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Depression is one of the leading causes of disability worldwide and its prevalence has increased further during the COVID-19 pandemic. There is a need for effective treatments that can be easily and cheaply disseminated worldwide. Behavioural activation is known to be an effective intervention for depression which can be disseminated by non-specialist practitioners. However, its exact mechanism of action is currently unknown, which impedes our understanding for how to deliver it most effectively. The aim of this thesis is to examine the efficacy of a 4-week course of non-specialist behavioural activation and to investigate its possible mechanisms of effect. To this end, two experiments were carried out with participants suffering from low mood. The first study examined the intervention in an online video format during the COVID-19 pandemic and compared it with a passive control group. We examined its effects on self-reported measures of mood and found significant improvements on measures of depression, activation, state anxiety and anhedonia. We also found that the intervention led to a more positive affective bias on accuracy and misclassification measures of the Facial Emotion Recognition Task. Moreover, early changes on emotional cognition correlated with later improvements in depressive symptoms. The results of this study indicate that this format of behavioural activation can not only be effective during a global pandemic, but its effects may be carried out through early changes in emotional cognitive processing, which could help us predict who it will be most suitable for. The second study compared the intervention to both an active control group, which only carried out activity monitoring, as well as a passive control group. We again found that behavioural activation had significant beneficial effects on self-reported measures of mood and activation in comparison to both of the groups. Activity monitoring on its own also led to significant decreases in depression symptoms, albeit to a lesser extent than behavioural activation. We did not replicate the emotionally cognitive effects from the first study, possibly due to reduced power as a result of technical and COVID-19 related disruptions to the data collection. We found that early increases in environmental reward predicted future decreases in depression symptoms, indicating another mechanistic factor that may be important for the success of behavioural activation. We found no significant effects of the two behavioural interventions on actigraphy parameters indicating participants' physical activity and circadian rhythm. Early changes on these parameters did not predict future depressive symptoms, suggesting that they may not be mechanistically involved. In conclusion, both of the experiments clearly showed that a 4-week format of non-specialist behavioural activation can provide significant benefits on self-reported mood measures. Moreover, activity monitoring on its own may be a useful intervention for depression. These findings can inform policy related to mental health provision during societal crisis periods and other times of unusual strain on mental health services. Reward processing and actigraphy factors did not appear to play a mechanistic role in behavioural activation. Further replication is needed to clarify the effects of the intervention on emotional cognition and environmental reinforcement, which may be promising mechanistic factors allowing for prediction of treatment success.

Critical Review of the Literature: Attachment Patterns and Autobiographical Episodic Memory Functioning: A Systemic Review of Adult Studies to Advance Clinical Psychological Science. Patterns of insecure attachment are associated with psychopathology but the mechanisms involved remain poorly understood. Cognitive science proposes that attachment patterns are influenced by the autobiographical memory system and in turn influence its ongoing functioning. Disturbances in autobiographical memory represent cognitive risks for later emotional difficulties. We systemically reviewed 32 studies (in 27 articles) examining the association between attachment patterns and autobiographical episodic memory (AEM) in individuals from the age of 16 (i.e., from young to older adulthood). Attachment patterns were associated with key areas of AEM phenomenology, including intensity and arousal; detail, specificity, and vividness; coherence and fragmentation; and accuracy and latency. These associations appeared to be moderated by contextual and individual factors; mediated by emotional regulation and schema-based processing; linked to mental health outcomes. Attachment patterns may also influence the impact of certain AEM-based manipulations. We conclude by providing critical discussion and a research agenda for bringing together attachment, memory, and emotion, with a view to promote mechanism-driven treatment innovation in clinical psychology. Service Improvement Project: Assessment of Digital Risks in Child and Adolescent Mental Health Services: A Mixed-Method, Theory-Driven Study of Clinicians' Experiences and Perspectives. Children and adolescents in the UK spend increasingly more time in the digital world, raising societal fears about digital risks in this