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There are differences in the effectiveness of therapists reflected in the outcomes their patients achieve; this variability can be substantial and is called the ‘therapist effect’. For example, the most effective therapists have twice the recovery rate of the least effective therapists. How and why some therapists are more effective than others, is therefore important to understand. To explore this further this thesis has two sections. The first section systematically reviews the literature to assess whether training is effective in improving the competence of therapists. The second section reports an empirical study exploring whether therapist interpersonal skills and self-reflection are associated with the outcomes their patients achieve. Section One: Previous reviews have been conducted about the effectiveness of training. The most recent of these was published in 2013, therefore, the focus of the current review was on studies published from 2013 to 2020. Twelve new studies were identified. The findings were indicative that training does increase competence of therapists and this seemed to be especially the case when training was of longer duration and involved components of practice with real world clients. However, the general quality of the research was low, so conclusions are made cautiously. It is recommended that more high-quality research is required to better understand the effects of training interventions on therapists’ competence. Section Two: Therapists (N=61) completed surveys about their self-reflective abilities, social skills and interpersonal problems. Supervisors (N=19) of these therapists were also asked to rate the therapists’ self-reflective abilities. Patient depression and anxiety outcomes for these therapists were collected from electronic clinical records (anonymously). Patient outcome data (N=3112) was available for N=42 therapists; corresponding supervisor reported data was available for N=18 therapists. Statistical analysis using multi-level modelling indicated that therapists’ higher self-reported social skills were associated with better treatment outcomes for depression, but not for anxiety. Therapist-reported self-reflection and interpersonal problems were not related to treatment outcomes. A sensitivity analysis suggested that important outlying therapists’ responses might undermine relationships between therapist-reported self-reflection and treatment outcomes. There was insufficient supervisor data to make meaningful conclusions. These findings contribute to a growing literature concerning why therapist effects occur and what steps may be taken to increase the effectiveness of therapists. Future research should continue to strive for understanding about the characteristics/abilities that make therapists effective and what can be done to instil or enhance effectiveness.

Cognitive Behavioural Therapy (CBT) is a widely used psychotherapy. CBT has a large evidence base indicating its effectiveness for a range of psychological difficulties. However, research has indicated that CBT is frequently not offered to service users who might benefit from it. Furthermore, CBT that is offered is often of poor quality, with therapists failing to use evidence-based techniques. It has been suggested that research into therapists’ beliefs about Evidence-Based Practice (EBP) and CBT might provide insight into the under-provision of high-quality CBT. Additionally, research into service users’ beliefs about CBT could provide insight into whether these beliefs are similar or different to therapists’ beliefs. The similarity of service users’ and therapists’ beliefs has implications as to whether service users’ preferences for therapy are understood and acknowledged by therapists. This thesis aimed to contribute to research in this area by investigating service users’ and therapists’ beliefs and attitudes regarding EBP and CBT. The first part of the thesis reports a systematic literature review and meta-analyses. These explored the link between therapists’ beliefs and attitudes regarding EBP and therapists’ usage of EBP CBT. Nineteen studies were included within the systematic review and seven studies were included within each of two meta-analyses. Results indicated associations between therapists’ attitudes or beliefs towards EBP and therapists’ use of EBP CBT in most studies. Effect sizes varied from small to large, although the majority were small. Associations were found for both positive and negative attitudes and beliefs. Associations were found for attitudes towards EBP overall, as well as beliefs regarding specific EBP CBT techniques. Meta-analyses found a significant association between therapist openness to EBP and EBP CBT use, but not between intuitive appeal of EBP and EBP CBT use. The second part of the thesis reports a quantitative research study. This study explored the beliefs of therapists and service users on the importance of alliance and adherence to techniques across three stages of CBT. Therapists were also asked to predict service users’ beliefs regarding alliance and adherence importance. Results indicated that therapists view adherence and alliance as more important than service users do, with the largest discrepancy found over alliance in early therapy. Therapists were also found to accurately predict service users’ beliefs about the alliance. However, therapists underestimated the importance of adherence to service users. Personal characteristics and experiences of CBT were found to be associated with therapists’ and service users’ beliefs, respectively. Taken together, both parts of the thesis suggest that therapists’ beliefs about EBP and CBT can impact their delivery of CBT. Furthermore, therapists might hold different beliefs about CBT than service users. Therapists might also make incorrect assumptions regarding the nature of service users’ beliefs about therapy. These differences in beliefs and incorrect assumptions could have important clinical implications, as therapists’ beliefs might be influencing them to deliver therapy that is incongruent with service users’ preferences.

It is well known that psychotherapy is beneficial to patients struggling with mental health difficulties. A barrier to this is patient dropout; the phenomenon of patients dropping out prematurely from therapy. Research has found that this leads to worse outcomes for those that dropout prematurely. Dropout has been studied within the literature for individual therapies and across services, however, there continues to be gaps in knowledge. Particularly as there are issues with the definition of dropout, as this varies across services and between therapists. Improving Access to Psychological Therapies (IAPT) is a national primary care service in England that began in 2008, as in other services worldwide IAPT has difficulties with high rates of dropout and patients reattending the service after dropping out. Research into IAPT dropout is fairly new as the service has only been running since 2008. Therefore, this work aims to explore and define dropout within IAPT services by examining the literature. It also aims to examine the percentage and predictors of patient dropout within IAPT. Part I is a systematic literature review that combined the results of 12 studies looking at or discussing patient dropout in IAPT services. Findings show that the average rate of dropout is 31% and the most common definition of dropout is patient non-attendance any time after the initial assessment without prior agreement between therapist and patient of ending therapy. Several factors were found to be associated with patient dropout across patient factors: psychological distress, health difficulties, alcoholism, deprivation and unemployment. Therapist factors: poor relationship with therapist, less effective therapists had higher levels of dropout. Service factors: long waiting lists, poor communication, location, invitation methods, pathways and dissatisfaction with the service. Part II is a secondary analysis of the PRaCTICED trial data set, it was a noninferiority trial that compared cognitive behavioural therapy (CBT) and person-centred experiential therapy (PCET) outcomes in patients with depression accessing IAPT services. A preliminary analysis and a multilevel logistic regression analysis were completed on the dataset to look for predictors of patient dropout on patient and therapist variables. There were 332 patients and 34 therapists used for the multilevel analysis. Findings found several predictors for patient dropout, including age, deprivation, resilience, number or sessions and treatment type. These findings together increase the understanding of patient dropout within IAPT services and allow for these factors and predictors to be considered by services and therapists when working with patients. Future research should focus on looking at both patient, therapist and service level factors to get a richer understanding of all the potential predictors that may be leading to patient dropout.

The Improving Access to Psychological Therapies (IAPT) initiative was launched in 2008 in the United Kingdom (UK) to offer evidence-based psychotherapies to patients with anxiety and depression in a stepped care service delivery model. The programme reports evaluation data in the form of monthly and annual reports of recovery rates by service and care commissioning group. In recent years the plurality of intervention in this programme has also been expanded. A systematic review and meta-analysis was conducted to review the published practice-based studies arising from the first 10-years of the English IAPT programme, focussing on the effectiveness of IAPT interventions delivered in routine practice. A total of 60 studies were included overall, with n=29 of those making up the meta-analysis. Results found large pre-post treatment effect sizes for depression and anxiety, and a medium pre-post treatment effect size for functional impairments. Implications for future work include exploring how IAPT can become more effective for people with comorbid long-term conditions and medically unexplained symptoms and improving the designs of practice-based studies. The research report investigated the effectiveness of cognitive analytic therapy (CAT) within the IAPT programme at step 3 (high intensity). Outcome comparisons with the ‘treatment as usual’ intervention offered at step 3 (i.e. cognitive behavioural therapy; CBT) were completed. Longitudinal multilevel modelling (MLM) was used to investigate symptomatic changes over time and between groups. Results suggest equivalence between CAT and CBT in an IAPT setting. CAT and CBT trajectories of symptom change do not appear to differ over time during the therapies. Implications for CAT being offered as a first-line treatment within the IAPT programme are discussed.

Family Based Treatment (FBT) is a recommended therapy for children and adolescents living with an eating disorder; it is founded on research evidence, and is most effective when it is delivered according to the manual. Routine and regular weighing of clients is an essential component of FBT (Lock & le Grange, 2013). Despite the importance of weighing, nearly half of therapists delivering FBT do not weigh as suggested by the manual (Kosmerly et al., 2015). Deviation from the model might be a result of factors relating to the therapist, as opposed to being driven by the client's needs. Therefore, this thesis aimed to a) review the literature to better understand whether and how therapist factors influence the delivery of FBT, and b) investigate whether asking FBT therapists to make implementation intentions (a specific 'if-then' plan that states exactly when, where, and how a behaviour will be carried out (Gollwitzer, 1993)) could support them to adhere to evidence-based weighing. Ultimately, the project hoped to inform how clinicians can be supported to deliver FBT in accordance with protocol, to the benefit of the client. The first part of this thesis identified nineteen studies to be included in a literature review. Findings suggested that therapists' emotions (e.g. whether they felt anxious), cognitions (e.g. whether they believed FBT could meet the needs of certain clients), and behaviours (e.g. if family members could be engaged with the treatment) were linked to a) whether treatment was carried out in line with protocol, b) how well the client engaged in the treatment, and c) the extent of the client's eating disorder symptoms. Other factors, such as when parents felt empowered, and where a team had access to training and support also positively impacted on outcomes for the client. However, the methods used by several studies included in the review were criticised, therefore conclusions should be interpreted with caution. The second part of this study aimed to investigate whether prompting FBT clinicians to set a goal intention and form an implementation intention would help them to increase weighing behaviour. This study randomly allocated eighty-four FBT therapists to one of two conditions: 1) 'experimental' (participants were asked to make an implementation intention) or 2) 'control' (participants continued providing FBT as usual) condition. All participants completed an online survey, at three time points. Participants were asked questions relating to their general anxiety, specific anxiety about weighing, intentions to weigh, and the percentage of their clients that they weighed. Only the experimental group were given information about the importance of weighing, and asked to form an implementation intention to weigh their clients. Findings showed that clinicians experienced an increase in anxiety about weighing once they had made an implementation intention. Furthermore, forming implementation intentions only increased weighing behaviour among clinicians who already had strong intentions to weigh their clients. Future research is needed to explore further ways in which FBT therapists can be supported to work in line with the research evidence. Together, these findings help us to begin to understand therapist's experience of delivering FBT, and how we might better support therapists to carry out FBT in line with the manual.

