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This research investigated the construction of autism in clinical and social terrains. Study one drew from Critical Discursive Psychology (CDP) to examine the language of psychoanalytic psychotherapists in constructing the phenomenon of autism spectrum disorders. This study relied on interview data with eight experienced psychoanalytic psychotherapists using a Free Associative Narrative Interview design. The investigation of the therapists’ discourses revealed four main interpretive repertoires that organised the rhetorical agenda’s of participants. The analytic notions of interpretive repertoires, ideological dilemmas and subject positions demonstrated how neo-liberal political frameworks influenced the therapists' negotiation of the meaning of autism. The implications of this discursive framework were subjected to a critical analysis revealing the limitations that they impose on the possible ways of being for autistic people. The second study used multimodal analysis to investigate an activist’s momentary identities on a “viral” YouTube video entitled: “In My Language” (see appendix 4). It focused on the verbal and non-verbal elements of the video material. The analytic attention predominantly settled on the interplay between the various semiotic resources that the activist utilised to negotiate a multiplicity of meanings. A wide range of identities produced by the participant’s social actions, exploring a political manifesto against the social oppression exerted on people with autism. The findings suggested that meaning-making inside this video was intricately related to the pathological language that saturates autistic lives from their beginning. This study also considered how multimodal designs of research could add to the investigations of disability and autism studies, pointing to the need to employ more autism lead research in the clinical and non-clinical sites. The findings from both studies highlighted two critical factors in autism as a discursive and multimodal phenomenon occupying a socio-cultural niche. A) Autism evolves through a conflictual and irreconcilable discursive framework. This conflict reflects profound issues of power that were taken as residing in a micro-fascism political dynamic. B) A need to break from the dichotomous deployment of autism in the current political setting is becoming apparent. The current clinical and social arrangement needs to change; a negotiation in which psychoanalytically and relationally inspired disability politics may become central. Part of this new “diplomacy” lies in engineering new discursive research designs that could offer the opportunity for the two realms to inter-relate in unforeseen and unpredictable ways.

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

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

There is a body of evidence showing that childhood trauma is associated with psychotic experiences (PEs). Establishing whether this association is causal and what mechanisms mediate this relationship is needed to understand how psychosis develops and help inform interventions to mitigate the risk of PEs. The first study in this thesis investigates whether exposure to interpersonal violence and neglect is causally associated with PEs, whether there are sensitive periods of exposure, and if different types of trauma are differentially associated with PEs. The subsequent studies in this thesis examine whether information-processing biases are associated both with trauma and PEs, and whether these biases lie on the causal pathway from trauma to PEs. Analyses were carried out using data from ALSPAC, a large UK birth cohort. A systematic review and meta-analysis of childhood trauma and psychosis-related information-processing biases was also conducted. Childhood trauma was associated with PEs and this was largely unchanged after adjustment for confounders. The greatest increase in PE risk was associated with exposure to multiple types of trauma, consistent with a dose-response relationship. There was little evidence to support the presence of sensitive periods of risk or of differential effects of specific types of trauma. When examining information-processing biases I found that an increased expectation of change (reversal) and sub-optimal belief-updating (decision noise) were associated with PEs, and not explained by confounding. Childhood trauma was also associated with greater decision noise, but not with the other belief-updating processes examined. However, there was little evidence that decision noise mediated the relationship between trauma and PEs. The systematic review provided some evidence that childhood trauma is associated with a bias to attribute the cause of events to external factors, but not with the other biases examined. I conclude the thesis with a critical evaluation of the results, within the context of the studies’ strengths and limitations, and discuss the extent to which they support a causal relationship between exposure to trauma and PEs, and whether abnormal-belief updating processes are on this hypothesised pathway. Further research should utilise interdisciplinary approaches and longitudinal data to establish what mechanisms contribute to the psychosis pathway in order to identify targets for intervention that can mitigate the effect of trauma exposure on PE and other mental health outcomes.

Identity formation during adolescence plays an essential role in seeking an answer to the question of “who am I”. This fundamental period of self-understanding is particularly challenging for ethnic minority youth from immigrant families as they negotiate between two divergent cultural worlds: their heritage culture and their society of settlement. Alongside this negotiation, second-generation immigrant youth can experience ethnic discrimination and additional challenges related to their acculturation. These experiences can be associated with a wide range of negative and positive mental health outcomes. In the UK context, researchers have examined distinct ethnic identities and acculturation processes, however, they have largely neglected the sizeable Turkish community. This is an important omission because Turkish minorities are one of the vulnerable ethnic groups who have possible cultural difficulties, social disadvantages and mental health problems in the UK. The present study addresses this lacuna in the literature by examining second-generation Turkish young people’s ethnic identity formation and mental health in England. The theoretical backbone of this research draws upon Umaña-Taylor et al.’s (2004, 2014) ethnic identity development model and Berry’s (1997, 2001, 2005) model of acculturation to examine ethnic identity formation and acculturation. Adopting a mixed-methods design, this thesis investigates the complex relationships between ethnic identity formation and mental health (using indicators of life satisfaction, self-esteem, depression and psychological well-being) among second-generation Turkish young people by considering their acculturation experiences and perceived ethnic discrimination in the context of England. To achieve this aim, self-report surveys (N=220) and semi-structured interviews (N=20) were conducted amongst 16-18-year olds. Structural equation modelling was used to analyse the quantitative data and thematic analysis was utilised to analyse the qualitative data. Survey results show that greater ethnic identification (having a meaningful and positive ethnic identity which is actively explored) is associated with positive mental health, and lower levels of assimilation and perceived ethnic discrimination partially mediating this relationship. However, these associations can be complexified when young people’s multiple social identities and acculturation experiences are considered. Qualitative results suggest that the complexity of social identities can be beneficial for ethnic identity development and acculturation processes when young people sense the multiplicity and complexity of these identities. Contextual (e.g. positive social relationships-particularly with parents, community support, diversity) and individual (e.g. blending different cultures, use of multiple languages and social identities, diversity awareness) factors are fundamental in making sense of multiple identities, developing a positive meaningful ethnic identity and different variants of integration. These findings have important implications for theory, research, policy and practice in second-generation youth growing up between cultures.

The relationship between psychoanalysis and race, which includes the external feature of skin colour, has been contradictory due to psychoanalytic principles privileging the internal world. This has the effect of marginalising race, and other socio-cultural contexts such as gender, sex, culture, ethnicity, and class, which are fundamental elements of one’s subjectivity, sense of self, and how we relate to others. Psychoanalysis is now practised in a highly diverse and pluralistic society, but there remains very little understanding of how the external world, in the form of racial difference, affects the internal dynamics, in the psychoanalytic encounter. Considering these pertinent issues, this study investigated whether race, which includes the colour difference (external feature) between the client and therapist affect the transference (internal response), and the relationship that subsequently develops. The study gathered views from 14 psychodynamic and psychoanalytic psychotherapists (6 White, 4 Black, 2 Asian, and 2 Mixed Asian and White) generating in depth, nuanced understanding of how issues of racial difference emerge and how therapists engage with them in the consulting room. Through engaging therapist from diverse racial backgrounds, the study was innovative and derived rich, varied perspectives, giving it both depth and breadth. The study utilised Interpretative Phenomenological Analysis (IPA) as a qualitative research data analysis methodology (Smith, Larkin and Flowers, 2009). While being mindful of the philosophical tensions between phenomenology and psychoanalysis, a psychoanalytic lens was integrated in the analysis process to fully capture the participants’ experiences in the psychoanalytic encounter. From the data analysis, all 14 candidates strongly considered race to be an integral element of their work, and highly relevant to the relationship. They also considered race as a vehicle and an entry point to transference manifestations, bridging the gap between the external world and the internal world.