age group. Professionals are not always aware of the ever-developing research or guidance available around digital safety. This gap underscores the need to understand current experiences and determinants of digital risk assessment, including clinicians' views on barriers and facilitators. A mixed-method design was used. Fifty-three clinicians working in child and adolescent mental health services (CAMHS) in South England took part in a survey; of these 12 took part in semi-structured interviews. A psychological model of behavioural change (COM-B: capabilities, opportunities, motivation, and behaviour) guided the analyses. Survey data revealed that clinicians showed awareness and concerns for several digital risk issues but there appeared to be gaps in their knowledge and practice. Interview data revealed different factors influencing staff enquiry about digital risks in CAMHS. These included aspects of capabilities (knowledge and skills), opportunities (resources, organisational context, and empowerment of youth), and motivations (habit change, emotional experiences, and professional identity/role). Targeting both staff-level and organisation-level barriers to digital risk assessments in CAMHS is crucial. This study informs service improvement to ensure that children and young people safely navigate the digital world. Main Research Project: Specificity of Episodic Future Thinking in Adolescents: Comparing Autism Spectrum, Childhood Maltreatment, and Typical Development. Autism and maltreatment are associated with seemingly overlapping difficulties across functional domains (e.g., social, emotional, and sensory) as well as high rates of psychiatric problems. A cognitive approach focussing on affect-laden cognition, such as episodic future thinking (FT), may inform the differentiation of these developmental differences and treatment innovations in mental health in these presentations. Three groups of adolescents aged 10-16 completed a newly adapted Autobiographical Future Thinking Test in an online written format. The groups were i) autism, ii) maltreatment, and iii) typical development (TD), matched in age, sex, and socioeconomic status. The maltreatment group generated fewer specific future events relative to the TD group, while FT specificity in the autism group did not significantly differ from the other groups. Lower FT specificity was associated with more depressive (but not anxiety symptoms), particularly in the autism group. Overall, these findings shed light on the cognitive profiles of both autism and maltreatment and indicate potential novel intervention targets for mental health. Our study also lays the foundation for future studies comparing these two development presentations with improved designs and a broader set of cognitive and clinical domains.

In the world of contact sports there is rising concern about the long-term effects of sport participation on athletes' brains. Apart from concussions, the repetitive subconcussive head impacts (RSHI) in sports have been suggested to be detrimental for brain health. RSHI in football are thought to be linked with the onset of neurodegenerative diseases, like Chronic Traumatic Encephalopathy and Alzheimer's disease. However, to understand how and why the athletes' brains might suffer in the long-term, we should first understand the acute brain changes caused by the potential risk factors for brain damage (concussive and sub-concussive impacts). The experimental studies of this PhD thesis aim to investigate the acute effects of heading, the main source of RSHI in football, on the brain functions of athletes, by using a mixture of sensitive neuroscientific modalities. Secondary data is used in this thesis for method development and to examine the broader problem posed by sport-related head impact. Chapter 1 expands on the aims of the thesis. Chapter 2 presents the current state of the literature on RSHI. Chapter 3 includes a scoping review of the literature on biofluid markers use to assess the effects of RSHI highlighting the high heterogeneity of the existing studies and providing guidelines for future studies. Chapter 4 includes an investigation of the injury characteristics and prognosis of sport-related traumatic brain injury (TBI). It highlights the seriousness of sport-related TBI and specifically sport-related mTBI, whose remaining effects can potentially be worsened by the burden of RSHI during play. Chapter 5 investigated the effects of RSHI on balance in various ways, providing no evidence of an effect, while chapter 6 provides evidence for associative memory changes caused by heading. The following chapters (7 & 8) attempted to further examine the alterations in cognitive functioning post heading and present the first EEG evidence that the cognitive functions of attention, memory and learning are acutely affected by RSHI. After showing that RSHI affect mainly association learning and attention processes and not affect response inhibition, motor control and motor learning, chapter 9 aimed to examine the replicability of RSHI effects on motor cortex inhibition, providing evidence of no effect. The outcome of this thesis is that RSHI have detrimental effects to athletes' cognition, mainly in the functions of learning and attention, while motor control appears to remain intact.