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

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

Background: Attachment theory has made significant contributions to clinical psychology and there is an interest increasing in attachment-informed approaches to therapy. Attachment research suggests that successful psychotherapy relies on therapists’ attachment security and their ability to reflect on the therapist-client attachment interplay. However, therapists with insecure attachment often struggle with lower reflective function (RF). Personal therapy (PT) can develop RF and attachment awareness in clinical psychologists (CPs). Aim: To study how reflecting about CPs’ relationships with their personal therapist contributes to their awareness and understanding of their own attachment and its implications for their practice. Methods: From a social constructionist approach, 12 CPs were interviewed. Thematic analysis was used to analyse interview transcripts. Results: Thematic analysis resulted in three main themes: constructing and understanding their own attachment; bringing in an emotional dimension into attachment; and the clinical implications of attachment awareness. Conclusion: Through PT, CPs’ increased their awareness about their own attachment. The idea of attachment security was deconstructed, in support of a range of attachment responses that CPs can reflect about when interacting with others. This forged a sense of robustness in the self from where to work relationally with clients, raising clients’ awareness about their relational needs in the TR.

Background: The past decade has seen an increase in the use of communication technology such as smartphones and social media platforms. Although this improvement in technology might support enhancing communication, socialisation and even education, it also increases the risk of child sexual exploitation. Not only do more children now have access to technology to share personal information which could then be exploited, but more individuals have access to that technology to download, produce and share children sexual exploitation material (CSEM). It is impossible to have an accurate understanding of the prevalence of individuals having sexual interest in children (SIIC) and accessing CSEM who have not been caught. Research suggests that SIIC is commonly seen in the general population and does not solely prevail in sex offender populations. There has been an increase in the past decade in CSEM offences and convictions and organisations have been implemented to support individuals who self-report SIIC. Although research shows that these individuals who committed CSEM offences generally are at low risk of reoffending, certain factors do increase that risk. Law enforcement and criminal justice professionals are required to evaluate their level of risk to inform management, supervision and treatment in the community. The Child Pornography Offender Risk Tool (CPORT) was created specifically for this offender population and has been found to show significant predictive validity for any recidivism and any sexual recidivism; but has not been validated yet in a Scottish population. Method: Firstly, a systematic review of the literature was conducted to investigate the prevalence of individuals who self-report SIIC and their correlates to obtain a better understanding of the phenomenon. Secondly, the empirical research study aimed to replicate the most recent CPORT validation study to investigate the CPORT’s predictive validity in a sample of 144 Scottish CSEM offenders. Like the CPORT validation study, Receiver Operating Characteristic (ROC) and logistic regression analyses were conducted to explore its predictive validity. In addition, the CPORT’s Sensitivity, Specificity, Positive Predictive Value (PPV) and Negative Predictive Value (NPV) were added to the investigation of its predictive validity in this study. Results: A total of 27 studies were analysed in the systematic review and results indicated a mean prevalence rate of SIIC between 16%-21%. Findings also suggested correlates of SIIC such as the presence of mental health problems and adverse childhood experiences. In the empirical research study, ROC and logistic regression analyses indicated that the CPORT significantly predicted any recidivism (Area Under the Curve, AUC = .79), any sexual recidivism (AUC = .79) and CSEM recidivism (AUC = .75), suggesting that it is a valid risk assessment tool for Scottish CSEM offenders. These results were also supported by the other indicators of predictive validity assessed in this study. Conclusions: Overall, the findings from the systematic review suggest that selfreported SIIC in the general population is relatively common and some studies have indicated that individuals from the general public have already accessed CSEM or would do so if they were certain to avoid detection. However, prevalence rates did vary greatly from one study to another, depending on the definition of SIIC and recruitment method used. Generally, the findings indicated inconsistencies in terms of methodology and definition/diagnostic criteria of SIIC and poor external validity. The sensitive nature of this topic likely increases the difficulties that researchers encounter in recruiting representative samples as well as relying on participants’ self-reported answers. The empirical study indicated that the CPORT is a valid risk assessment tool to be used in a Scottish population of CSEM offenders. The implications of this research suggest that the CPORT could be used with a combination of other tools assessing dynamic and protective factors to inform relevant authorities and support them in the supervision and management of individuals with CSEM offences. Strengths and limitations of the systematic review and the research were discussed with implications for clinical practice and recommendations for future research.

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

Background: Weight stigma poses a significant risk to the physical and psychological health of obese people (Puhl et al., 2018). A range of literature highlights that people regularly experience shame, humiliation, and rejection because of their weight. People defined as obese (BMI 30kg/m2) see impacts on their identity, self-esteem, and mental health because of the internalisation of pervasive negative attitude to people classified as obese. Over the past number of years, we have seen increasing medicalisation of obesity. Currently, there is an on-going debate in the United Kingdom regarding whether obesity should be designated as a disease. While some argue that disease designation will reduce stigma and increase access to services (Widling, 2019), the British Psychological Society (BPS) suggest that obesity should be considered as arising as a result of a complex interplay of social, biological and psychological factors (BPS, 2019). People living with obesity must navigate these sometimes-conflicting ideas. This study seeks to explore the lived experience of obesity and the ways in which people who have accessed NHS weight loss services internalise and embody the dominant social ideas regarding obesity. Method: This study adopted a phenomenological epistemological position. Eight semi-structured interviews were completed (eight women aged 38-71) with people who had accessed NHS weight loss services. Results: Data was analysed using interpretative phenomenological analysis with a focus on the phenomenology of Merleau-Ponty and concepts of embodiment. Four key themes and eight sub-themes were identified. These include: The experience of a large body and the embodiment of the social construct of weight, making sense of weight gain, the social function of weight, and making sense of weight-based difficulties through dominant conceptualisations. Conclusion: Weight stigma can become internalised to an extent that it significantly influences obese peoples’ self-image and relationships. Obese people are acutely aware of the judgments that others make of them. They can feel that they fulfil a role in social groups, often holding others’ anxieties about control and body size. People with obesity make sense of their weight through life experiences and events, however, it can be difficult to express nuance in a society that sees obesity as a moral or medical issue. Different perspectives on the issue of obesity as a disease were expressed, however, there was a sense that disease designation could not adequately address the issue of weight stigma, which is the issue of utmost importance for participants in this study.

Background: UK professionals’ understandings of their roles with regards to service users’ sexualities is an under-explored area in clinical research and training, particularly within forensic mental health pathways where they may be exclusively conceptualised in terms of their potential negative underpinnings and outcomes. Secure services typically have no policies governing or promoting sexual expression, and tend to prohibit sexual intimacy. However, recent developments in national guidance and findings emerging from UK-based and international research raise questions as to this approach’s utility in providing rehabilitative care. To date, no research has investigated forensic hospital policy-makers’ sense-making practices around detainees’ sexualities. Aims: This study aims to examine hospital policy-makers’ understandings of forensic detainees’ sexualities, and how these relate to their experiences of practice and their vision of a policy governing sexual expression in hospital. The research is one part of a broader project that has previously explored detainees’ and professionals’ understandings of how sexualities operate within forensic institutions, and aims to support the development of policy and training materials. Methods: The present research draws upon a social constructionist epistemology, using a qualitative, thematic decomposition approach to examine the socially-sedimented discourses at play within the forensic hospital. Ten policymakers were recruited the largest provider of forensic inpatient services in the UK, and participated in semi-structured interviews. Findings: Three themes were identified: 1) Risk and Uncertainty, 2) Artificial Realities, 3) Detained Bodies. The implications of each of these are discussed in terms of their sub-themes. Conclusion: Despite being broadly consistent with policy-makers’ understandings of holistic, rehabilitative practice, the prospect of lessening restrictions on detainees’ sexual expression presents a number of challenges and concerns. ‘Traditional’ institutional and populist discourses concerning forensic professionals’ responsibility to prevent harm tended to supersede those supporting positive risk-taking and human rights-based approaches. The propensity for UK tabloid media to depict forensic detainees and professionals in an unfavourable light, and the accompanying potential for increased government scrutiny, was understood as a primary barrier to enacting less restrictive practices. The hospital itself was positioned as vulnerable to the predations of wider society.

Background The clinical relevance of compassionate care is now widely accepted and is currently one of the most cited requirements for best practice in guidelines and policies. The latest Improving Access to Psychological (IAPT) Services manual states that effective and efficient approaches should be balanced with compassionate care (NHS England, 2019). However, despite its current centrality, the concept lacks a consensual definition and a framework for practice in this context. Aim Knowledge of relational aspects, such as compassion, is best elicited by exploring individual experiences and perceptions (Robert et al., 2011). Therefore, an empirical understanding of compassionate care in IAPT based on the perspective of service users, the recipients of compassionate care, is essential. To the day, there is limited research investigating service users’ conceptualisations of compassionate care, and studies have generally been based in physical healthcare settings, arising questions regarding the generalisability of the findings to an IAPT service. To address the identified gap in the literature, this study will investigate service users’ understandings and experiences of compassionate care in an IAPT service. Method This grounded theory (GT) study used semi-structured interviews to investigate how service users understand and experience compassionate care in an IAPT service. Thirteen people who used or had used an IAPT service were interviewed. Drawing from the constructivist GT guidelines of Charmaz (2014), the analysis process was iterative in nature, occurring simultaneously with data collection, using methods of transcription, systematic coding, memo writing and diagramming. Findings The analysis yielded five categories, each containing specific themes. Together, they constitute the grounded theory model ‘Humanising Responses to Distress’. This is the first empirically based model of compassionate care in a psychological therapies service in the UK. The model defines compassion as a humanising response to distress. This response involves striving to understand the individual experience, acting to meet the person’s needs, empowering the person and creating a secure relationship with them. Conclusions The components of the compassion model provide insight into how service users understand and experience compassionate care in IAPT. The model highlights the importance of prioritising individualised, relational and empowering approaches over rigid and prescriptive interventions that are not tailored to service users’ needs and preferences. Therefore, the current emphasis on standardised approaches and outcome measures may have a negative impact on compassionate care in IAPT as defined by service users.

