysis, with four themes emerging; 1) The Occurrence of Violence; 2) The Determination of Violence; 3) The Impact of Violence; and 4) The Elimination of Violence. In conclusion, participants believed patient violence, such as physical and verbal abuse from patients and their relatives, is an unavoidable part of their work. Despite some positive outcomes of patient violence, the effects of patient violence were found in the main to be negative, with substantial psychological impacts being noted.

The aim of this research is to explore the facilitation, experience and measurement of flow (Csikszentmihaly, 1979), and group flow in particular, through individual and collaborative creating and to note the potential implications of this for identity, wellbeing and conflict. Previous research on group flow facilitated by collaborative arts is limited to the medium of music (Pels, Kleinert & Mennigen, 2018; Gaggioli, Chirico, Mazzoni, Milani & Riva, 2015; Gloor, Oster & Fischbach, 2013; Hart & Blasé, 2016; Keeler, Roth, Neuser, Spitsbergen, Waters & Vianney, 2015; Macdonald, Byrne & Carlton, 2006; Sawyer, 2006; Zumeta, Basabe, Wlodarczyk, Bobowik & Paez, 2016). There is also very little research exploring the role of identity within collaborative arts and possible implications for intergroup conflict resolution (Zelizer, 1997; Nemeth & Nemeth Brown, 2003; Crocker & Luhtanen, 1990; Worchel & Coutant, 2004; Zelizer, 2003; Balkrishnan; 2017; Lee, 2013). Research addressing these concerns is presented in six studies in this thesis. Study 1 measured flow using Jackson & Marsh’s (1996) Flow State Scale and found no difference in flow scores between art and non-art collaborative task groups, indicating that capturing the ephemeral nature of flow in a group art activity presents particular empirical challenges. More propitiously, study 2 explored identity, experiences of flow and of collaborative creating through semi-structured interviews with University of Salford students, where thematic analysis revealed the development of themes from initial negative feelings and assumptions toward the out-group; comfort with the initial in-group; a sense of responsibility/respect for all; a need to express; unity/togetherness; and change in feelings/atmosphere. Themes indicate the lived experience of group flow and potential implications for identity and the salience of group conflict. Study 3 draws data from Study 1 and performs a semiotic analysis of artwork procured from each creating condition. The semiotic analysis identified symbols including unity and peace and provided useful insights into the experiential nature of collaborative creating placed in a setting where participants initially identify as opposing groups. Study 4 demonstrated no significant differences in flow (measured again using the Flow State Scale) between individual and collaborative creating, but also revealed a significant positive relationship between flow and the engagement construct of stress (measured by Helton’s Short Stress Scale), thus implicating flow in wellbeing and psychological health, potentially regardless of the type of art activity involved. Study 5 draws from data from Study 4, and performs a semiotic analysis of artwork taken from the individual and collaborative creating conditions. Symbols were identified from the collaborative condition, that highlight inclusivity and potentially synchronicity that can be closely related to being in group flow (Sawyer 2015). Insights on differences between individual and collaborative creating are also identified. The 6th and final study explores the creating experience further through exploring the lived experiences of artists through Interpretative Phenomenological Analysis (IPA). From the artists’ perspectives, 6 super-ordinate themes were derived including my art, my own; groups coming together to create; a relaxed, safe space; blending; the inevitable conflict; impact, openness and release. From these themes, the lived experience of group flow is demonstrated and discussed in the context of identity, wellbeing and conflict. Overall this research has potentially important implications for identifying the appropriate ways in which to measure flow and group flow, provides insight into the experiences of artists engaging in collaborative creating, and indicates a prospective role for flow in wellbeing and for identity salience and the perception of inter-group conflict.

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