Background: Many people live with long-term conditions and subsequent difficulties with their mental health. Demand on psychological services is high, and initiatives need to address barriers to accessing these services. Group programmes use resources efficiently, but the relative effectiveness of different types of groups is unknown. This research adapted an evidenced-based acceptance and commitment therapy group intervention. It aimed to compare the feasibility, acceptability and preliminary effectiveness of this intervention, among specific-diagnosis and mixed-diagnosis groups. Methods A mixed methods pilot and feasibility study. Participants attended a specific-diagnosis or mixed-diagnosis group. The intervention comprised of 7, two-hour weekly sessions with an 8-week follow-up session. Outcomes included health-related quality of life, illness perceptions, depression, and anxiety, measured at baseline, post-intervention, and 8-week follow-up. Subsequently participants and health professionals (facilitators and referrers) attended qualitative interviews which explored their views on acceptability, informed by the Theoretical Framework of Acceptability. Results Both group conditions had similar improvements in psychological distress, illness perceptions and health-related quality of life, with significant improvements across time for anxiety, depression, energy, emotions, and general health. There was no overall differential effect of group, or a group by time interaction on any of the outcomes. Feasibility measures including retention (attended at least 3 sessions), true completion (attended all 8 sessions) and mean adherence rates were high and comparable across both group conditions. Acceptability was high across patient and health professional perspectives, with no marked difference between group conditions. Conclusions Pilot and feasibility testing revealed the intervention was feasible and acceptable in both group conditions. This preliminary data indicated a similar degree of improvement across group conditions. A randomised controlled trial and further comparative research is necessary to confirm tentative findings. This research indicates that services could flexibly plan their resources, based on patient need and capacity demands.

Medication adherence describes the health-related behaviour of the ingestion of medicines by those prescribed them, and in the manner prescribed by their Health Care Professionals. Non-adherence and poor adherence to medication regimes is a common, highly complex problem that contributes to substantial worsening of disease, death and increased healthcare costs. In 2003 the World Health Organization (WHO) declared it a major public health concern. There is a known psychological component to non-adherence and rates of non-adherence have been associated with patients' beliefs about medication, specifically doubts about the need for medicines and concerns regarding their use. There are no clear-cut, universally recommended, evidence-based guidelines or strategies to tackle the problem of adherence, but there is evidence to suggest that successful interventions often contain both cognitive and behavioural components, and when these are combined with traditional approaches (reminders and pill boxes etc.), outperform them. A novel intervention aimed at addressing non-adherence was designed using principles and techniques drawn, primarily, from Cognitive Behavioural Therapy (CBT), which could be delivered by healthcare professionals (HCPs) during routine consultations with patients about medicines. The intervention was taught to 93 HCPs. It was evaluated using parallel-design mixed methods, and utilised existing models for evaluating training impact, assessing various stages of outcome. Numerous quantitative and qualitative investigations revealed that HCPs were highly satisfied with the course, that their knowledge and skills statistically significantly improved and that this effect lasted for at least 6-months. Furthermore, aspects of job satisfaction statistically significantly improved from the beginning to the end of the course. Qualitative investigations at 6-months reported behavioural change amongst course attendees leading to helpful, productive consultations with their patients. Patients who had received a consultation with trained HCPs found them to useful and empowering with regards to choices and actions about their health and treatment. The final study failed to demonstrate a statistically significant improvement in self-reported adherence or beliefs change in regard to prescribed medication but showed trends that warrant further investigation.

There is a need to find better treatments for fibromyalgia and its primary feature chronic widespread pain (CWP), and to explore mechanisms by which current treatments work. This can be done by examining evidence from epidemiological studies and randomised trials. This thesis is comprised of five publications looking at behaviour and beliefs of people with CWP. It investigates alcohol consumption behaviour as a possible treatment for CWP by looking at population-level data. It also investigates current treatments, particularly how beliefs about treatments might affect outcomes, using data from a trial. The first paper looks at the association of alcohol consumption behaviour and CWP in an observational study. It found moderate consumption is associated with reduced risk of CWP and less pain-related disability in people with CWP. The next looks at the same association stratified by changes in alcohol consumption behaviour, as changes in drinking might be due to pain status rather than vice versa. It replicated the results of the first paper in people who had not changed their alcohol consumption behaviour. The third paper uses Mendelian randomization to determine the causal effect of alcohol consumption on the risk of CWP. This paper concluded observational study results do not represent a beneficial effect of alcohol consumption on pain. The fourth paper reports results from a randomised trial of cognitive behaviour therapy (CBT) and exercise for CWP to find out whether effects persist after completion of treatment. It found positive effects on self-reported health of CBT and exercise for people with CWP after treatment stopped. The final paper examined how patients' beliefs about treatment might affect outcomes. It found those with higher expectations for treatment effectiveness were more likely to report improvements. Findings show how studying beliefs and behaviours of people with CWP helps identify further research questions to improve treatment.