Background Psychoanalytic approaches have decreased in use as a therapy in the UK. After an initial growth in Britain post World War One, the subsequent emphasis on using empirically supported treatments resulted in cognitive and behavioural approaches being prioritized. Neoliberalism and austerity measures have led to an emphasis on short-term, low cost treatments, and the further marginalization of psychoanalytic approaches. There is no research exploring its use within clinical psychology in the NHS, despite increased research supporting its utility and a policy emphasis on patient choice. Aims This research will aim to explore how clinical psychologists use the psychoanalytic approach within the NHS and their experience of the approach. Methods A mixed methods approach was used. A quantitative online survey of clinical psychologists working within the NHS in the UK (N=189) collected demographic data as well as information about modalities used and their services, clients and training characteristics. An interview was used to explore the experiences of clinical psychologists of using the psychoanalytic approach within the NHS. Results It was found that a higher percentage of participants (18%) used the psychoanalytic approach than expected from previous research. A greater majority used CBT and third wave approaches. Most participants using psychoanalytic approaches worked with adults with severe and enduring difficulties in secondary care settings. From the interviews, participants spoke about having little space and practical time to use psychoanalytic approaches within services. Participants spoke about how the approach was useful to provide space for clinicians and clients to reflect and build a therapeutic relationship. However, some participants expressed concern that it could be regarded as elitist and inaccessible to some client groups. There was debate about the future of psychoanalytic approaches within the NHS. Conclusions Some clinical psychologists use psychoanalytic approaches in practice and find it useful, although there are service barriers that constrain its use within the NHS that should be addressed. Strengths and limitations of the study are discussed and recommendations made for future research.

The number of people in exile is rising. Forced migrant populations often navigate treacherous journeys, experiences of losses, and hostile realities in reception countries. Black and Minority Ethnic (BME) Lesbian, Gay, Bisexual, and Transgender (LGBT) refugee and asylum-seeking people present with special psychological and socio-economico-political challenges; yet little is still known about how services can support their healing. Existing literature investigating resilience and wellbeing cartographies in this population is sparse and has neglected to examine collective understandings of resources, alongside the performative aspects of local resistances. Hoping to offer valuable insights into how we can all ethically stand by this population’s needs, this study endorsed a collective narrative participatory design, to explore collective ways of resisting oppression amongst BME LGBT refugee and asylum-seeking people, through concerning itself with how such stories can be constitutive of healing. A social constructionist epistemology was appropriated. Purposeful sampling procedures were pursued in collaboration with a London-based charitable organisation to locate suitable participants. Data comprised participants’ story-telling, as captured over two sequences: individual and collective. Story-telling was aided through the co-construction of a novel metaphor: ‘The Passport of Life’. ‘Narrative Analysis’ was employed for the processing of the data, the direction of which was co-shaped with participants. Findings indicate that participants’ (collective) story-telling is crafted as a site for resistances to emerge and be re-affirmed. Resistance pathways are inextricably linked to participants’ diverse subjectivities, reflecting respective opportunities and constraints. Participants’ narrativisation of their intersectional subjectivities mirrors their multiple contextual realities and is indicative of an ‘ever-becoming’ process that challenges the fixedness of borders and dominant western identity conventions. Healing is constituted as a dynamic process, bound by discursive and physical configurations of spaces of togetherness and belonging, which have re-definitional, hope-inducing, and social justice properties. The results also support the use of participatory, narrative, and creative means (e.g. metaphors) for expanding people’s (untold) stories and supporting opportunities for healing and social justice.

Aims: People who are homeless are among the most vulnerable and socially excluded populations. While they have several mental health and physical health needs it has been suggested that many barriers prevent them from accessing the support they need. Healthcare professionals’ attitudes have been identified to have a significant influence in accessing care. Clinical psychologists have a significant role to play in working with homelessness, but their views towards homelessness are yet to be explored. This study evaluated clinical psychologists’ perspectives towards homelessness, what influences them and how they influence their practice. Method: Semi-structured interviews were conducted with twelve clinical psychologists working in secondary care mental health services. Thematic analysis was performed to identify their views towards homelessness. Results: The analysis identified three themes: (1) ‘Homelessness is a complex, social phenomenon’ describing the multi-layered nature of homelessness, whilst identifying non-blaming attitudes with the recognition that homelessness can happen to anyone, (2) ‘Homelessness is not for psychology’ describing that people affected by homelessness are not suitable for psychological therapy unless their basic needs are firstly met and (3) ‘Our role as Clinical Psychologists’ describing that clinical psychologists are not just therapists and acknowledging the influence clinical training, experience working with the population, and values have on professionals’ perspectives towards homelessness. Conclusion: Concluding this study identified that clinical psychologists have a significant role in ending psychological distress rooted in health and social inequalities. Services and organisations will need to nurture and support clinical psychologist to work with homelessness while they address service barriers to develop accessible services for all. Clinical training will need to prepare future psychologists to work more systemically to address the social determinants of health and help clinical psychologists to develop skills in consultations, working at a wider systemic level and at a policy level to address social issues such as homelessness, which contribute to psychological distress.

This study seeks to understand how therapists experience their work with clients who selfrefer as living in poverty. Poverty is very rarely highlighted within counselling psychology publications and very little empirical research exists relating to how therapists understand this phenomenon. The under researched nature of poverty is surprising given this issue is becoming a topic of current debates alongside a rise in the number of individuals living in poverty and self-referring for therapy. The present study highlights a range of difficulties that therapists may face whilst working with clients living in poverty, how these difficulties may affect the work and how such difficulties are managed. The aim of these findings is to increase current knowledge about what is possible within the world of therapy and to raise awareness from which practitioners, students, training institutions and policy makers could become more informed. Eight psychotherapists took part in semi-structured interviews and Interpretative Phenomenological Analysis (IPA) was used in analysing the data. The results elicited three superordinate themes: the first, “Resilience in the struggle to engage with therapeutic work”, the second theme involved “Struggling to promote social activism” and thirdly, “Navigating multiple challenges and barriers’. The findings are examined in light of how they illuminate and diverge from various aspects of poverty-related literature and research. Suggestions are made for training, supervision, and practice, and for future research relating to poverty and mental health.

Background: The legal framework for governing involuntary treatment in England and Wales is set out in the Mental Health Act (1983) which gives health professionals power, in certain circumstances, to detain, assess and treat people considered to have a ‘mental disorder’, in the interest of their own health and safety or for public safety. It is accompanied by a Code of Practice and other statutory safeguards that aim to preserve service users’ human rights. While some people find psychiatric inpatient treatment helpful and necessary, there are growing concerns that services are failing to protect service users’ human rights. Aims: To deepen an understanding of how service users’ human rights are respected on psychiatric inpatient wards. Key research questions were: what are voluntary and involuntary inpatient service users’ experiences of staff respecting their human rights; what are voluntary and involuntary inpatient service users’ experiences of being informed about their rights; and what impact do these experiences have on voluntary and involuntary service users? Method: A mixed methods approach used. Semi-structured interviews with twelve service users with experience of psychiatric inpatient treatment in England were carried out. In addition, a brief 10-item questionnaire was completed at the end of each interview. Interviews were transcribed and analysed using thematic analysis. Data from questionnaires were analysed using descriptive statistics. Findings: Five themes were generated to describe participants’ experiences: Deprived of Rights; Rights Upheld, Emotional Impact; Battle for Rights; and Information about Rights. Participants’ raised a number of concerns with regards to how their human rights were respected. Their accounts were characterised by restrictions on liberty and autonomy, a lack of privacy dignity and respect, and issues relating to equality and discrimination. Concerns were also raised regarding the provision of information about their legal rights. Implication: Interventions across multiple levels are required to promote a human rights-based approach. Organisational policies and practices must be scrutinised; staff must be made aware of how human rights apply to their work and offered regular support to cope with the emotional demands of the role; and a review of government policy is needed to examine structural factors that both inhibit and promote change.

Mental health professionals regularly make judgements about the plausibility of others’ belief claims and have the socially sanctioned power to label a belief as delusional. However, little is known about how these judgements are made and the little research that exists suggests that they may be susceptible to a range of influences. There is also relatively little research exploring how the general public judge the plausibility of belief claims despite their judgements influencing who accesses professional help. As those who train as mental health professionals come from the general public, as a first step to better understanding professionals’ judgements about belief plausibility, it seemed reasonable that this study explored influences on the general populations’ judgements. In contrast to traditional quantitative approaches which require a priori assumptions about the investigated constructs, a Q-methodology approach was adopted as it is designed to explore numerous available accounts on a particular topic. Conspiratorial beliefs were also chosen as it is likely that a general population sample will have encountered them and they also share certain features of the rarer unusual beliefs encountered in mental health services. The author conducted two Q-sorts; the first was designed to better understand how participants conceptualised conspiracy beliefs, whilst the second involved an exploration of the factors that might influence plausibility judgements. An online Q-methodology programme was used and 57 participants were recruited via opportunity sampling. The data was analysed using PQMethod (Schmolck, 2002). Analysis of Q-sort 1 extracted five different factors, or viewpoints, for conceptualising conspiracy beliefs whilst Q-sort 2 extracted four accounts describing which aspects of a belief or believer made it less credible. The areas of commonality and difference between these factors was discussed with reference to the relevant literature for both conspiracy and delusional beliefs. The study was also critically reviewed and wider implications discussed.