Literature Review: Objectives: Research indicates that illness representations are associated with the management of health conditions. They are therefore important to understand when supporting people to best cope with their illnesses. This systematic review aims to summarise and synthesise the literature exploring illness representations and associated coping responses in people experiencing more than one chronic condition. Methods: A systematic review of literature published prior to November 2018 on MEDLINE, Embase, CINAHL, Web of Science and PsycINFO databases. Search terms included three broad areas; multimorbidity, health and illness representations. Results are synthesised using a narrative approach. Results: Eight papers are included in the review and comprise qualitative and quantitative research designs. Findings indicate that illness representations in those with multimorbidity vary across conditions and individuals, while people hold representations relating to both individual conditions and multimorbidity. These representations have been associated with medication adherence and self-management behaviours. Conclusions: This narrative synthesis highlights that representations have a role in coping. There is a need to consider illness representations in clinical consultations and in the delivery of care to improve condition management. Further research is needed to establish how this may be best achieved and to consider other variables which may influence representations and coping. Developing a theoretical framework which may account for both single and multimorbid representations will be important for such future research. Keywords: Multimorbidity, chronic condition, common-sense model, illness representation, systematic review, narrative synthesis. Empirical Paper: Objectives: Research has highlighted an association between illness representations and coping responses, such as self-management, medication taking and treatment-seeking. However, illness representations for common mental health symptoms when experienced alongside multimorbidity are poorly understood. The current study aims to understand how people experiencing multimorbidity represent and respond to their common mental health symptoms. Methods: Semi-structured interviews were conducted with thirteen participants experiencing mild to moderate symptoms of anxiety and/or depression alongside physical multimorbidity. Thematic analysis combined with deviant case analysis was used to analyse the data. Results: The results provide an understanding of illness representations and coping responses for common mental health symptoms in those experiencing multimorbidity. Four key themes were identified; 1) interconnected conditions, 2) methods of responding to mental health difficulties, 3) relationships: the importance of connection and understanding, and 4) narrow treatment options. Conclusions: Illness representations for common mental health symptoms appear to have a role in guiding coping responses, including treatment-seeking. Having an awareness of people’s illness representations will be useful in clinical practice to guide consultations and interventions. By understanding and working with illness representations and increasing primary care accessibility we may begin to improve coping and treatment-seeking within this population. The implications of this research will be useful in allowing health services to meet the needs of the growing multimorbidity population and close the mental health treatment gap.

This research examines therapists’ accounts of how social class operates within therapy and its impact on the therapeutic relationship. The topic of class in therapy has rarely been addressed in the counselling psychology literature, with only a few papers published on this topic (e.g. Balmforth, 2009; Chalifoux, 1996; Kaiser & Prieto, 2018; Thompson, Cole & Nitzarim, 2012; Trott & Reeves, 2018). This study aims to address this omission by exploring the accounts of eighty-seven practicing psychologists, counsellors and psychotherapists, from trainees to experienced practitioners, who completed an online qualitative survey about social class in therapy. Critical thematic analysis was used to analyse therapists’ accounts of their own social class status and class as a form of difference more broadly, their accounts of working therapeutically with class differences and their sense-making around the relationship between class and mental health. I identified oppositional sense-making in the data, where one (smaller) group of therapists located individuals’ mental health difficulties within their socio-political context and described class differences in therapy as something that cannot be transcended by the therapeutic relationship. Another (larger) group of therapists drew upon ‘oppression blind’ (Ferber, 2012) discourses that removed clients from their socio-political context and dismissed social class as an important factor in therapy. When it came to their own class background, most participants used rhetorical strategies to disavow a middle class status and distance themselves from middle class privilege. Implications for practice and recommendations for future research are discussed.

Burns are the fifth most common cause of non-fatal childhood injuries. In addition to the trauma of suffering a burn, the painful and intrusive medical procedures required to treat them can impact on the developing child cognitively, emotionally, psychologically, and socially. A child’s burn injuries and their treatment can also have a significant psychosocial impact on parents, affecting their health and mental well-being. Parents can experience a reactive distress including elevated stress, anger, anxiety, depression, post-traumatic stress, guilt, marital and financial problems, and increased responsibility and load, during the acute phase of treatment. Many must also divide their time to meet the needs of any uninjured siblings, and between work, the hospital ,and home. This PhD used mixed methods to explore the experiences, access to support, opinions of peer support, and support needs amongst parents and carers of burn-injured children. Thirteen interviews were conducted with parents, followed by a survey of a further 57 parents. The majority of parents reported that they were offered support, particularly during the acute phase of treatment. Most often, this was from nursing staff. Despite this, many parents also reported to feel isolated. Access to peer support has been recommended in the British Burn Care Standards (2013, 2018), and parents recognised the potential value of this. However, factors such as guilt, the pain of recollection, perceived stigma, time pressures, and distance to the hospital can make accessing such support difficult. The results of this research suggested that online delivery of supportive peer-informed information could be particularly appealing to parents, particularly that which retained the peer voice. With widespread access to the internet and growing dependence on computers and mobile devices, it is common for adults in the UK to seek health-related support and information on the Internet. Many parents involved in this research had searched online for burn-related information following their child’s injury but found this to be lacking. Therefore, using a partnership-based method of website development, www.SupportingChildrenWithBurns.co.uk was developed and tested with nine parents and 22 professionals before being publicly released and accessed worldwide. An initial evaluation of the performance of this new resource over the first 6 months is provided.

In this Doctorate of Psychotherapy and Counselling Dissertation, I offer a variety of different perspectives on queer shame and body shame in the context of trekking experiences. The overall project of this thesis is to offer some glimpses into the ongoing and ever-changing process that surrounds these topics. I draw methodological inspirations from Mason's (2011) conceptualization of Facet Methodology as well as Gale's (2018) conceptualization of Methodogenesis. I approach this with a poststructuralist perspective that follows flashes of insight through various assemblages, drawing on Deleuze and Guattari (1987). Being inspired by Haraway (2016), I attempt to foster a more-than-human view of the world. I employ a variety of methods for this inquiry, drawing largely on writing-as-inquiry (Wyatt, 2019; St. Pierre, 2008; Richardson, 2008) and autoethnography (Holman Jones & Harris, 2019; Gale, 2018; Wyatt, 2019). Emphasis is also drawn from dialogue and the unfinalizability of subjects (Bakhtin, 1984; Frank, 2004; Willis, 2009; 2013). I draw on themes from queer theorists including Halberstam (2011; 2015), Holman Jones and Harris (2019), and Butler (1997), among many others. The chapters of this thesis each contribute something to understanding queer shame and body shame experiences, and then offer something that we might use to work with that shame productively. I have concluded by emphasizing the entangled nature of our realities, and our interconnectedness. We strive to build lives work living, lives which allow us to live and die well together. The greatest source of strength in precarious times is the making of queer kin. Connecting with our queer families that are more-than-human and stretched across aeon time opens the door of possibility for us to make use of (at least) six different ways of working with queer shame and body shame: Decoding, Multiplicity and Becoming Queer, Daemonizing, Suffering/Resisting/Hoping with, (Re)Storying, and Being Together in Precarity.