Centuries after it was first described, dissociation is one of the most poorly understood constructs in clinical psychology. Used interchangeably to signify either a symptom or an aetiological process, the term 'dissociation' has attracted multiple definitions incorporating a diverse range of experiences. The confusion conceptualising dissociation, as well as longstanding debates arising from significant theoretical and socio-historical challenges in the field, have contributed to the under-recognition of dissociative phenomena across clinical settings, and to difficulties researching the topic. As a result, the psychological mechanisms underpinning dissociation remain unknown. More precisely, to date, there are no cognitive models explaining the development or maintenance of dissociation that have been developed through extensive causal testing of proposed factors, and accordingly, there are no translational psychological treatments specifically targeting this construct. Furthermore, due to its importance in the field of trauma, dissociation has rarely been explored as a transdiagnostic experience in its own right, nor has there been full consideration of its influence across the spectrum of psychological distress. This omission may be particularly important in the field of psychosis, where there is increasing evidence that dissociation has robust links with positive psychotic symptoms, such as paranoia, delusions, and hallucinations. Dissociative experiences have even been implicated as a possible cause of such difficulties, as they create conditions ripe for uncertainty, misinterpretation, and distress. In the same way, dissociation has been suggested to sustain psychotic symptoms. Therefore, under-recognised in its own right, dissociation has until recently also been under-recognised in terms of its importance in psychosis, and is only now being explored as a potential novel treatment target. In order to overcome the legacy of decades of entrenched debates and confusion, new approaches to exploring dissociation are needed. Network analyses are based on network theory, which proposes that mental health problems can be understood in terms of patterns of activation between symptom 'nodes' connected in a network of conditional dependencies. Such analyses are gaining increasing popularity in mental health research and may be well-suited to providing fresh insights into dissociation as they allow the estimation and visualisation of inter-correlations between multiple variables at once. Some forms of network analysis may also benefit the field through the generation of novel testable hypotheses: directed acyclic graphs estimate the probable direction of effect between correlated variables using statistical probability and may therefore be particularly valuable in early-stage research. Aims The aims of this thesis are to clearly define the phenomenon of dissociation, demonstrate its importance in psychosis, and begin a scientifically robust interrogation of the construct which will inform the future development of a cognitive model. In order to achieve this, the first half of the thesis develops tools required for valid research from a cognitive perspective: a precise definition of the construct, and two self-report measures with which to assess dissociation and cognitive appraisals of dissociative experiences. In the second half of the thesis, state-of-the-art network analyses are used to locate dissociation within the wider context of mental health (including in relation to both common affective and psychotic experiences), and to begin determining the psychological factors underlying dissociation. Finally, key findings of the thesis are tested in the context of psychosis. Methods Data were collected from four participant cohorts: a small psychosis patient group (n=12, Chapter Two), two large online general population samples ('Mapping Dissociation in Mental Health': n > 8000, Chapters Three and Five; and 'Understanding Dissociative Experiences': n > 8000, Chapters Four and Six), and a large psychosis patient group ('Exploring Unusual Feelings', n=1038, Chapters Three, Four and Seven). Chapter Two uses a qualitative study of twelve NHS patients with psychosis diagnoses to better understand the lived experience, and hence describe the construct of, dissociation in psychosis. In Chapter Three, a systematic review of dissociative measures is carried out and triangulated with the results of Chapter Two in order to propose a novel theoretical framework which describes dissociation as it will be conceptualised for the purposes of this thesis. The theoretical framework is empirically tested via factor analysis of data from the Mapping Dissociation survey, generating a novel self-report measure of the new conceptualisation of dissociation. This measure is then validated using data from the clinical study Exploring Unusual Feelings. Chapter Four introduces a second psychometric tool: a measure of cognitive appraisals of dissociation developed with data from the Understanding Dissociative Experiences survey and validated using data from Exploring Unusual Feelings. Chapter Five explores the relationship of dissociation to other mental health presentations, including psychotic and affective symptoms. Data from Mapping Dissociation are modelled in two network analyses - a Gaussian graphical model and a Bayesian inference with directed acyclic graphs (DAGs) model. Chapter Six uses the same analytical methods to explore the relationships between dissociation and specific psychological factors in data from Understanding Dissociative Experiences. Psychological factors explored in this study include affect intolerance, perseverative thinking, anxiety sensitivity, alexithymia, and body vigilance. Finally, Chapter Seven tests the key findings from the previous two chapters in a large clinical patient sample (Exploring