Aim: Polish migrants are currently the largest immigrant population in the UK. This study aimed to explore what the NHS is currently doing for this population and what needs to change for the services to be more accessible to Polish migrants. Method: Freedom of Information Act Requests (FOIRs) were sent to all 56 Mental Health Trusts to investigate whether the NHS is serving Polish migrants by monitoring access to services. An online survey of Polish migrants was used to address the research question “What might need to change in order to make mental health services accessible/used by Polish migrants in the UK?”. The survey participants were recruited online through Facebook groups and online Polish news media. Data was analysed using descriptive and inferential statistics. Results: Forty six Trusts responded to the FOIRs. The results indicate that very few Trusts collect information on access to services by Polish migrants. No Trust reported having developed a race equality strategy that attempts to address the needs of Polish service users specifically. Six hundred and five Polish people completed the online survey. The majority of participants (76.5%) identified as female and the average age was 35. The results indicate that a high proportion of Polish migrants are likely to experience mental health difficulties. Identified causal factors included work stress, isolation and loneliness, family stress, relationship problems and migration. The current study found that out of the 369 participants who reported mental health problems 40.9% sought support for their difficulties through the NHS. Participants who sought help had, on average, lived longer in the UK (p = 0.001). Barriers to accessing help included language difficulties, lack of time, lack of belief in services and experiences of fear and shame. Self-help strategies and family support were listed as protective factors. Recommendations: In line with developing culturally competent services the NHS should adopt a practical approach to engaging this community and focus on enhancing the relationship between Polish migrants and the GP, adopt community approaches and pay attention to the identified causal beliefs of distress which centre around psycho-social factors such as stressful work conditions and isolation.

Weight Loss Surgery (WLS) is considered the ‘gold standard’ treatment for individuals with ‘severe’ obesity (NICE, 2014). WLS produces rapid weight loss within the first two years as a result of the reduced size of stomach and reduced absorption of nutrients. Recent research has highlighted that WLS patients must also navigate significant internal and systemic psychosocial changes as they receive greater appreciation and respect as a result of their smaller size (Groven et al., 2013). The aim of the research reported in this thesis was to examine how patients negotiated and understood their own identity in the wake of profound social and physiological change. A critical realist epistemological position was taken in order to explore these shifts from an embodied and social power perspective. A qualitative methodology involving nine semi-structured interviews, with nine participants a minimum of two years post-surgery was employed. The interviews were analysed using Thematic Analysis. The analysis focused around three themes concerning post-WLS identity: (1) A Life Worth Risking, (2) Battle of the Body, (3) A Search for Belonging. Participants described the influence of weight-based stigma on their everyday lives prior to surgery, including within close relationships and the health sector. These negative attitudes appeared to be reflected in how participants viewed themselves and treated their body. As a result, post-surgery participants described how their weight loss facilitated renewed confidence, increased personal freedom and appreciation for their body. Relief from weight-based stigma allowed participants to reflect on the impact societal discrimination had had on their lives and encouraged them to challenge these attitudes in others. This thesis discusses implications for further research, practice and policy to support the long-term outcomes of individuals post-WLS.

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

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

Bipolar disorder (BD) is a fairly common, highly heritable psychiatric disorder which can be highly disabling to those who suffer from it. There is a limited understanding of early precursors to BD that might be helpful to inform prediction models and knowledge of aetiology. Few population-based longitudinal studies have examined associations between measures of childhood psychopathology/cognitive functioning and BD, or phenotypic manifestations of increased genetic risk for BD in childhood. I investigated whether childhood psychopathology and cognitive domains examined from ages 8-11 years were associated with hypomania examined at ages 22-23 years. I then conducted a systematic review to identify phenotypes associated with genetic risk for BD, measured using a polygenic risk score (PRS) approach. Finally, I investigated whether increased genetic risk for BD, using a BD-PRS, was associated with various psychopathology and cognitive domains in childhood and hypomania in young adulthood. Findings from Chapter 4 suggest that borderline personality disorder (BPD) traits in childhood are strongly associated with hypomania, particularly the ‘risk-taking/irritable’ factor. Better performance in the domains of working memory, problem solving ability, verbal learning and emotion recognition are also associated with hypomania, with stronger association with the ‘active/elated’ factor (Chapter 5). Findings from Chapter 6 highlight a limited literature on phenotypic manifestations of increased genetic risk for BD in childhood/adolescence. Individuals with increased genetic risk for BD are more likely to have ADHD, and have poorer executive functioning, processing speed and performance IQ in childhood (Chapters 7 and 8). This thesis adds to a limited literature examining associations between measures of childhood psychopathology/cognition and hypomania in the general population, and about how increased genetic risk for BD is manifest in childhood/adolescence. Further work to examine the robustness of these findings in other populations at various stages of development are required, and to elucidate the mechanisms that underlie the associations observed.

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

Schizophrenia is a disabling neurodevelopmental disorder whose risk factors are diverse, aetiology is unclear and symptoms remain inadequately treated. The development of animal models with improved face, construct and predictive validity would facilitate our understanding of its neurobiology, and aid development of novel therapeutics. In this thesis, the combination of maternal immune activation (MIA) in pregnant dams and post-weaning social isolation (SI) of resultant rat offspring is evaluated to determine whether this ‘dual-hit’ neurodevelopmental model produces a more comprehensive array of behavioural and neurochemical changes akin to those observed in schizophrenia than either intervention alone. At gestational day (GD) 15, pregnant dams received a single intraperitoneal (i.p., 10 mg kg-1) or intravenous (i.v., 6 mg kg-1) injection of a viral mimetic, polyinosinic:polycytidylic acid (poly(I:C)), or vehicle saline (1 ml kg-1). Resultant offspring were housed in groups or alone (in isolation) from weaning. In adulthood, male offspring underwent comprehensive behavioural analysis using paradigms relevant to the positive, negative and multiple cognitive domains of schizophrenia and potential mechanisms underlying behavioural abnormalities were studied. Regardless of route of administration, poly(I:C) alone had relatively subtle effects. Interestingly, i.p. poly(I:C) conferred an unexpected resilience towards SI-induced behavioural (locomotion, aggressive behaviour and conditioned fear) and immune abnormalities. Investigations into potential early molecular mechanisms showed a sophisticated interplay between stress experience and gender on long-term behavioural and immune outcomes. When combined with SI, i.v. poly(I:C) resulted in some additive effects on certain behavioural measures related to the positive, negative and cognitive symptoms (locomotion and ultrasonic communication). The same combination, however, promoted resilience against SI-induced immune changes, suggesting an alternative underlying mechanism than with i.p. poly(I:C) administration. Neither poly(I:C) nor SI had any effect on working or spatial memory, or sensorimotor gating. Therefore, despite producing some behavioural phenotypes with translational relevance to schizophrenia, further improvements and validation of the MIA and SI protocols are required to identify any benefit of or molecular mechanism involved in the ‘dual-hit’ model assessed in this thesis. Finally, the effects of SI on cortical gene expression were examined and interesting changes in genes associated with pathways including the circadian clock, mitogen-activated protein kinase (MAPK) signalling and dopaminergic neurotransmission were observed. These altered genes are discussed in the context of previous SI studies and their potential translational relevance to schizophrenia is considered.

Reflecting teams (RTs) are used in family therapy in order to introduce multiple perspectives and provide the 'difference that makes a difference'. The sparse research that exists suggests that reflections made by a RT may be a factor in the change process for family members. This study aims to further understanding of the helpfulness of reflections in family therapy. It is hoped that this will support therapists in RTs to be as effective as possible, reflecting in a way which optimises progress. A quantitative longitudinal questionnaire method was used in order to collect data on family members' perceptions of the helpfulness of reflections made by an RT during their family therapy sessions. The results show that certain types of reflections are less helpful than others and the helpfulness of reflections was found to contribute to the change process for family members. This is discussed in relation to how the RT could be considered as part of the change process in family therapy. Reflections on the research process are also provided along with limitations and recommendations for further research.

This thesis explored how Equine Facilitated Psychotherapy (EFP) shapes processes of change for clients with histories of trauma from the perspective of intersubjectivity. Study One involved a thematic analysis of responses to an online semi-structured questionnaire about an EFP experience. This study was completed anonymously by EFP clients, practitioners and trainees, and found that relationality and non-judgemental interactions contributed to processes of change. Study Two was an ethnography of Equine Facilitated Learning (EFL) and EFP training completed by the researcher. Study Two was analysed using a thematic analysis of the researcher’s field notes and reflective diaries and found that intersubjectivity between horse and person facilitates reflection on shame. Study Two raised questions about how to achieve connectedness with the other when working with clients with trauma. This thesis aimed to enhance understanding of how intersubjectivity can be used to understand processes of change with primarily experiential non-verbal interventions. Given the prevalence of offenders with histories of trauma deemed non-responsive to treatment, this research aimed to improve understanding of how context and relationality contributes to processes of change for clients who may struggle with traditional talking based therapies.

Literature review: Background: Drug use is a problem that has a significant health impact on individuals and financial impact on society. Time perspective, the extent to which individuals focus on the past, present, and future, has been shown to have a significant impact on health-harming and health-protecting behaviour. Objectives: The main aim of the present review was to investigate the relationship between time perspective and drug use. It aimed to investigate which time perspectives, past, present, and future, are associated with increased or decreased drug use. It also aimed to investigate the relationship between time perspective and the way that people think about drugs and drug use (drug use cognitions). Methods: A systematic search strategy was used to identify all the available empirical research that has investigated the relationship between time perspective, as measured by the Stanford time perspective inventory or the Zimbardo time perspective inventory, and drug use. Thirteen studies met the inclusion criteria for review. Results: Results suggest that individuals with higher future time perspective are less likely to use illicit drugs. They are also likely to hold negative attitudes towards drug use. Individuals with higher present time perspective are more likely to use drugs, and to use them more frequently and in greater quantities. They are also more likely to hold positive views about drug use. Conclusions: There is emerging evidence to suggest that increased future time perspective is protective against drug use while increased present time perspective represents a risk factor for drug use. Empirical paper: Research suggests that time perspective, the extent to which individuals focus on the past, present, and future, might play a significant role in predicting aggression. However, research in this area has typically conceptualised and measured aggression as a unitary construct. No research has, to date, considered the relationship between time perspective and clinically important subtypes of aggression: reactive-proactive and impulsive-premeditated . The present study examined whether reporting an increased deviation from a balanced time perspective, reflecting the extent to which individuals can cognitively switch between past, present and future time perspectives, predicts increased reactive and proactive aggression, and impulsive and premeditated aggression. A sample of 389 adults completed measures of aggression, time perspective and emotion regulation. As expected, proactive and premeditated aggression, which are characterised by the planned use of aggression, were not associated with an increased deviation from a balanced time perspective, suggesting that these subtypes of aggression are not associated with difficulty switching between past, present and future time perspectives. Reactive and impulsive aggression, which are characterised by unplanned, impulsive aggressive outbursts, were found to be associated with an increased deviation from a balanced time perspective, suggesting that these aggressive subtypes are associated with increased difficulties switching between time perspectives. Contrary to expectations, however, an increased deviation from a balanced time perspective was not clinically predictive of increased reactive or impulsive aggression when controlling for a range of emotion regulation abilities. Clinical implications and areas for future research are discussed in relation to the study findings.