The field of mental health and gaming has grown with the surge of the digital gaming industry in the last thirty years. While research on video games in regard to mental health, especially their effects on children, concerns about pathological use, and potential applications health interventions, is becoming a known field of study, there are many more avenues for approaching games that have yet to be explored. There are three nexuses in which research into games and their relationship with mental health are underrepresented: 1. Qualitative, experience-focused research; 2. Research focusing on adult populations; and 3. Research on traditional games. Where these three nexuses meet, there is an absolute dearth of research. Given substantial previous work into the impact of games on human culture and society, and promising results from other populations and types of games, this thesis considers whether this might be a worthwhile subject area for future mental health research to expand on. With this epistemic gap in mind, this thesis uses an ethnographic approach grounded in social realism to provide a foundational inquiry into whether traditional games can be considered therapeutic for adults. The hope for this research is that its results may be applicable and usable by further academic work from a wide breadth of different disciplines and onto-epistemic approaches. Using the game Magic: The Gathering as a case study, this work analyses the digital artefacts and experiential accounts offered by players, the design elements that are worked into the game, as well as the personal experiences and insights of the author as a Magic player, therapist and researcher. By marrying observations and experiences from the ludic field of Magic: The Gathering with theories from counselling and psychotherapy, the author outlines a process by which we might determine whether an activity is therapeutic. By applying this definition to narratives and outcomes offered by players online, this research concludes that traditional games can be therapeutic for adults, and further inquiry is needed to fully understand what impacts and potential benefits traditional games could have on the field of mental health for adults. With this conclusion in mind, this thesis also offers an understanding of how one might theorize or conceptualize the ways a game can be therapeutic. This thesis maps out a potential path through which therapeutic affect evident in outcomes may develop in relation to game-play interactions, through a process of working with culturally established boundaries and expression both in-game and in the community that constitutes a process of contained reality-testing. This process is also explored alongside the complex relationship and entanglement of wider social discourses and contexts that Magic is a part of, such as assumptions made about games as a whole as well as issues of difference and diversity in gaming. In doing so, this research offers a model of how mental health research into games can be applied at an experiential level, as well as creating a reference point for the potential further application of counselling and psychotherapeutic theories in game.

There is a limited amount of academic research within social sciences investigating the experiences of queer people in post-Soviet Central Asian countries. My study aims to address this gap in the literature by focusing on the everyday narratives of queer people in Kazakhstan within a framework of power and agency, primarily using the theories of Michel Foucault and other scholars such as Hannah Arendt and Erving Goffman. In this study, ‘queer’ is understood as broadly encompassing the whole spectrum of nonheterosexual and non-cisgender identities. By looking at the narratives of queer people within their socio-historical context, this study aims to elucidate two key issues: in Kazakhstan, what regulates queer lives, and how do people negotiate their queer subjectivities? The qualitative study uses a Foucauldian-informed thematic analysis of interviews with eleven people who identify as queer and live in Kazakhstan. The findings reveal that practices of regulation of queer people in Kazakhstan range from legal and medical regulation, surveillance within different everyday contexts, limiting career prospects, and internalised gaze and oppression. Crucially, I argue that despite the manifold regulatory practices, the narratives of queer Kazakhstani participants of this study highlight the artful ability to navigate and negotiate the existing regulatory and power structures to live fulfilling and authentic lives. This study contributes to the scholarship on post-Soviet gender and sexualities by developing a deeper understanding of nonheterosexual and non-cisgender subjectivities in the context of Kazakhstan.

Recent theories in the field of computational psychiatry regard schizophrenia (SCZ) and autistic spectrum disorders (ASD) as impairments in Bayesian inference performed by the brain. In Bayesian terms, perception is a result of optimal real-time integration of sensory information (’likelihood’), which is intrinsically noisy and ambiguous, and prior expectations about the states of the world (‘prior’), which serve to disambiguate the meaning of the sensory information. Priors capture statistical regularities in the environment and are constantly updated to keep up with any changes in these regularities. The extent to which prior or likelihood dominate perception depends on the uncertainty with which they are represented, with less uncertainty resulting in more influence. Individuals with ASD and SCZ might show impairments in how they update their priors and/or how much uncertainty there is ascribed to prior and likelihood representations, leading to differences in inference. While this Bayesian account can be argued to be consistent with many previous experimental findings and symptoms of SCZ and ASD, recent experimental work inspired by these ideas has produced mixed results. In this work, we investigated possible Bayesian impairments in SCZ and ASD experimentally by addressing some of the methodological limitations of the previous work. Most notably, we used an experimental design that allows to disentangle and quantify separate influences of priors and likelihoods, and we tested both SCZ and ASD patient groups as well as autistic and schizotypy traits in the general population. We administered a visual motion perception task that rapidly induces prior expectations about the stimulus motion direction, leading to biases and occasional hallucinations that can be well described by a Bayesian model. In this task, autistic traits were found to be associated with reduced biases, which was underlied by more precise sensory representations, while the acquired priors were not affected by autistic traits. Patients with ASD, however, showed no evidence of increased sensory precision, while there also were no impairments in the acquisition of priors. We also found no effects in the acquisition of priors or sensory representations along schizotypy traits and in patients with SCZ. However, under conditions of high ambiguity SCZ patients were less likely to hallucinate the stimulus than controls. The second part of the thesis is focused on further exploratory analyses conducted using these same datasets. First, we investigated post-perceptual repulsion effects in our task and whether they were related to trait or group differences. We found clear evidence of repulsion from the cardinal directions. In addition to that, we found evidence for a repulsion from the central reference angle, which was randomly selected for each participant and which could only be inferred from the stimulus statistics. Furthermore, we found the repulsion from the central reference angle to be reduced along schizotypy traits. Interestingly, in both SCZ and ASD groups this repulsion was also found to be negligible. While these results are exploratory, they might point to a trans-diagnostic features of ASD and SCZ. Second, we investigated within-trial dynamics of evidence accumulation by constructing a Continuous Choice Drift Diffusion Model (CDM) – an extension of the classical binary choice drift diffusion model. The results of this model showed that increased sensory precision along AQ found in a Bayesian model was underlied by faster drift rates, while slower responses and reduced hallucinations in SCZ were explained by a larger decision threshold. In addition, this model provided a more complete characterization of the performance in this task (by including reaction times) and it serves to emphasize the importance of accounting for exposure to stimulus duration and judgement time in future studies investigating Bayesian inference. Together, this work provides novel experimental evidence that speaks to the hypothesis of impaired Bayesian inference in ASD and SCZ. Furthermore, the analysis of reference repulsion effects and within-trial dynamics provide additional insight related to SCZ and ASD differences that extend beyond the Bayesian framework.