Unusual Feelings). Results Within the context of non-affective psychosis, dissociation is described by patients as having a negative impact on their relationships with other people, and on their existing mental health difficulties, mood, cognition, daily functioning, and sense of self (Chapter Two). As well as highlighting the significant difficulty inherent in describing their highly subjective nature, the results also reveal that a common denominator of participants' dissociative experiences is a felt sense of anomaly (FSA) where this is conceptualised as a subjective feeling of oddness or strangeness. Triangulation of these results with a systematic review carried out in Chapter Three leads to the proposition that FSA may take a number of 'forms' (e.g. unreality, unfamiliarity, detachment) and affect any of a range of 'domains' (e.g. perception of the external environment, experience of one's emotions). Empirically testing the proposed theoretical framework using factor analysis reveals seven key factors of FSA-dissociation: anomalous experiences of the self, body, and emotion, and altered senses of familiarity, connection, agency, and reality. The self-report scale developed in this chapter was found to be psychometrically robust in general population and clinical groups, and is therefore used as the primary measure of dissociation throughout the thesis. Chapter Four develops and validates a new measure of cognitive appraisals of dissociation and demonstrates its additional explanatory power above that of FSA-dissociation alone when predicting hallucinations and paranoia scores in a clinical group using regression analyses. These results, as well as the results of Chapter Five, support the hypothesis that dissociation has a causal influence on positive psychotic symptoms. In Chapter Five, network analyses find that dissociation is a probable cause of paranoia, grandiosity, and cognitive disorganisation. Dissociation is also found to have a robust relationship with hallucinations, but as with its relationship to depression and anxiety, the direction of influence is unclear. Network analyses in Chapter Six find direct relationships between dissociation and cognitive appraisals, safety behaviours, perseverative thinking, low general self-efficacy, and low alexithymia. Testing these candidates for potential maintenance mechanisms of FSA-dissociation in a clinical group (Chapter Seven) reveals direct relationships between dissociation and cognitive appraisals, safety behaviours, perseverative thinking, affect intolerance, and low alexithymia. The results of these network analyses also support the hypothesis that dissociation is related to lower wellbeing, and may cause psychotic symptoms: both paranoia and hallucinations had direct relationships with dissociation. Conclusions This thesis defines the construct of dissociation (as it is experienced in the context of non-affective psychosis) as having a core phenomenological experience of a felt sense of anomaly (FSA). Dissociative experiences of this kind are experienced as distressing, disruptive, and appear to be a probable cause of cognitive disorganisation, paranoia, and hallucinations. They may be experienced in relation to a range of 'domains' (e.g. one's body or emotions) and involve different 'types' of anomaly (such as unfamiliarity or detachment). Appraisals of such experiences typically include fears about social, biological, or psychological ill effects, as well as concerns about lack of control or agency. Such appraisals are important in the development and maintenance of dissociative experiences and may partially explain the effect of dissociation on psychotic symptoms.

People with experience of problematic alcohol use (PAU), cognitive impairment and alcohol-related brain damage (ARBD) seek help at Salvation Army community programmes. Realist evaluation, which inspired this research, encourages exploration of people's reasoning when resources are introduced into their lives. Realists anticipate varying intervention outcomes, expected and unexpected. Research findings may challenge but also provide evidence to create or strengthen interventions. This research sought evidence about 'what works for which people with PAU, cognitive impairment and ARBD in what circumstances in Salvation Army community programmes, how and why?' Findings related to micro-actions and outcomes, small steps rather than giant leaps, creating opportunities for salutogenic flow in the midst of rippling complexities associated with PAU and cognitive impairment. Flow arose in the non-judgemental intervention context where people repeatedly accessed basic need resources. Their generalised resistance resources strengthened and recovery-orientated sense of coherence grew. As recovery resources to others, peer credence was given to those who had "worn the T-shirt". The Salvation Army crucially provided the physical and social context where individuals seeking help could access core resources, provided by peers, staff and volunteers whose approach extoled, 'Three strikes and you're welcome'. People were offered realistic hope, with acknowledgement that though life's whirlpools could draw them back into PAU's depths, others could share experiences offering encouragement towards sustained recovery. Hope extended to people whose recovery seemed remote, their aspirations focusing on avoiding withdrawals and maintaining alcohol intake. Their hopes received daily fulfilment. Alcohol consumption continued through individual and peer group resourcefulness. Basic needs were met by staff, volunteers and peers offering stigma-free affirmation of worth. While not reaching the 'ease' end of the salutogenic continuum, the pull of the 'dis-ease' end precipice appeared held back. Supported by people to whom they mattered, those facing that precipice did not do so in isolation.