Background: Persistent pain represents a significant burden for individuals and society, exerting a profound effect on quality of life and posing a significant strain on healthcare resources. Novel interventions are needed to reduce the impact of psychological comorbidities on people who live with pain but also to improve pain self-management, enhance people’s quality of life, and help them live a fulfilling life in the presence of pain. Aims: The aim of this research was to develop a novel psychosocial intervention to accompany osteopathic treatment for people from Southwest Wales who live with persistent pain and psychological comorbidities. The MRC framework for developing complex health interventions (Craig et al. 2000, 2008) guided the development of this intervention. Methods: A pragmatic approach that included a mixture of methods and procedures was chosen. The first phase consisted of conducting two qualitative studies to determine the needs and experiences of people living with persistent pain as well as the perspectives of osteopaths who treat them. A systematic review was conducted alongside to investigate the effects of osteopathic treatment on psychosocial factors in people living with persistent pain. The second phase consisted of utilizing the data from the first phase to inform the development of the novel intervention based on Acceptance and Commitment Therapy (ACT) principles. Focus groups and one-to-one interviews were the preferred data collection methods while data analysis was carried out using Thematic Analysis (TA) and Framework Analysis (FA). Findings: The intervention appeared to be feasible with the support of the osteopaths. The intervention was found acceptable and no barriers to participation were reported. Program attendance was 82.5% and the participants engaged well with the exercises and with the ACT model in general. At one-month follow up, the participants reported that they continued to practice mindfulness, and continued to apply their knowledge of ACT to their personal circumstances. Conclusion: Delivering a brief ACT-based intervention for people living with persistent pain was feasible and acceptable. All of the nine participants reported positive experiences. The collaboration between osteopaths and psychologists in supporting people who live with persistent pain demonstrates both innovation and potential and should be further explored in the future.

In this project, I present a grounded theory of how peer-led Hearing Voices Network Groups (HVNGs) impact people who attend them. By conducting intensive interviews and attending groups as an observer, I developed a theory of the outcomes and processes of change that people experience in peer-led HVNGs. I used member-checking (Charmaz, 2014) to make sure my analysis was consistent with the experience of people who took part. Through this considered and thorough process of conversation and collaboration with people who hear voices, I have developed a theory grounded in the knowledge and insight of people’s lived-experience of HVNGs. HVNGs provide support that is fundamental to the well-being of people who attend them. Therefore research in this area has the potential to impact people’s lives by contributing not only to the growing evidence base regarding the benefit of HVNGs, but also by understanding how this benefit is achieved. Based on my analysis, I have theorised that the impact of hearing voices groups includes fundamental shifts in i) how voices and the voice-hearing experience are understood, ii) the sense of agency in their lives, and iii) an enhanced sense of valuing oneself and others, developed through sharing mutual support (the experience of ‘being in the same boat, helping each other’). In order to understand the impact of hearing voices groups, I also consider the voice-hearing experience (Blackman, 2001) as a whole. Based on my data, I conceptualise this as a holistic experience that includes perceptual/sensory, social and meaning-making/agentic factors. I consider the stigma, loss of agency and confusion of meaning that can attend negative voice-hearing experiences in relation to trauma research, as well as other approaches. The contribution of this research to the field of counselling psychology and psychological therapies is the creation of a theory of what voice-hearers value and experience in peer-led HVNGs. This research represents the first attempt at a full theory construction of this topic using an accepted methodology. Theory creation in this area is important for a number of reasons. Firstly, since hearing voices groups represent an increasingly popular approach both within NHS Trusts and other settings, it is increasingly necessary to understand the processes and mechanisms of change in these groups. Secondly, without basing theory construction on the actual experiences of people who hear voices, research in this area is susceptible to misinterpretation and misunderstanding. Finally, insight into the experience of hearing voices and how peer-led hearing voices groups address this experience can inform work in the wider field of hearing-voices research.

This research portfolio, submitted in part fulfillment for the Doctorate in Clinical Psychology, contains a systematic literature review, and a large-scale research project. Both papers were prepared for submission to peer-reviewed journals. The individual paper abstracts are detailed below. (i) Abstract of Systematic Review: Posttraumatic growth refers to positive psychological changes occurring following exposure to traumatising life events. Attachment styles have been demonstrated to predict post-trauma outcomes. The present review explored the relationship between attachment styles and posttraumatic growth via meta-analytic review of 16 studies, examining the relationship between posttraumatic growth and secure, dismissive, preoccupied, and fearful attachment styles. Four correlational meta-analyses revealed a significant small positive relationship between secure attachment and posttraumatic growth (r= .22, p < .001); a significant small negative relationship between dismissive attachment and posttraumatic growth (r=-.12, p < .001), an extremely weak relationship between preoccupied attachment and posttraumatic growth (r=.01, p=.85), and a significant small positive relationship between fearful attachment and posttraumatic growth (r=.11, p < .05). Findings provide useful information for clinicians regarding the potential impact of attachment style following traumatising exposure, and have implications for psychological assessment, formulation, and intervention goal-setting. (ii) Abstract of large-scale research project: Objective: This study examined a model of predictors of posttraumatic growth in a sample of 85 trauma-exposed adults. It sought to establish the predictive relationship between posttraumatic stress and growth, and whether this was impacted by trauma-related factors (trauma typology, time since most distressing trauma), demographic characteristics (age, gender and number of psychological therapy sessions) and trauma appraisals (betrayal, self-blame, fear, alienation, anger and shame). Method: A quantitative survey methodology was employed in this cross-sectional study. Participants were 56 males and 28 females, with a mean age of 48.26 years, recruited from psychological support services in Northern Ireland. Participants had experienced an average of 4.11 traumatising events. Results: Hierarchical multiple regression modelling was used to analyse predictors. This demonstrated that the number of psychological therapy sessions participants had attended (b = .33, p = .009) and betrayal-based trauma appraisals (b = .47, p = .001) were positive predictors of posttraumatic growth. Shame-based appraisals negatively predicted posttraumatic growth (b = -.42, p = .020). In the final model, posttraumatic stress, trauma-related factors, age, gender, and four of the six trauma appraisals were non-significant predictors. Conclusion: The predictive relationship between posttraumatic stress and growth may be better explained by the number of psychological therapy sessions the participant has had, and appraisals of betrayal and shame.

The environments and contexts in which individuals are embedded have a clear role in triggering and maintaining mental health difficulties. Adventure and wilderness therapies provide a radically different environment and way of experiencing oneself. Such a context may facilitate change and support recovery and growth. This thesis examines the application of such therapies for individuals with mental health difficulties. The first chapter reviews the evidence regarding sustained outcomes of adventure therapy for individuals with mental health and emotional disorders. Thirteen studies met the inclusion criteria, ten examining adolescents with mixed presentations and three focussing on adults with specific mental health conditions. There was evidence of significant follow-up outcomes (3-18 months) across the majority of clinical, behavioural, self-concept and quality of life measures. The promising findings, but generally ‘weak’ quality of these studies, call for further exploration of such approaches and more robust research designs. The second chapter employed ethnography to examine sail-training as an adjunctive intervention for individuals open to Early Intervention for Psychosis Services (EIPS). The voyages presented a radical contextual shift characterised by purpose, structure and routine, an intensive and inescapable social environment, the introduction of challenge and adversity and a novel and changing ocean environment. This context supported several positive processes including active engagement and, through this, the development of skills, finding of roles, growing confidence, social-connection, resilience, and a shift in outlook characterised by aspiration for change. Individuals also experienced challenges, struggles and, at times, resistance. The approach has positive implications for social and functional recovery, and these are discussed in relation to its unique features. Areas for future research are also explored. The final chapter discusses the broader implications of this research and introduces a process model developed during the empirical research. It concludes with the researcher’s personal reflections on the research process.

This thesis explores the experience of compassion satisfaction and compassion-focused groups amongst mental health staff. The narrative systematic literature review focused on identifying factors associated with higher compassion satisfaction in mental health professionals. A search of five databases identified 35 relevant studies. Findings indicated that a range of compassion satisfaction variables were investigated in mental health staff, such as self-care practices, workplace support and belongingness, cognitive facets of empathy, and competence. The review concluded that a range of organisational factors can help promote compassion satisfaction, thus protecting mental health professionals from burnout and compassion fatigue. The review is limited by the cross-sectional nature of the included studies. The empirical paper employed a mixed-method design to explore the feasibility and acceptability of compassion focused groups for staff working in inpatient mental health services. Ten participants completed session-by-session feasibility and acceptability measures. Eight participants were interviewed to explore the experience of the group and reasons for attrition. In spite of high acceptability ratings, supported by themes of positive affect, common humanity and changes in relating to self and others, the group had high attrition. Interviews were analysed using thematic analysis, identifying an overarching theme relating to systemic barriers to attending with five main themes: (1) The nature of the ward; (2) Slowing down is not allowed; (3) It’s not in our nature; (4) Guilt and threat; (5) We’re not important. The results indicated that although compassion-focused groups may be experienced as a helpful intervention, they are not feasible to offer in the current design unless the identified barriers are addressed. Implications for future research, theory development and clinical practice are discussed.