The t(1;11) translocation is a mutation unique to a Scottish pedigree, members of which have been diagnosed with schizophrenia, bipolar disorder, recurrent major depressive disorder and other related disorders. The translocation is significantly linked to increased risk of these diagnoses. It disrupts three genes, only one of which, DISC1, encodes a protein. A number of experiments have explored the function of DISC1 as a molecular scaffold and developmental regulator. DISC1 and its interactors have roles in processes of relevance to psychiatric disease. These include neuronal precursor proliferation, migration and integration in the developing and adult brain, neurite outgrowth, mitochondrial activity, which is particularly important in neurons due to their high energy demands, and intracellular trafficking, especially critical in neurons due to their highly elongated morphology. Although various DISC1 mutations have been investigated in the past, it is only with advances in technology that neural cells derived directly from translocation carriers, and therefore carrying the translocation plus their genetic background, have been generated and analysed. In addition a recently described mouse model mimics the effects of the translocation upon DISC1 expression. It does so by removing endogenous Disc1 exons corresponding to those distal to the breakpoint in translocation carriers, and fusing the remaining endogenous 5’ Disc1 genomic sequence to human chromosome 11 genomic sequence distal to the translocation breakpoint. The result is a chimeric gene with 5’ mouse Disc1 joined to a segment of human DISC1FP1, the non-coding fusion partner of DISC1 located on chromosome 11. This leads to loss of wild-type Disc1 and prediction of chimeric transcripts encoding aberrant C-terminally truncated forms of Disc1. This thesis builds on the work of previous researchers to characterise the RNAsequenced transcriptome of ‘cortical’ neurons derived from induced pluripotent stem cells from various members of the pedigree. Both heterozygous and homozygous mutant mice have also been utilised to generate RNA-sequencing data from the hippocampus and cortex. The thesis not only describes the differential expression of genes and exons, but also carries out a series of analyses to examine whether proportions of certain cell types are altered, as well as whether differentially expressed genes are highly associated with specific cell types. RNA-Seq data have been analysed for differential expression at the gene and individual exon level using DESeq2 and DEXSeq, respectively. This has revealed over 1,200 differentially expressed genes in human neurons carrying the translocation, which predict changes to functions relating to intracellular transport and synaptic activity. In addition, a number of genes have been verified by RT-qPCR as being differentially expressed in these neurons. These include genes of known relevance to schizophrenia such as DRD2, which encodes the D2 dopamine receptor, NTRK2, which encodes the BDNF receptor NTRK2, and BBS1 which encodes the DISC1 interactor and centrosomal protein BBS1. The human neurons also show significant overlap with previously published dysregulated genes in human neurons carrying other DISC1 mutations, as well as with genes associated with schizophrenia by large-scale genome wide association and copy number variation studies. Human neuron RNA-Seq data have also been examined for evidence of local effects of the translocation upon gene expression, and no obvious strong effect was found. The pattern of gene dysregulation in heterozygous mutant mouse cortex overlaps with that of the mutant human neurons. Gene expression changes in the mutant mouse cortex have also been verified by RT-qPCR in the genes Arc and Avp, and the list of implicated genes also shows overlap with genes associated with schizophrenia by large-scale genome wide association and copy number variation studies. An RNA-Seq deconvolution analysis was carried out to look for evidence of altered proportions of cell types at both the broad and more specific cell type level. This compared the observed expression of hundreds of genes in in the RNA-Seq samples against their expression in publically available RNA-Seq data of specific cell types. There does not appear to be any strong and consistent effect of the t(1;11) or mouse mutation on cell proportions. However, the data indicate greater than expected dysregulation of genes that are highly enriched in specific cell types. This includes certain subtypes of astrocyte. Mutant mouse cortex also shows dysregulation of genes associated with several subtypes of interneuron and pyramidal neuron, including parvalbumin positive interneurons. This indicates that, while the proportions of cell types appears to be unaffected by the translocation or mouse mutation, specialised cellular functions may be perturbed. To conclude, this thesis highlights a number of processes which appear to be disturbed by the translocation and mouse mutation. In all models, RNA-Seq evidence suggests signalling pathways of known relevance to psychiatric disease have been affected without significant alteration of cell proportions. This concurs with histological analyses of the mouse model by previous researchers. This thesis also describes the overlap between genes implicated in the study of this unique mutation as well as those implicated by studies seeking common or rare mutations predisposing to schizophrenia, supporting the hypothesis that different genomic risk variants and mutations converge upon certain molecular pathways that are especially important in this illness. The implication that the t(1;11) may alter the activities of certain cell types is also notable and future work can elucidate the cell-specific effects of the translocation.

This is a research project aims to reconceptualise reflexivity and experience to think anew about making sense of ourselves. Methodologically, I think through different traditions to diffract my concepts of interest, arriving at – necessarily temporary – renewed articulations. The traditions that I mostly use are poststructuralism, posthumanism and to a lesser extent, psychoanalysis in a relational strand. The new conceptualisations that I put forward are not only theoretically – abstractly – important, as if theory could be divorced from life. Instead, these new conceptualisations are important because they produce new worlds: different ways of becoming a subject, different ways of articulating affective experience, different questions, different tools, different problems, and so on. In coherence with that, at different points throughout this research, I bring to the page how these reconceptualisations are influenced by my experiences – including my experience as a psychotherapist – and how these reconceptualisations produce me and my experience differently. Based on a relational perspective, we do not pre-exist our relating but are produced through relating – not only in interpersonal terms but in materialdiscursive ones. In coherence with this, my conceptualisation of reflexivity shifts the understanding of it as a discrete activity performed by a bounded subjectivity that captures how things ‘are’ to understand it as an ever-present way of relating to ourselves that is not performed by an already bounded subject but produces a particular kind of subjectivity and a certain world. With this relational, material-discursive and performative understanding of reflexivity, I contend that the possibility of questioning our assumptions is not given by an individual decision but requires yielding to the foreignness of unknown fields that might unwittingly shift our assumptions and hence we are able to see what we were previously taking for granted. Furthermore, I emphasise the need to develop a meta-reflexivity that asks about the ways of relating that we are enacting and what they are producing. Originally, my conceptualisation of reflexivity is made with, not against, diffraction. I contend that we never find pure reflection or pure diffraction but different shades of them, as in a diffraction pattern. Moreover, I propose that when we hold diffraction as the superior term, we unavoidably betray our best intentions and reproduce the representationalism that we were so keen to avoid. I further elaborate the benefits of a diffracted reflexivity and of using meta-reflexivity with diffraction. Throughout the thesis, I argue to regard different concepts and theories as more or less useful for particular contexts because of how they produce these very contexts. I value the theories in their productions rather than in their truthvalue because there is not a world to discover but a production of worlds through practices of knowing. In coherence with this, I read the concept of experience through the lenses of existential phenomenology, poststructuralism and posthumanism. I let myself be taken by each of these traditions, opening up to what they produce. I, intra-actively with the three traditions – and my psychoanalytic background – arrive at an articulation of the concept of experience. I think of experience as an impersonal affect with its own force to produce us as subjectivities. This experience can be elaborated from the felt sense rather than from our cognition to enable a movement in our experience and in our ways of subjectivation. Finally, I assert that we do need to critically consider where this experience/affect is taking us because it can lead to reproduce dynamics that can be detrimental. To conclude, in this thesis I grapple with reflexivity and experience to think differently about the practices of making sense of ourselves. In very broad terms, I would say that I have arrived at the following ideas: 1. In making sense of ourselves we are also producing ourselves. 2. We do not make sense intentionally and separately from our relational, affective, and materialdiscursive engagements. Strictly, it is not that ‘we’ make sense of ‘ourselves’, but a greater intra-active assemblage makes sense and produces ourselves and the world in that movement. 3. There is no way of neutrally judging which ways of making sense and producing ourselves and the world are better or truer. 4. There is not a way to control the way in which we make sense, rather we ‘find ourselves’ making sense. And 5. Given the previous points, the only thing we can do is to be curious about how we are relating to ourselves when making sense and to wonder what that relating is producing.

The last couple of decades have seen a significant increase in the fields of research and clinical practice inspired by the theory of mentalising. Mentalisation, the capacity to understand one's own and others' behaviour in terms of mental states, is considered to be a "defining human social and psychological achievement" (Fonagy & Allison, 2014). The dialogue between mentalising theory and other fields such as developmental psychopathology or the neurosciences has added complexity and nuance to the understanding of this mental capacity. However, there is a gap in the research literature concerning the assessment of mentalising during therapeutic sessions. This assessment has often been done at the beginning and end of the treatment, missing session-to-session variations and the possibility to inquire about a mentalising style and its outcome in psychotherapy. This thesis describes the development and preliminary validation of the Mentalising Profile Q-set (MQS), an observer-rated measure that aims to bridge the gap between scientific research and clinical observations by describing the mentalising process of patients undergoing psychotherapy in a jargon-free language. The MQS focuses on the patient and provides a picture of the mentalising process in relation to its four polarities and pre-mentalising modes of experience. The data used in this research was derived from the Randomised Evaluation Study of Dynamic Interpersonal Therapy (REDIT) and the Tavistock Adult Depression Study (TADS), two trials that worked with depressed patients, although with differences in clinical characteristics. The preliminary results suggest that the MQS is an instrument that can differentiate groups of individual mentalising profiles and their likely effect on therapeutic outcomes, as assessed by the HRSD-17, at the beginning of treatment. The MQS contributes to the extant literature on assessment instruments and, at the same time, expands on the role of the capacity to mentalise in the therapeutic outcome.