Schema therapy is a leading contemporary approach to treating mental illness. The therapy integrally uses self-report measures of negative schemas (“long lasting patterns of emotions, cognitions and memories”), and the negative parenting patterns that are linked to the development of these schemas. However, the negative parenting measures are insufficient, and there are no corresponding measures of positive schemas or positive parenting patterns. Study 1 focused on the development of a measure for positive schemas, the Young Positive Schema Questionnaire (YPSQ). Study 2 focused on the development of a measure for positive parenting patterns, the Positive Parenting Schema Inventory (PPSI). Finally, Study 3 empirically showed that the subscales of the Young Parenting Inventory (YPI) were not robust, and it provided a revised alternative (YPI-R2). For all three studies combined, community samples (n = 204 to 628) were collected from five countries in Asia (India, Indonesia, Malaysia, Singapore, and the Philippines) as well as the United States. The factor structure of the three instruments (the YPSQ, PPSI and YPI-R2) was stable in both Eastern and Western samples (in multigroup confirmatory factor analysis). All three scales showed prediction of mental health over and above what was possible with previous measures (incremental validity). The scales were not simply proxies for previously measured constructs (divergent validity). These scales also demonstrated significant associations with other established measures of parenting (construct validity). They also showed associations with negative schemas, well-being and ill-being (convergent validity). This thesis provides the tools needed to include a focus on positive as well as negative schemas and parenting patterns in both research and clinical practice. It also shows the benefits of so doing.

Bipolar disorder is characterized by episodes of mania and depression and serious suicidal risks. Recent studies reported high mental imagery susceptibility (general use of imagery in daily life and emotional impact of prospective imagery) in euthymic bipolar patients. This thesis aims to: a) replicate these findings in patients at different phases of bipolar disorder and with varying degrees of bipolarity, and b) explore how mental imagery susceptibility, ruminative processing, and behavioural approach system (BAS) sensitivity interact to amplify mood symptoms. Chapter 1 provides an overview of current theories of mood amplification and recurrence in bipolar disorders. Chapter 2 details the local validation of scales used in the thesis. Chapter 3 (Study 1) investigated whether mental imagery susceptibility, positive rumination and BAS sensitivity were elevated in remitted bipolar I disorder compared with major depressive disorder and non-psychiatric controls. Results suggested that these cognitive variables were elevated in remitted bipolar I disorder. Positive rumination also interacted with positive prospective images to predict bipolarity. Chapter 4 (Study 2) found that these cognitive variables were elevated in bipolar I disorder during manic and euthymic phases, compared to major depression. Further, the number of positive prospective images predicted recovery status and manic symptom severity. Chapters 5, 6 and 7 report that, compared with people without bipolar spectrum conditions, these cognitive characteristics were elevated in sub-threshold bipolar disorder (Study 3), individuals with high bipolar risks based on a behavioural paradigm (Study 4), and individuals with high familial risk (Study 5). Studies 3-5 confirmed that positive and negative prospective images interacted with rumination to amplify hypomanic and depressive symptoms respectively. Chapter 8 (Study 6) showed that suicidal flash-forwards function as a psychological escape from perceived entrapment and defeat in suicidality. Based on these findings, Chapter 9 proposes novel imagery-based techniques for targeting problematic imagery in bipolar disorders.

Background: Inflammatory Bowel Disease (IBD) is a group of chronic gastrointestinal diseases with a relapsing nature. The two main types are Crohn’s disease (CD) and ulcerative colitis (UC). Both CD and UC patients experience very similar and distressing symptoms: acute abdominal pain, vomiting, malnutrition, fever, fatigue, diarrhoea and rectal bleeding. These symptoms are disabling and have a severe impact on physical and psychosocial wellbeing. Around 30% of patients suffer from moderate to severe psychological distress and have difficulties coping with the illness even in remission. However, it appears that mental health is overlooked by clinicians who often focus on physical gastrointestinal symptoms only. Mindfulness-Based Cognitive Therapy (MBCT) is evidence based, group psychological intervention that has been successful in reducing depression and anxiety scores in patients with depression while improving overall quality of life. However, MBCT has never been tested in the IBD population before. PhD question: Can MBCT be used as an adjunct therapy to IBD symptom management, for improving IBD patients' general well-being and quality of life? Aims and objectives: The overall aim of the thesis was to develop and collate the evidence for a definitive randomised controlled trial (RCT) testing the effectiveness of MBCT for patients with inflammatory bowel disease (IBD). The thesis brings together six publications. The six publications were integrated into four objectives that collectively contributed in answering the overall PhD question. Results: The findings from the first three publications highlighted the disease-related concerns and psychological needs for patients with IBD. The findings from the last three publications highlighted how feasible it is to use MBCT in IBD and emphasised the IBD patients’ perspectives about MBCT. Conclusion: The thesis concluded that a definitive RCT of MBCT for IBD patients is both feasible and acceptable.