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

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

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

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

Aim: Our work builds on recent findings that (a) it is possible to devise algorithms for structured, focused and not timely treatment of schizophrenia (Agid et al, 2011) and (b) while prescribed later than it should be, Clozapine is the most effective antipsychotic treatment for adult treatment-resistant schizophrenia (Howes et al., 2012). However, there is no algorithm-based treatment for early onset schizophrenia, but rather generic, overly lengthy and non-specific guidelines (NICE 2012 and NICE 2013) and there is insufficient similar research in relation to, and therefore the use of, Clozapine treatment for treatment-resistant early onset schizophrenia. Hence our work aims to investigate the use of antipsychotics for early onset schizophrenia, and develop an hypothesis regarding a structured treatment to be tested prospectively like some studies did for adult schizophrenia (Agid et al, 2011) to reach clear, concise, algorithmic recommendations and become a solid basis for clinicians to make decisions for effective first-line treatment of early onset schizophrenia and effective treatment of treatment-resistant schizophrenia, hence having our study be a significant stepping stone towards the development of clinical decision making tools for the effective treatment of early onset schizophrenia. Hypotheses: Firstly, there are antipsychotics to prescribe for early onset schizophrenia, which are more effective than others and have manageable side effects. Secondly, Clozapine is the most effective antipsychotic for treatment-resistant early onset schizophrenia and is not sufficiently used due to unfounded concerns with regards to its side effects. Methods: Following a period of comprehensive review of available studies on the use of antipsychotics in children and adolescents, which we describe in chapters 1 and 2, we concluded we could not engage in a time limited (within the number of years we had set out to conduct our study) prospective study since doctors would not straight away engage in prospective studies to prescribe specific medications. This is because doctors follow guidelines (NICE 2012, NICE 2013) that are focused on the risks related to prescribing antipsychotics emphasizing what patient-dependent side effects to avoid when considering prescription and are therefore generic, unclear and ineffectively large citing many possible antipsychotic drugs. We instead opted to perform retrospective statistical analysis of two long-term treatments datasets documented with sufficient consistency over long periods to credibly be able to recommend future studies to engage in very specific prospective studies such as the algorithm-based approach to first-episode schizophrenia by Agid (Agid et al, 2011). Those long-term treatment datasets were: 1. The prescription collection records in a nation-wide unbiased population demographic and clinical dataset of youth with psychosis who were prescribed with Clozapine. The electronic records of 100 patients at the South London and Maudsley NHS Foundation Trust’s child and adolescent psychiatry services which we studied over 2 years. This was a population prescribed antipsychotics as part of their routine inpatient treatment, with data collected at baseline before antipsychotics switch / initiation and 3, 6 and 12 months thereafter. One-way ANOVA Power analysis was completed to ascertain appropriateness of the sample analyzed in the above-mentioned 2-year study. Results: 1. The whole body of literature on the use of antipsychotics for early onset schizophrenia highlights the need for further evidence in relation to efficacy and safety. 2. In the study we conducted with a 100-patient sample, which findings we ratified by performing a power analysis, we found that: A. Olanzapine was the most effective antipsychotic and patients prescribed with it were less likely to discontinue treatment, however it also resulted in the highest proportion of side effects; and B. Clozapine was the least prescribed antipsychotic (less than 0.5% of the sample) and only for one third of those with poor treatment response from Olanzapine. The antipsychotics examined were generally well tolerated. However, the overall rate of side effects was low suggesting that many side effects are either missed or not recorded in routine settings. 3. Clozapine is the most effective antipsychotic for patients with treatment-resistant early onset schizophrenia. Strict routine monitoring of its impact during treatment can provide an adequate level of comfort in its use. Conclusions: 1. All antipsychotics routinely prescribed to inpatients are associated with improvement in terms of global function. 2. Olanzapine showed evidence for efficacy superiority, suggesting that olanzapine should be considered as first line medication. This statistically significant fact was ratified by other studies completed in the year after the completion of our study (Zhu et al., 2017). 3. Clozapine is the most effective antipsychotic for patients with treatment-resistant early onset schizophrenia. Tools for its monitored prescription (such as blood measurement tools for youth) should serve as effective decision-making tools for clinicians wanting to use Clozapine more often and earlier in treatment.

There has been an increase in the number of adopted children seen by psychotherapists (Rance, 2003), and yet little is known about the nature and function of the interventions with adoptive parents that run alongside this work (Whitefield and Midgley, 2015; Robinson, Luyten and Midgley, 2017). This study explores the experiences of four psychoanalytic child psychotherapists, who work in a specialist fostering, adoption and kinship care child and adolescent mental health service (FAKC CAMHS), in carrying out parent work with adoptive parents. Semi structured interviews were used to collect the data, which was then analysed using Interpretative Phenomenological Analysis (IPA). Seven superordinate themes shared between clinicians emerged from the data: ‘Seeing the child’, ‘Talking about the trauma’, ‘Getting alongside’, ‘Going there’, ‘Seeing the parent’, ‘Finding the space’, ‘Bridging the gap’. The practitioners’ experiences conveyed the complexity of working with adoptive parents, the approach they took, and the dilemmas and technical challenges they came across. Parallels between the findings and the literature on psychoanalytic theory and practice around work with looked-after and adoptive children and psychoanalytic parent work were found. It is argued that the insights the study provides could be drawn upon to further define, inform and provoke debate about the contribution child psychotherapists make to this work and the possible need for further training and support for child psychotherapists in this specialist area.

Treatment resistance (TR), affecting approximately 20-30% of patients with psychosis, has a high burden both for patients and healthcare services. I provided a general introduction to TR in Chapter 6 and highlighted the need to identify TR earlier in the course of the illness, so that an effective treatment, such as clozapine, can be offered promptly. The purpose of this thesis was to identify clinical, demographic, and genetic predictors of TR, using information identified when a patient first presents to clinical services with psychosis. First, I reported the results of a systemic literature review, which synthesised predictors of TR identified in longitudinal, observational studies (Chapter 8). Younger age of onset was the most consistent predictor of TR, but this review also indicated that, to date, studies have not used statistical methods specifically designed to identify predictors that have a high chance of predicting TR in future patients. Existing literature has primarily used methods designed to capture the magnitude of association, between predictors and TR, within the study sample. Second, I reported the results of my own analysis using a dataset created by combining existing longitudinal, first episode psychosis cohorts. This dataset, known as STRATA-G (and described in Chapter 7), included patients who had a minimum of one year follow-up, provided a DNA sample, could be classified as either TR or non-treatment resistant (NTR). I found significant associations between TR and both younger age of onset and fewer years in education (Chapter 9). I created a predictive model of TR that selected nine first episode variables and could, after internal validation, correctly classify 59% of TR patients and 65% of NTR patients (Chapter 9). Third, I reported the results of a genome-wide association study (GWAS) of treatment resistance, which was used to create a polygenic risk score for TR (Chapter 10). This polygenic risk score was significantly associated with TR in the STRATA-G sample. Fourth, I investigated whether age of psychosis onset mediated the relationship between genetic burden for TR and subsequent TR, using STRATA-G (Chapter 11). Age of onset was not associated with genetic risk for TR and there was no evidence it mediated the relationship between the polygenic risk score for TR and subsequent TR. Finally, I expanded on the discussion of the findings in the preceding chapters (Chapter 12). Here, I placed my findings in the context of the wider literature and discussed the limitations of my data. I discussed the future of prediction modelling in TR; the potential uses of a prediction model, in both clinical practice and research studies, and the importance of future work to validate the findings reporting in this thesis.

Previous research has investigated socially based threats, such stigmatisation and shame, among people with psychosis. However, studies have typically considered these social experiences in terms of being the consequences, rather than causes, of psychosis. There have been some studies looking at stigma and shame as causal mechanisms in emotional symptoms (e.g. anxiety and depression) in the context of psychosis, and of post-psychotic trauma, but not of psychosis itself. One possible reason for why this may have been overlooked is that stigma and shame have not traditionally been regarded in ‘threat’ terms, with traumatic-like, perhaps dissociative, properties of their own. Social rank theory (Gilbert, 1992) offers an understanding of these socially-based experiences within their evolutionary context, with links to developing threat-monitoring, -processing, and -protective strategies. Social rank theory therefore provides a theoretical rationale within which to examine stigma and shame through the lens of threat and threat-protection mechanisms. These social rank threats can be investigated for links to traumatic, dissociative processes, and hence as potential contributors to causal pathways in psychosis. This thesis investigates the interaction of these social and dissociative processes in psychosis (Section A: Studies 1, 2, and 3). It also develops and tests the acceptability of a new psychological therapy that specifically targets social mechanisms, e.g. reducing shame and increasing social safeness, among people with psychosis (Section B: Study 4). The first study designed and tested a measure of psychotic-like experiences (PLEs) that could be used for the other studies. Study 1, a questionnaire design study, analysed data from online participants for a) item selection, and b) psychometric evaluation. Scores were provided by 532 participants, and a new scale, the Transpersonal Experiences Questionnaire (TEQ), was developed. The 19-item TEQ was found to be a unidimensional scale with satisfactory internal consistency (0.85), good utility for longitudinal hypothesis-testing, and particular reliability for people endorsing a high number of PLE items. Study 2 investigated the longitudinal relationship between dissociation and PLEs, and the moderation effects of social variables, shame and social safeness, on this relationship. Participants (n=314) provided online data at two timepoints (0 and 6 months) and the analysis demonstrated a significant interaction between dissociation and shame on PLEs, despite the absence of a direct association between dissociation and PLEs. Social safeness significantly moderated this interaction effect, but not in the expected direction: higher social safeness was associated with more pronounced dissociation-shame interaction effects. In Study 3, participants (n=30) were recruited from a ‘nonclinical- in-crisis’ population; i.e. those seeking support for PLEs, but from spiritual organisations rather than mainstream services. This sample had significant trauma histories and high levels of dissociation. Endorsing a higher number of PLE items was related to more distress; however, once total endorsement scores were controlled for, PLEs were rated as more positive (‘enriching’, ‘safe’ and ‘pleasant’) than negative (‘distressing’ and ‘disruptive’). The positive PLE dimensions were correlated with spirituality, post-experience growth, and social safeness. Negative PLE dimensions were correlated with depression. The second section of the thesis reports the development and initial piloting of a new clinical intervention called Compassion Focused Therapy for Psychosis (CFTp). CFTp specifically targets building social safeness experience and compassion motivation systems with the aim of regulating threat-based dissociative processes in psychosis. Study 4 was a case series study, in which NHS participants with distressing experiences were randomised to multiple baseline periods of 2, 4 and 6 weeks, before a 26-session individual therapy. Seven out of eight participants completed the full 26 sessions. At the single case level of analysis, over half the completers showed clinically reliable improvements in depression (5/7), stress (5/7), general wellbeing (5/7), anxiety (4/7), and voices (3/5). One showed a deterioration in anxiety (1/7) and dissociation (1/7). At the group level of analysis (n=7), there were significant improvements in group mean scores of depression, stress, wellbeing, voices and delusions, and at 6-8 week follow-up, the wellbeing, voices and delusions improvements remained significant. Further investigations are required of the theoretical relationships surfacing in this thesis, as well as the evaluation of CFTp. Specifically, the future modelling and testing of three-way interacting mechanisms (dissociation x social rank x attachment) in pathways to PLEs is recommended. For CFTp to be considered as a clinical treatment, it requires further testing in a pilot Randomised Controlled Trial, with different therapists, and with researchers who are unaware of the group allocation.