Background People with severe mental illness (SMI) have an increased risk of cardiovascular disease (CVD). Research in the general population suggests that social support may protect against CVD morbidity and mortality, however little is known about social support and cardiovascular health in people with SMI. Objectives For people with SMI: 1. Assess the effectiveness of CVD risk-reducing interventions that involve supportive others 2. Develop and integrate a social support strategy into a CVD risk-reducing intervention in primary care 3. Explore the relationship between social support and cardiovascular health behaviours 4. Describe how existing social support was explored within initial appointments in a CVD risk reducing intervention in primary care. Methods Systematic review, longitudinal and cross-sectional observational study and qualitative thematic analysis of intervention appointments. Results Few studies were identified on effective interventions that used existing support networks to improve cardiovascular health in people with SMI. Recommendations for involving supportive others in CVD risk reduction were identified from focus groups, workshops and UK clinical guidelines These included exploring how to involve supportive others, respecting confidentiality and identifying strategies for those without social support. Higher social support predicted significantly greater appointment attendance in unadjusted but not adjusted analyses and greater medication adherence. There was no association between higher perceived social support and greater physical activity, healthier diet, lower alcohol use or being a non-smoker. Social support was explored in first appointments, with most participants identifying a supportive other. Reasons to involve others included companionship, positive feedback and health improvements for supportive others and participants. Some participants described family or friends as negative influences on their health. Conclusions Perceived social support may be an important facilitator for adherence to CVD medications, but there was limited evidence for an association between perceived social support and other CVD health behaviours in people with SMI. Harnessing positive social relationships within interventions should be considered as a strategy for encouraging uptake of CVD health behaviours in people with SMI. Further work is needed to develop interventions that increase social support and improve health outcomes for people with SMI who have limited social contacts.

Psychotherapy process research is important in developing technique and enhancing clinical skills. Silence, as an aspect of child and adolescent psychoanalytic psychotherapy, has been a neglected area of research, despite it being acknowledged as an often challenging yet therapeutically useful aspect of the work. This study aims to explore silence in adolescent psychoanalytic psychotherapy, by studying the emergence of silence in therapy sessions and the adolescents' views. Three Short Term Psychoanalytic Psychotherapies of adolescents with depression were sampled, and silences occurring in six sessions of each therapy were coded using the Pausing Inventory Categorization System (PICS). The study identified that in the three therapies sampled, on average almost one-third of session time was spent in silence, and that most of this silence was coded as 'obstructive'. The study also found that the change in silence amount through each stage of therapy was different in each patient-therapist dyad. Follow-up interviews conducted with the adolescents were analysed using thematic analysis and found that the adolescents expressed negative feelings about silence in their therapy. Findings from the follow-up interviews were related to silence and outcome data to suggest processes that may have been taking place in each of the therapies. A key hypothesis was that the majority of the silence in the therapies sampled appeared to relate to conflict, which could be viewed as both an aspect of the developmental stage of adolescence, and a symptom of depression. Clinical implications of the findings indicated that long silence do not appear to be useful in adolescent therapy in the way they are considered to be in adult therapy, and so adaptation of therapeutic technique is required.

Hearing voices (also known as auditory verbal hallucinations) can be a distressing experience. Negative beliefs about voices are associated with negative emotional and behavioural consequences. It is important to understand peoples' experiences with voices and the different stages of managing them. However, there is no conclusive empirically supported theoretical model illustrating the phases that individuals may encounter when coping with their experiences over time. Typically, research has focused upon retrospective accounts of voice hearing. The aim of this dissertation was to develop an empirically supported model of the stages of voice hearing. This was achieved by examining service users' experiences with voices over time, identifying different phases of managing voices, and exploring how these phases affected therapeutic intervention. Chapter one is an introduction to the research in this area. Chapter two outlines the methodological processes and issues within this programme of research. Chapter three provides a systematic literature review of longitudinal studies examining distressing voices in clinical populations. Chapter four examines time one interviews and discusses the barriers and enablers to the disclosure of voices. Chapter five reports the findings from interviews with clinicians and explores the barriers and enablers to starting and continuing a conversation about voices with service users. Chapter six presents a model developed from an integration and evaluation of existing models in relation to data generated from interviews conducted longitudinally. Chapter seven summarises findings, discusses the theoretical and clinical implications, outlines the limitations of the programme of research and proposes future directions to continue the research.

This thesis examines ‘patient publications' produced at various points in the period between 1844 and 1918 within three particular mental health hospitals in England and Scotland, in order to explore how creative expression was used by staff and patients in treatment and recovery. My analysis, based upon a body of new archival research, is structured around a collection of case studies: New Moon, the journal produced by the patients at Crichton Royal Hospital at Dumfries from 1844 until 1937; Under the Dome, the patient and staff magazine of London's Bethlem Royal Hospital published from 1892 to 1920; and The Hydra, created by patients at the Edinburgh institution, Craiglockhart War Hospital between 1917 and 1918. By focusing on select numbers of these magazines - the first twelve issues of New Moon, the 1892 to 1903 numbers of Under the Dome, and the full catalogue of the short-lived The Hydra - in chronological order, the thesis analyses the limited runs of these magazines as diverse literary and historical objects, and explores the ways in which the titles demonstrate the development of the patient publication form. Following archival work on a range of patient publications in the period 1837 to 1995, these three publications were selected for analysis owing to their demonstration of the diversity and development of the patient publication form. The analysis of these three publications - as distinct but thematically related literary objects, and as representational of the wider chronology of the form - provides an inquiry into both the individual journals and their roles within the ‘asylum journal' format, and also into the format itself. The thesis aims to open up discussion of ways in which patient publications demonstrate newfound emphasis in sanatoria on creative expression in mental health care during this period. The study demonstrates ways in which individual hospital's ‘asylum journals', as complex products and reflections of their institutions, and the different expressions that the format has taken, variously represent ideological changes -specifically the introduction and development of moral treatment or moral therapy and its emphasis on humanitarian interactions between patient and staff - in asylum healthcare during the period. While acknowledging the discursive impact of the mental health institution on those who created writing and visual art for these titles, this thesis aims to centralise the voices and creative expressions of the patients in its analysis of New Moon, Under the Dome, and The Hydra.

This study explores the therapeutic mechanisms of Dance Movement Psychotherapy (DMP) in an in-patient setting for acute adult psychiatry through the qualitative dynamics of movement and the symbolic and metaphoric processes expressed during DMP sessions. Previous research has focussed on efficacy of DMP in relation to psychosis spectrum disorders, but there is little research on the mechanisms of DMP or the specific role of the moving body. The practitioner-researcher delivered weekly group DMP sessions of 90 minutes over ten weeks on two single gender in-patient wards in an NHS hospital. The dynamics of movement were evaluated using two aspects of Kestenberg Movement Profile (KMP), a movement notation instrument, related to complexity of relationships and ability to cope with the environment. The exploration of symbolic and metaphoric processes drew on self-reported questionnaires, case vignettes and psychotherapy process notes. Participants in the sessions echoed previous work in demonstrating an altered sense of space and time. Movement analysis, however, complemented previous work by indicating a specific imbalance in engaging with the future and the past. The study revealed several gender differences in the use of space and sense of self. Both men and women’s movement in the space lacked structure, a lack compensated through the movements of the practitioner-researcher. Participants expressed their sense of self differently by gender, such that men engaged more with one another as a group and women focussed more on the individual bodily self. Symbolic and metaphoric communications indicated a relationship between an altered sense of space and time, and the movement dynamics present that acted in synchronicity with the symbols and metaphors. The study draws out several implications for practice and practitioners of DMP including how to tailor intervention to help re-balance the altered sense of space and time with potential impacts on improved sense of agency.