Background: The prevalence of psychotic experiences (PEs) in the general population is significantly greater than comparable rates of clinical disorder, consistent with a continuum view of psychosis. Cognitive models of psychosis propose that response style and reasoning biases play an important role in determining the clinical consequences of PEs. Non-clinical individuals, with persistent PEs but no ‘need for care’, have been found to be less likely to endorse maladaptive response styles compared to a clinical psychosis group. Research is typically based on retrospective interviews, with the potential confound that maladaptive responses simply reflect intrinsically more distressing experiences within the clinical group. A novel way of addressing this issue is by exploring response styles across the psychosis continuum, using experimentally controlled anomalous experiences. In a second strand of research, individuals with persecutory beliefs have been found to make decisions on the basis of limited evidence in probabilistic reasoning tasks; the so-called ‘Jumping to Conclusions’ (JTC) data-gathering bias. Lack of belief flexibility (defined as the meta-cognitive capacity of reflecting on one's own beliefs, changing them in the light of reflection and evidence, and generating and considering alternatives) is commonly reported in around 50-75 percent of people with clinical delusions. To date, no study has compared clinical and non-clinical individuals with persistent PEs on these reasoning biases. Furthermore, there has been recent interest in integrating the literature on reasoning biases in psychosis with broader, dual process models of reasoning which distinguish between fast, automatic, Type 1 (‘experiential’) processes and slow, analytic, Type 2 (‘rational’) processes. Research in this area has tended to focus on self-reported rational and experiential reasoning with the limitation that certain reasoning processes may occur outside of conscious awareness. Finally, despite the clinical and theoretical relevance, there has been a relative lack of research focusing on the alternative explanations held by people with clinical paranoia and no current method of categorising content-level differences in subtypes of alternative explanations. This thesis investigated the role played by response style and reasoning in determining the clinical consequences of PEs, addressing the following research questions: Research Question 1: Do individuals with persistent PEs, with and without a ‘need for care’, show differences in response styles following exposure to experimentally controlled anomalous experiences? Research Question 2: How might the literature on reasoning biases in psychosis be integrated with broader concepts of ‘fast’ and ‘slow’ thinking within dualprocess models of reasoning? Research Question 3: Do individuals with persistent PEs, with and without a ‘need for care’, show differences in reasoning biases and associated ‘fast’ and ‘slow’ thinking? Research Question 4: What types of alternative explanations (AEs) are reported by individuals with clinical paranoia to explain the evidence for their persecutory belief? Research Question 5: Do the reasoning biases under investigation combine to form latent ‘fast’ and ‘slow’ thinking factors, which predict paranoia severity within clinical samples? Research Question 6: What are the implications of this investigation of response style and reasoning for cognitive therapy for psychosis? Method: The research questions were pursued in four cross-sectional empirical studies and one narrative review: Empirical Study 1: Two groups with persistent PEs (clinical; n=84; non-clinical; n=92) and a control group without PEs (n=83) were compared on response styles following experimental analogues of thought interference (Cards Task, Telepath) and hearing voices (Virtual Acoustic Space Paradigm). Narrative Review: A narrative review was conducted on the recent literature on reasoning biases, delusional beliefs and psychosis. The state-of-the-art knowledge from systematic reviews and meta-analyses on the evidence for jumping to conclusions was summarised, before a fuller discussion of the empirical literature on belief flexibility as applied to delusions. Empirical Study 2: Two groups with persistent PEs (clinical; n=74; non-clinical; n=92) and a control group without PEs (n=83) were compared on ‘Jumping to Conclusions’ (JTC) and belief flexibility. A randomly selected subset (n=104) was investigated to examine differences in use of experiential and rational reasoning when explaining PEs. Empirical Study 3: Alternative Explanations (AE; a component of belief flexibility) were investigated in a large clinical sample with distressing persecutory beliefs (n=274). A system of categorising the AEs held by individuals to explain the evidence for their persecutory belief was developed. Reliability analysis was conducted, and categories presented descriptively with reference to conviction and associated distress. AEs (combining sub-types) and main belief were compared with respect to belief conviction and distress. Empirical Study 4: Drawing on the same sample as Empirical Study 3, associations between presence of AEs and other reasoning biases (Possibility of being mistaken (PM) and JTC) and paranoia severity were investigated. The hypothesis that paranoia involves reduced ‘slow thinking’ and over-reliance on ‘fast thinking’ was tested using formally assessed reasoning biases and a latent variable analytic approach. Results: Empirical Study 1: The non-clinical group with PEs were less likely to endorse maladaptive response styles, such as attempts to avoid, suppress, worry about or control mental experiences, compared to the clinical group on all tasks. The clinical group were more likely to endorse unhelpful response styles compared to controls on two out of three tasks. The non-clinical group performed similarly to controls on maladaptive responding across all tasks. There were no group differences for adaptive response styles, such as cognitive reappraisal or mindful acceptance of experiences. Narrative review: Dual process models of reasoning, popularised as ‘fast and slow thinking’, were considered to offer a useful theoretical framework for 7 integrating research on reasoning biases in psychosis with implications for research and clinical practice. Empirical Study 2: The JTC reasoning bias was more common in the clinical group than the other two groups. Unexpectedly, no group differences were observed between clinical and non-clinical groups with PEs on measures of belief flexibility. However, the clinical group was less likely to employ rational reasoning, while the non-clinical group was more likely to use experiential reasoning plus a combination of both types of reasoning processes, compared to the other two groups. Empirical Study 3: 129 individuals (47%) were able to provide an AE for the evidence they have for their main persecutory belief. AEs were categorised, with excellent reliability, into eleven categories: Thirty percent of the AEs were categorised under a broad ‘Illness’ category with unelaborated mental health explanations the single most common subcategory across all AEs. As well as being the most common, this category was associated with the lowest level of conviction. Over fifty percent of the AEs fell within the broad psychological category of ‘Misinterpretation’. AEs which involved recognition that the experiences were not personal or specifically targeted (‘Misinterpretation: nonpersonalising’) were associated with the lowest distress of any sub-category, although conviction in these AEs was comparatively low. When combined across all categories, AEs were rated as less distressing but also held with lower conviction when compared to the main distressing belief. Empirical Study 4: The presence of an AE was associated with PM and mean beads drawn on the JTC tasks. Individuals with an AE showed lower conviction and paranoia severity compared to those with no AE, across a range of assessments. The components of belief flexibility (AE and PM) formed a latent ‘Slow thinking’ factor, with higher levels of slow thinking associated with lower conviction and paranoia severity across all measures. The JTC tasks also formed a latent ‘Fast thinking’ factor which, as expected, was negatively correlated with ‘Slow thinking’. However, contrary to expectation, ‘fast thinking’ was not positively associated with paranoia conviction or severity.

This thesis examines the expectancy question in contemporary psychoanalysis. While in other psy practices, this question is approached in relation to the delineation of the treatment process and the results that can actually be delivered via specific methods whose effectiveness has been measured and approved, in the psychoanalytic clinic of the Lacanian orientation, this question is not as straightforward. Generally, it is contended to be a subversive practice which ultimately reveals the Other as non-existent at the level of a universally-valid meaning, and hence as a fantasmatic construction at a purely subjective level. When approached, this question takes on the value of a defense against a skeptical, or, most commonly, against a critical stance or attitude towards psychoanalysis in terms of its effectiveness and scientific validity. This defense is arguably what psychoanalysis considers precisely to be its specificity: its irreducibility to a discourse that claims mastery over its reality and its refusal to resort to a reduction of the subject to clinical categories which presumably contain the truth of the subject’s symptom(s) and offer ready-made recipes on how to readjust the subject to normalcy. My argument is that this subversiveness is nothing other than an ego-reinforcement that is centered around a convincingly demonstrated subjective contentment with the irreducible remainder of the symptom, namely with what is at once untreatable and attests to the fundamental singularity of the subject. What I examine is the ways by which this subversiveness is appealing to analysts and analysands alike, especially since the analytic process is claimed to be solely dependent upon the analyst’s position of non-knowledge in the clinical encounter. As I will show, the identification of the analyst with this position creates an ‘objective reality’ of, and for, psychoanalysis, allowing for the conditions of the formation of the unconscious and thus the possibility of proof regarding its effectiveness, a proof dictating the reinvention of psychoanalysis.

Paper 1: High-risk behaviours (HRB) are understood to serve a function of regulating emotions in the absence of other adaptive coping strategies. Engagement in multiple HRBs during adolescence is known to contribute to increased risk of suicide and psychopathology. Dialectical Behaviour Therapy for adolescents (DBT-A) has received attention for treating HRB in adolescents over recent years. Previous reviews have either provided a narrow focus on one HRB in isolation, and/or have focused broadly on several interventions’ effectiveness in treating HRBs. This systematic review aimed to synthesise the literature across six databases, exploring the effectiveness of DBT-A (including both individual and group DBT sessions) on a range of HRBs in various settings. Eleven papers met the search criteria and were included within the review. A narrative synthesis of the findings provided evidence for DBT-A reducing a range of HRBs in comparison to control conditions, with particular benefits for suicidal ideation and self-harm. Improvements in self-harm were more likely to be maintained over follow-up, whereas between-group differences in other HRBs were often lost over time. Studies varied considerably in quality, treatment length, frequency, and intensity. The implications for future research and practice are discussed. Paper 2: Objective: Following early life stress (ELS), individuals have been shown to develop maladaptive coping strategies including externalising behaviours such as aggression that persist across the life span. Yet, little is known about the possible underlying mechanisms for this association. This study explored these relationships using neuroimaging methods and clinical data from a 30-year longitudinal dataset investigating adults with ELS and cross-sectional controls without ELS. Methods: Forty-one participants (Mage = 25.66 years, SD = 2.96) participated in the study: 15 participants with ELS, and 26 controls. Participants completed the Amygdala Reactivity Paradigm while a functional magnetic resonance imaging (fMRI) scan was recorded to probe amygdala reactivity and behavioural responses to emotionally salient stimuli. Blood-oxygen-level-dependent signals from bilateral amygdala and relevant subfields were analysed and correlated with clinical measures of coping in adulthood, and aggressive/hostile behaviour across the lifespan. Results: Although fMRI data showed no significant between-group differences on contrasts of interest, key differences were noted on trials of neutral faces. Compared to controls, individuals with ELS demonstrated significantly faster reaction time on all trials with greatest difference for neutral faces, and significantly less accuracy on trials with negative faces and shapes, but not neutral faces. Higher amygdala reactivity to neutral faces was significantly positively correlated with emotion-oriented methods of coping in adulthood, and aggressive and hostile behaviours during mid-adolescence and adulthood but not childhood or late-adolescence.