Part one: Literature Review The aim of this review was to summarise and examine the literature on parent self-efficacy in parents of children with learning disabilities. Literature searches identified 9 studies which were included in the review. Due to the diversity of the papers reviewed, a synthesis of the methodological issues and review findings was completed. Despite the methodological weaknesses described in the review, there appears to be a growing body of evidence to suggest a relationship between parent self-efficacy, parent stress and child behaviour in parents of children with learning disabilities. Part two: Research Report A correlational design was used to examine the relationships between parent perception of self-efficacy, perception of behaviour and parent attribution in parents of children with learning disabilities. Participants were recruited from specialist schools and via a national learning disability website and a total of 18 parents participated in the study. Correlational analysis revealed a significant correlation between parent self- efficacy and perceived severity of behaviour, particularly hyperactive behaviour, and higher levels of parent self-efficacy were associated with lower levels of child behaviour difficulties. Higher levels of perceived child behaviour difficulty were not associated with attribution of cause of behaviour to the child and attribution of cause of behaviour was not associated with parent self-efficacy. Child emotional difficulties were associated with attribution of the cause of the behaviour to the situation rather than the child and higher perception of child pro-social behaviour was associated with higher levels of belief of child ability to control behaviour. Parents of children presenting with high levels of prosocial behaviours were related to attributions of the cause of behaviour to specific situations. Part three: Critical Appraisal An appraisal of the research process was undertaken. This included personal reflections, challenges of completing the research, learning points and recommendations for future research. Part four: Service Evaluation A mixed methods design was utilised to evaluate the efficacy of an intensive support service with one family (a pilot). The evaluation consisted of two parts. Part 1 aimed to evaluate child behaviour change, parent perception of ability to understand and manage child difficulties, and attainment of goals identified by the parent prior to the intervention. Part 2 utilised a focus group to capture staff experiences of working within the intensive support team and to elicit team recommendations for future development of the service. The findings from the evaluation did not show a significant change in child behaviour, however, substantial progress was made towards the goals highlighted by the parent prior to the intervention and significant increase in parent perception of self- efficacy was reported. Team experiences of the intensive support service and several recommendations for the future development of the service were summarised and described following the focus group meeting.

Short-Term Psychodynamic Psychotherapy (STPP) has developed as a form of intensive, focal psychodynamic psychotherapy with treatment applications across a range of mental health disorders. The concept of 'ego capacity' has a central place in STPP, based upon a core principle that accelerated treatment is enabled through working at an optimum level of a patient's ego capacity. Precise evaluation of ego capacity is required to determine choice and application of treatment interventions. Theoretical underpinnings suggest change and improvement in ego capacity are expected during and at the end of treatment. Although core to theory and practice of STPP the evaluation of ego capacity has attracted limited research and remains difficult to undertake clinically. The study aimed to derive knowledge and understanding of the evaluation of ego capacity in the clinical practice of STPP. A five-stage ethnographic method was undertaken with an expert practitioner group. Interviews and analysis included video-based adapted Interpersonal Process Recall procedures. Informants were enlisted in reflexive analysis of their own data to uncover explicit and implicit practices and understandings used in routine evaluations of ego capacity. Ego and ego capacity were differentiated and described as units of knowledge. A framework for the evaluation of ego capacity was developed that comprises levels, dimensions and indictors used in the evaluation of ego capacity. Dimensions and indicators within the framework contained an observational focus used to differentiate between levels of evaluation of ego capacity. This development has implications for practice, theory and research.

There is limited available research on the lived experience of hallucinations; with most existing research focusing on unimodal auditory hallucinations. Two systematic literature reviews suggested future research should study hallucinations across multiple modalities, their co-occurring feelings, and the circumstances and personal histories they arise within. To develop a conceptual lens, methodological approach, and research design to study these novel areas, theories of feelings (Cromby, 2007, 2015; Langer, 1967) and feeling-traps (Cromby & Harper, 2009; Scheff, 2012) were drawn upon alongside embodiment research scholarship (Ellingson, 2017; Reavey, 2011). Sixteen service-users from an NHS early intervention in psychosis service experiencing hallucinations most days, took part in a four-stage research design for up to eight weeks. This generated prospective and retrospective data on hallucinations arising in any modality through semi-structured interviews and arts-based methods of completing a visual diary with micro body-maps (for one week), an arts-based task and a visual life-timeline. This generated the first known body-maps of the feelings experienced during hallucinations. Participants reported unimodal and multi-modal hallucination experiences, which were characterised by a variety of feelings (emotional, extra-emotional, of knowing, of reality, generalised or localised within the body) and were situated in participants' unique lived circumstances and ongoing personal histories. The analysis demonstrated numerous novel aspects of circumstances in Britain were relevant to the lived experience of hallucinations including: time, location, company, activities, spirituality, digital technology, adverse and positive childhood experiences, education, work and employment, material (in)security and welfare, homelessness, drugs and alcohol, inequality and discrimination, and formal and informal networks of care. Future research and interventions aiming to reduce distress, may appropriately seek to prioritise improving the lived circumstances which people are struggling to navigate. Future hallucination research may also benefit from the application of feeling theories and the current research protocol which effectively generated a comprehensive dataset.

Psychiatric disorders are among the leading health concerns worldwide, with one in four people being affected by a mental health problem at some point in their life. While the economic burden has been on the rise, progress in treatments have remained stagnant due to the complexity of such disorders. To gain a better understanding in the aetiology of psychiatric disorders, in this thesis, I investigated the relation of environmental factors, genetic variation and methylation with brain structure/function and reinforcement-related behaviour and psychopathology. This work aims at (i) characterising mechanisms by which environmental influences, including psychosocial stress exert their effects on behaviour, (ii) identifying epigenetics/genetic markers related to behaviour and development of psychopathology, and (iii) examine how brain structure/function could relate the underlying biological mechanisms associated with behavioural outcomes. In the first half of this thesis, I examined the effects of DNA methylation in the longitudinal IMAGEN imaging - genetics cohort of 2000 adolescents and related them to measures of psychopathology relevant for different psychiatric disorders, including substance use. In two separate epigenome-wide studies, novel biological mechanisms underlying substance use wereidentified: allele-specific differential methylation of SPDEF (Chapter 3) and longitudinal differential methylation of roughly 11,000 genes (Chapter 4) were found to be associated with adolescent alcohol consumption respectively. In both studies, changes to the brain were also found to be involved in the gene-behaviour relationship. The second half of this thesis, I investigated the translational aspects of biological mechanisms underlying behaviour and psychopathology. In collaboration with other research groups, I replicated novel findings of alcohol-associated DLGAP2 methylation in post-mortem brain tissues (Chapter 5) and alcohol-related effects of SMPD3 in mice (Chapter 6), in normal human populations drawn from both the IMAGEN cohort and UK Biobank respectively. With virtually no progress in development of novel treatments over the last couple of decades and a constant increase in burden of psychiatric diseases, it is pertinent that psychiatric research aims at improving psychiatric nosology and discerning psychiatric pathology. Overall, this thesis contributes to existing literature and highlights the importance of multimodal approaches into better understanding the complex biological underpinnings of psychiatric disorders such as substance use.

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

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

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

Schizophrenia is a severe neuropsychiatric disorder which is within the top ten causes of disability in the developed world. While we currently do not fully understand the aetiology of schizophrenia, a wealth of genetic, epigenetic, and epidemiological evidence suggests a neurodevelopmental origin, and that dysregulation of the immune system and infection can play a role in aetiology. This has been supported throughout the last decade and the “big data” revolution. Genetic and epigenetic data gathered through genome and epigenome wide association studies, have identified over 100 genetic risk loci for schizophrenia. Further to this there have been a number of epidemiological studies examining the effect of environmental risk factors to schizophrenia. However, many of these genetic, epigenetic, and environmental risk factors have no clear mechanism by which they cause disease. Many of these studies published present evidence for the “risk factor” involvement but fail to validate their findings in model systems, to establish how these risk factors cause disease. The main aim of this thesis was to develop functional assays and methods to validate genetic, epigenetic, and environmental risk factors in human cellular based models to elucidate how these risks can contribute to disease. From this work I have developed a protocol for knocking out risk genes, and have identified a role for the schizophrenia risk gene AS3MT in neuronal development. I have also developed several pipelines to validate epigenome wide association studies, and link how changes in DNA methylation can affect gene expression, at both the regional level and at individual genomic loci. And finally, I have examined what effect, if any, the active component of cannabis, which is an established environmental risk factor for schizophrenia, has on the DNA methylome, to understand how environmental risk can cause disease. In summary, the work presented in this thesis represents the movement from large scale (epi)genetic analysis and statistics to functional lab validation. This thesis contains several methods for the functional validation of identified (epi)genetic risk loci and risk factors for schizophrenia in a cellular model. From this we can now begin to explore how these changes in genetics, epigenetics, and environmental risk factors biologically link to the development and progression of schizophrenia and other neuropsychiatric disorders.

Types of homelessness are wide-ranging and can include street homelessness, staying in temporary accommodation like shelters or hostels, and unsuitable accommodation like squats, tents or other temporary dwellings (Bramley, 2017). A vast amount of time, money and resource has been allocated to determine the causes of homelessness, but the problem persists. A recent count of rough sleepers in the United Kingdom shows a rise of 134% over the preceding six years (National Audit Office, 2017). For the homeless individual, the realities of being unhoused are in stark contrast to the average housed individual: increased risk of long-term physical health problems (Homeless Link, 2014), cognitive and neurological impairments (Backer & Howard, 2007), and mental health difficulties (Rees, 2009). Homeless individuals are also at great risk of physical and sexual assault (Breakey & Fisher, 1990) and more likely to develop suicidal thoughts and behaviours over time than the general population (Eynan et al., 2002). There are systemic consequences of homelessness, including an increased spend by health services; an estimated £85 million per year (Department of Health, 2010). Despite various strategies to both prevent and intervene, homelessness remains a significant problem for health and social care agencies and a challenging moral dilemma for society. Although there is a significant body of research examining the antecedents of homelessness, the multi-dimensional and systemic factors that can lead to a person becoming homeless are often denied or minimised. This can create a situation where society perpetuates the problem of exclusion that it seeks to alleviate (Jordan, 1996; Wilkinson & Pickett, 2009; Cooper & White, 2017). This can lead to demoralisation and disappointment among front line support staff working in services (Adlam, Kluttig, & Lee, 2018). Responses to lack of success in services reaching out can vary but can lead to the individual retreating further from reach (Armstrong, 2018) and services becoming increasingly difficult to access (Fitzpatrick & Pleace, 2012). The systematic literature review (Chapter One) sought to explore the contribution of the Capability Approach to the provision of mental health services. The Capability Approach is a human development framework which has contributed to the advancement of social justice and a recognition of the interaction of micro, meso and macro factors on an individual’s health and wellbeing around the world (Nussbaum, 2011). The application of the approach to mental health is more recent, and to date, there has not been a comprehensive exploration of how this approach has been applied to mental health services. The research paper (Chapter Two) addressed the experiences that formerly homeless individuals had in seeking help and support, and also asked professionals working in homeless services what it was like to provide services to homeless people. The systemic barriers and individual challenges were discussed. A qualitative methodology was used to capture the experiences of both groups of participants, using 1:1 interviews for individuals with lived experience, and focus groups with professionals.

This portfolio represents the research component of four years’ training towards qualification as a psychotherapeutic and counselling psychologist (PsychD) at the University of Surrey (UK). A brief introduction outlines my interest in and approach to the chosen topic area; namely, music performance anxiety (MPA). This is followed by a research development dossier consisting of three separate projects: Year 1: a critical literature review exploring how MPA has been examined in extant research; Year 2: a quantitative, cross-sectional enquiry which draws on attachment theory to examine associations between attachment patterns and MPA, and the extent to which any such relationship is mediated by perfectionistic behaviours, and Year 3: a critical discourse analysis (CDA) exploring the ways that performing musicians construct their experiences of MPA.

This thesis consists of a literature review, a research paper and a critical appraisal. The focus of this thesis is to understand the impact of welfare reform and austerity on individuals, with particular focus on mental wellbeing. In attempt to explore the impact of stigma on individuals who claim benefits a qualitative metasynthesis of 18 papers was completed. Findings demonstrated that individuals experienced multiple levels of benefit stigma, that stigma had social and emotional impact, individuals adopted various strategies to manage their stigmatised identity and that benefits stigma created an atmosphere of distrust and suspicion within communities. The research paper specifically explored the impact of applying for Personal Independence Payment (PIP) on mental wellbeing. PIP is a form of disability benefit introduced under the Welfare Reform Act. Thematic analysis of qualitative data yielded from 16 interviews led to the development of six related themes: 1) PIP is ‘gruelling’ throughout: designed to frustrate?; 2) ‘Treated like a criminal’ - a dehumanising, criminalising process; 3) ‘It’s life threatening for some people’ - impact of PIP on mental health; 4) ‘It feels like they’re trying to cull the weak’- lacking a sense of belonging and worth in society; 5) ‘They need to make improvements’ –how PIP could be improved. These findings captured the distressing nature of the PIP process. Finally, the critical appraisal provides a reflective stance on a central issue underlying many of the recommendations made within the literature review and empirical paper- the role of Clinical Psychology in politics and social justice. It is argued that psychological thinking can offer unique insight into some of the most pressing issues society faces. Therefore we have a responsibility to contribute our research findings and our theoretical understandings to public, social and political debates.

This thesis offers a critical exploration of the roles played by ideas of space and containment in psychotherapy. A wide range of existing approaches to the notion of therapeutic space in depth psychology are presented (particularly Freudian, post-Freudian, Jungian and post-Jungian perspectives). The dominant models of containment in psychotherapy are then interrogated. The thesis discusses these models from different perspectives, drawing on various disciplines, such as art, social studies, cultural studies and philosophy. Specifically, the thesis aims to employ approaches derived from psychogeography, with a focus on the praxis of 'aimless walking', in order to shed new light on classical concepts of therapeutic space and containment in depth psychology and psychotherapy. It is asked whether and how we can progress to consider alternative models of therapeutic space, leading to the proposal of what the author terms 'psychogeotherapy'. This fresh approach is not offered as an instant solution to the problems noted with existing approaches, nor are such approaches inappropriately dismissed. A feature of the thesis is its analysis of various psychogeographical personal testimonies. The thesis is to be considered not only a critical piece of writing, but also a fresh and creative account of the work of psychotherapy.