This body of work comprises a Systematic Literature Review (SLR), research paper and a critical appraisal. SLR Background: There has been an increasing trend to develop self-report assessments of voices. Assessments are crucial for research and clinical practice. However, no SLR of measures has been conducted since 2009. Methods: Databases were systematically searched (MEDLINE, PsychINFO and Scopus) from 2009 to 2019. Measures were assessed for the quality of methods used and measurement properties. Results: Twenty-one measures were identified, none of which were rated at ‘adequate’ or better in more than 3 of 10 areas in their methods used in measure development. No measures had involved voice hearers in the development of item pools. Conclusion: Further research is necessary to develop measures. This should involve people with lived experience. Research paper Background: Relational therapeutic approaches may be beneficial for voice hearers. However, there is currently no English language measure of the Voice Hearer Relationship (VHR) which assesses both positive and negative aspects of the relationship. This study sought to gain an in-depth understanding of VHR with a view to developing an item pool for such a measure. Methods: Qualitative interviews were conducted with voice hearers (n=7) and clinicians (n=8). Results: Thematic analysis revealed four themes. Based on this analysis 93 items were generated regarding the VHR. This item pool will form the basis of a new measure of the VHR. Conclusion: This study highlights that it is feasible to conduct qualitative research with voice hearers and clinicians for the purposes of developing an item pool regarding the VHR and this may contribute to the comprehensiveness of the measure. Critical Appraisal This chapter discusses: my epistemological position, the choice of analysis, biases in this research (and steps taken to address these), and future directions of this research.

The thesis entitled ‘Experiences of Psychological Distress, Uncertainty, and Coping Amongst People with Cancer’ explores the psychological experiences of individuals affected by cancer. A systematic literature review of the of the relationship between psychological distress and uncertainty amongst younger adults with cancer is presented in section one. Fifteen eligible studies were identified via database and hand searches. Risk of bias assessments were carried out. Findings demonstrated a highly significant relationship between uncertainty and psychological distress, with a number of studies indicating that uncertainty predicts psychological distress. Inconsistency in findings, however, suggests that other variables may influence this relationship. Risks of bias were identified across studies. A research study exploring patients’ experiences of coping longer-term with cancer of unknown primary (CUP) is presented in section two. Interviews were carried out with ten participants and data was analysed using interpretative phenomenological analysis. Three superordinate themes were identified: (1) ‘“Fuss and Bother”: The Upheaval of Everyday Life’, with subordinate themes of ‘Appointment threats’, and ‘Symptoms and side-effects’; (2) ‘“It’s the Unknowing”: The Enduring Uncertainty of CUP’ with subordinate themes of ‘“What the bloody hell’s that?!”’, ‘An uncertain future’, and ‘Hope’; and (3) ‘“Just Get on With It”: Managing and Moving Forwards’ with subordinate themes of ‘Maintaining normality’, ‘Acceptance’, and ‘Support’. Findings highlighted that the experiences of people living longer-term with CUP are comparable to those of other cancer patient populations, however, they also face a number of distinct challenges. A critical appraisal of the research paper is presented in section three. Within the critical appraisal, consideration is given to the epistemological and ontological assumptions made within the thesis, the position of the researcher and the importance of researcher reflexivity, and the research process. The ethics application and associated documentation are presented in section four.

Roughly one in a hundred people experience symptoms of schizophrenia during their lifetime, symptoms which include experiencing delusions and hallucinations, such as hearing voices (Johnstone and Frith, 2004). The frequency and intensity of symptoms is exacerbated by widespread negative attitudes and increases the likelihood that an individual will comply with command hallucinations (Harrison and Gill, 2010; Goldstone et al., 2012). In spite of this, the mass media continues to represent people with schizophrenia in an inaccurate and stereotypical way (Clement and Foster, 2008; Chopra and Doody, 2007). This fosters widespread misunderstandings and negative assumptions around the disorder. These misunderstandings gain traction because schizophrenia is widely misunderstood by the public at large (Jensen et al., 2016), and because people are unlikely to have first-hand experiences with people with schizophrenia. Despite the harmful nature of media representations, no study to date has seriously considered how misconceptions of schizophrenia and people with schizophrenia are mediated linguistically in the media. This is curious given that scholars in fields outside of Linguistics are increasingly recognising that the manner in which mental illness is represented plays an important role in reproducing stereotypical and prejudiced attitudes (Goulden et al., 2011, Kalucy et al., 2011). With these considerations in mind, this thesis draws on theories and methods from the field of Corpus Assisted Discourse Studies (CADS) to examine representations of people with schizophrenia in articles published in the British press between 2000 and 2015. This thesis uses a combination of corpus toolkits (Wordswmith 5.0, Sketch Engine) to examine repetitive lexicogrammatical patterns in articles published in the press that refer to schizophrenia and people with schizophrenia. It takes a particular interest in ‘non-obvious meaning’ (Partington, 2012:11), meanings that are only visible when examining how lexicogrammatical patterns converge around broader semantic and evaluative structures in large repositories of text. Do these patterns, working cumulatively over hundreds and thousands of texts suggest certain ways of understanding or viewing schizophrenia that would not be discernible to the naked eye? The root of the problem revealed in the analysis was a tension between reporting schizophrenia accurately and the press’ interest in reporting on schizophrenia in a way that is newsworthy in accordance with news values (Galtung and Ruge, 1965; Jewkes, 2015). In particular, there was a tendency to report on exceptional cases of people with schizophrenia (e.g. worst cases where people experience florid symptoms, people with schizophrenia who have succeeded creatively) that do not represent the majority of people diagnosed with the disorder. In the same vein, there was also a tendency for the press to repackage hard news as entertainment, for instance, by interdiscursively drawing on language and tropes associated with horror fiction. Salient language patterns converged around two main discourses: (1) that people with schizophrenia pose a risk to others, and (2) that people with schizophrenia who kill are intentional immoral agents. The analysis also identified a problematic metaphorical usage, which potentially reproduced the widespread misassumption that schizophrenia refers to a ‘split personality disorder’ (e.g. Jensen et al., 2015). I conclude by supporting a suggestion made in the academic literature (e.g. Ellison et al., 2018) that the diagnostic term ‘schizophrenia’ should be relabelled so that individuals diagnosed with the disorder do not carry the additional burden of negative stereotypes and misassumptions associated with the label.

Rationale: People with mental ill health face higher mortality rates than the general population with reported reductions in life expectancy of up to twenty years, often dying from common medical conditions that do not impact on mortality rates for the general population. Mental health nurses and mental health nursing students have a role in supporting the physical health of people with mental illness. Aim: The aim of this study is to explore what mental health nurses and mental health nursing students’ attitudes are toward managing physical health with a view to identifying factors that could help improve physical health monitoring and surveillance and help to improve physical well-being for service users. Methodology: A mixed methods convergent design was used. Quantitative data were collected via the Physical Health Attitude Scale, (PHASe) followed by semi-structured interviews with both qualified and student mental health nurses to explore their attitudes towards the management of physical health. There were 110 responses to the PHASe, in the quantitative arm of the study, and 9 registered and 4 student nurses were interviewed for the qualitative arm. Findings: The findings indicate that, although mental health nurses encounter a range of challenges in physical health management, they view it as a key component of their clinical role. Issues impact on mental health nurses when managing physical health included poor integration of health services, confidence of medical colleagues, and access to resources in terms of equipment to undertake monitoring and time to have meaningful conversations about physical health. Conclusion: Mental health nurses are committed to delivering holistic care. Physical health management requires input from clinicians and managers to ensure that time and equipment is available to undertake the work, and a more collaborative approach between mental health, primary care and acute care services is needed to ensure that patients are treated holistically in all health care settings.

In the last 30 years, new technology and the use of the internet has increasingly become part of people’s daily life and this is even more evident within the lives of young people. However, little research has investigated the impact of technology on young people and on psychotherapy practice. The research explored child and adolescent psychotherapists understanding of new technology in their therapeutic work with children and young people, and if their understanding of technology is illuminated by the concept of transitional objects. The research was conducted using the qualitative method approach, Interpretative Phenomenological Analysis (IPA) (Smith, Flowers and Larkin, 2009). Eight child and adolescent psychotherapists reflected on their therapeutic work with young people, during individual semi-structured interviews. The IPA method requires an in-depth analysis of interview data, as it focuses on participant’s experience of an individual phenomenon. The analysis of the interviews retrieved 4 recurrent super-ordinate themes; Therapeutic task, Relating, Shortcuts and Transitional Objects. The analysis of the interviews also found 4 sub-themes; Technology as defence, Exposure, Identity and Technology as positive. The results found that child and adolescent psychotherapists had wide ranging views on technology and whether it is illuminated by the concept of transitional objects. The majority of the participants viewed that for young people, their use of technology is intertwined with their identity, attachments and their attempts to manage stages of development and emotions. Technology is illuminated by the concept of transitional objects, based upon the commonly shared function of relieving anxious feelings and helping to manage feelings of aloneness. Some child and adolescent psychotherapists view that technology does not have the same qualities that fulfil the traditional concept of transitional objects. Irrespective of these differences, child and adolescent psychotherapists employ their psychoanalytic technique, to work with what a young person brings, technology or not.