The recently proposed Suicidal Drive Hypothesis challenges traditional perspectives regarding the relationship between suicidality and psychosis. It proposes a bidirectional framework in which suicidality may operate as a risk factor for, as well as an outcome of psychosis. Rooted within a context of threat responsivity, the hypothesis considers suicidality as an internally generated and self-directed threat and psychosis as an adaptive strategy which externalises this threat. Given encouraging preliminary evidence demonstrating suicidality – psychosis directionality the current thesis sought to explore the conceptualisation of internal threat, more broadly beyond suicidality, and to examine how psychosis varies in relation to it. A novel continuum of internal threat was modelled using data from the British Psychiatric Morbidity Survey (N = 8580). Exploratory and confirmatory factor analyses identified a correlated 4-factor structure of internal threat (low self-worth and subordination, depression, suicidal thoughts and self-harm) while subsequent factor mixture modelling revealed seven classes that in turn reflected graded levels of internal threat severity. Traumatic experiences and markers of social adversity conferred risk for class membership. Graded classes of internal threat severity were also modelled in separate population-based samples from the UK and Israel, using symptoms derived from established external threat (trauma)-related psychiatric phenomena (Complex PTSD and Borderline Personality Disorder) which, notably, have been meaningfully associated with psychosis. While clinical psychotic disorder status was associated mainly with extreme expressions of internal threat (i.e. suicidality), subclinical psychotic experiences (PEs) were associated with internal threat across the continuum from lower to more extreme levels. Furthermore, examination of PE connectivity at different levels of internal threat severity suggested an ‘evolving’ and ‘growing’ network of internal threat oriented psychosis. This thesis not only advances the Suicidal Drive Hypothesis but also introduces a broader conceptualisation of internal threat that may have applications beyond psychosis research. A broad array of clinical, theoretical and methodological implications of this research are considered throughout.

This study uses Interpretative Phenomenological Analysis to explore integrative psychotherapists' lived experience of recognising a personal blind spot in their therapeutic work. The five female participants aged between 42-60 years have between two and twenty years clinical experience. Each participant was interviewed on two separate occasions, with a period of one month between interviews. The inductive approach of IPA sought to capture the richness and complexity of participants' lived emotional experiences. Given the methodological challenges uncovering the implicit domain of participants' blind spots, researcher reflexivity served as a secondary but integral data source and provided the experiential context from which meaningful findings emerged. Three superordinate themes and seven subthemes emerged from the interviews: Feeling under pressure, Facing a Blind Spot and finding the missing piece, and Holding my own. Theme one explores participants' loss of self-awareness when personal vulnerabilities are triggered by client work. It also describes maladaptive coping skills such as avoidance, employed to cope with feelings of vulnerability and shame. Theme two describes the process of facing a personal blind spot where participants recognise the impact of their personal needs and history on their therapeutic work. Theme three describes how self-compassion helps participants develop an expanded sense of self-awareness and capacity to be emotionally responsive to their clients despite their personal difficulties. The findings suggest that when shame is hidden and unacknowledged, it impacts on therapists' ability to be emotionally responsive to their clients' concerns. Furthermore, unacknowledged shame is a primary cause of therapeutic ruptures in their clinical work. The study recommends that continued research be undertaken into resilience towards shame in order to prepare and protect therapists against the normative force of subjective negative self-appraisal when they experience feelings of incompetence in their therapeutic work. Some aspects of these findings can be found in previous research on countertransference with participants of varying experience and varying therapeutic modalities. Given the centrality of the therapeutic relationship as a vehicle for successful therapeutic outcome, research that furthers our understanding of therapist emotional resilience and personal efficacy can help guide training and supervision.

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

The main aim of this thesis was to explore therapist drift in the delivery of Cognitive Behavioural Therapy (CBT) in contexts outside the Anglo/European one. Since most of the research on therapist drift has come from these Anglo/European locations, this investigation was based on the premise that therapist drift could manifest differently in different cultural settings. In addition to these cultural factors, this thesis also aimed to explore what clinician-related variables could influence CBT delivery (e.g. anxiety, experience, age, personality), along with other patient-centred variables (e.g. patients’ emotional state, gender, ethnicity, and preferences within the CBT delivery process). For the purposes of this thesis, a series of empirical studies were carried out to explore therapist drift in the delivery of CBT in several countries, but with particular emphasis in Latin American countries. The studies consisted of: 1) A systematic review regarding cultural adaptations of CBT for Latin American patients; 2) A comparative study assessing therapist drift in Latin America and the United Kingdom; 3) A vignette-based study evaluating the influence of patients’ mood and gender and clinicians’ country of origin on CBT delivery; and 4) A comparative study of clinicians’ and patients’ perceptions of the importance of CBT techniques. The results from these studies indicated that different patterns of drift can be found in different cultural settings. These patterns can be influenced by both patients’ and clinicians’ characteristics. Clinicians are encouraged to identify whether these aspects are affecting their practice, and to take actions to reduce such impacts. Researchers are also encouraged to keep investigating therapist drift and its cultural underpinnings, so we can obtain better insight about how patients from different cultural settings might benefit from therapy.

Schizophrenia is characterized by the presence of several symptoms including social withdrawal, cognitive impairments and psychosis. Additionally, other less known traits are observed such as olfactory deficiencies, locomotor dysfunction and circadian and sleep disruption. It is unclear what are the factors involved in the progression and onset of these symptoms. Schizophrenia shows high heritability and several genes, among those that have been associated with this disorder, are related to calcium (Ca²⁺) signalling pathways. Genetically modified animal models of schizophrenia have started to be used to uncover the molecular and physiological mechanisms underlying the disease. However much remains to be elucidated. In this thesis the fruit fly, Drosophila was used to model some aspects of the classical and non-classical symptoms of schizophrenia, including olfaction, social interactions, locomotion, sleep and circadian locomotor rhythms. Characterisation of the previously proposed Drosophila schizophrenia model based on the Dystrobrevin binding protein-1 (DTNBP1), Dysbindin (Dysb) mutant, was used as a proof of principle. The results were compared to characterisation of two new genes associated with schizophrenia: the Rab-3 interacting molecule-1 (RIMS1) and the calcium channel subunit α1B (CACNA1B) called Rim and cacophony (cac) respectively in flies. Manipulating the expression of these genes had different contributions to behaviours that were reminiscent of some schizophrenia behavioural symptoms. Olfactory performance was assessed using single-fly video tracking exposed to an aversive odorant and social interactions were assessed by using a social space paradigm to measure the clustering of the flies. Both, olfaction and social behaviours were reduced in the Dysb and Rim mutants. Moreover, the effect of Rim on social behaviour was explained by a dysfunction in the olfactory system, accompanied by reduced terminal area and impaired Ca²⁺ handling of the projections sent by the antennal lobe projection neurons (AL PNs) reaching the lateral horn (LH). Rim and cac manipulations differentially contributed to learning and memory which was assessed by an aversive olfactory conditioning assay. Rim knock-down in the mushroom body spared memory, while cac knock-down impaired short- and intermediate-time memory. The memory defect of cac mutants was explained by impaired Ca²⁺ handling namely reduced Ca²⁺ influx upon a depolarizing stimulus. Using the Drosophila Activity Monitoring (DAM) Rim and cac mutants were shown to display circadian rhythm and sleep deficits. The changes observed in the Rim mutant were accompanied by impaired day/night remodelling of the small-LNvs (s-LNvs) dorsal terminals and impaired day/night PDF neuropeptide release. The results of this thesis add more information to the role of synaptic proteins related to Ca²⁺ signalling in schizophrenia-like pathology. Moreover, this work demonstrates the suitability of Drosophila genetic models to help understand the molecular and physiological basis of schizophrenia.

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

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

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

This DClinPsy thesis has been written in the format of three papers: a systematic review, an empirical paper and a critical reflection paper. Papers 1 and 2 will be submitted for publication in the journal entitled Research in Autism Spectrum Disorders. Paper 3 is not intended for submission. Paper one presents a systematic review investigating the relationship between Restrictive and Repetitive Behaviours (RRB) and anxiety symptoms. Paper two presents a quantitative study which explores the mediating role coping style has between autistic traits and symptoms of anxiety. Paper three presents a critical reflection on the process of conducting the research along with the methodological strengths and limitations contained in this thesis. The implications of the research for clinical practice and the relevance for clinical psychology are discussed.

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

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

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

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

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

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

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

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