This thesis has been conducted in part fulfilment of the Doctorate in Clinical Psychology. It comprises two parts: a systematic review and an empirical research study. These are two distinct articles both aiming to provide insight into the challenges of late life depression. Firstly, the ageing population will mean that mental health services are likely to see an increase in older people with depression, many of whom will have neurological conditions common in late life, including dementia, stroke and Parkinson’s disease. These conditions have a high risk of depression associated with them. Addressing depression can have a significant effect on quality of life and at present there is limited evidence for effective treatments for depression in neurological conditions. Researchers and therapists have previously been reluctant to conduct psychological therapy with this population, however, there is preliminary evidence that psychological therapies can be efficacious for this population. CBT is structured, goal focused and orientated in the present therefore may be easily adapted for the needs of people with neurological conditions and associated cognitive impairment. Chapter one presents systematic review of this literature, titled ‘Cognitive and behavioural therapies for the treatment of depression in people with dementia, stroke and Parkinson’s disease’. Secondly, depression in the general older adult population will also present challenges for mental health services. Psychological therapies have been shown to be equally effective for older people as they are for younger adults. However, there are a range of gerontological issues that must be considered when working with older people. For example, cohort beliefs, interpersonal role changes and physical health changes may all impact on the way an older person conceptualises their difficulties. In particular, depression in older people has been associated with negative attitudes about ageing. Cognitive theory states that attitudes are mood-state dependent and if negative or dysfunctional attitudes are modified, this can result in improvement in mood. Exploring the attitudes of older people with depression will aid our understanding of late life depression and may provide useful information on whether attitudes to ageing should be specifically addressed during therapy for depression. The current research study explores attitudes to ageing with a clinical sample of depressed older adults and compares attitudes with non depressed control participants. Chapter two outlines the full methodology used in the research study and chapter three contains the research study, titled ‘Attitudes to ageing and clinical depression in older people’, presented within a journal article format.

Tools for measuring competence in delivering Cognitive Behavioural Therapy (CBT) provide a means of assessing the training of new CBT therapists and ensuring the quality of treatment provision within routine practice, provide a framework for delivering formative feedback, promote ongoing self-reflection, and are essential to establishing treatment integrity in research trials. As such, identifying an optimal strategy for assessing the competence with which CBT is delivered is crucial to the continued progression of the field. However, research in this area has been somewhat limited to date. Thus, there are at present no evidence-based best practice guidelines outlining the way CBT competence should be assessed. Furthermore, many of the assessment measures currently available have been widely criticised, indicating a need for improved tools for assessing CBT competence. To begin addressing this issue, the first two chapters of this thesis focus on reviewing and evaluating current assessment methods. Chapter one provides a systematic review of current methods of assessing CBT competence and chapter two outlines a qualitative exploration of experts’ understandings and experiences of assessing CBT competence. Findings from these studies provide tentative recommendations for practitioners and researchers assessing CBT competence. These initial studies also highlight ways in which the assessment of CBT competence could be improved and therefore provide a platform for guiding subsequent thesis chapters which focus on further developing existing assessment measures. Specifically, chapters three to six focus on the development and evaluation of a novel CBT competence rating scale: the Assessment of Core CBT Skills (ACCS). The ACCS builds upon currently available scales (especially the Cognitive Therapy Scale- Revised: CTS-R) to provide an assessment framework for assessors to deliver formative and summative feedback regarding therapists’ performance within observed CBT treatment sessions and for therapists to rate and reflect on their own performance. Development of the ACCS involved three key stages: 1- theory-driven scale development (chapter three), 2- an ‘expert’ review of the content validity, face validity, and usability of the scale (chapter four), and 3- an evaluation of the scale involving a pilot study examining its psychometric properties (chapter five) and a focus group examining its usability and utility (chapter six). Results from these studies indicate that the ACCS is a useful learning tool, is easy to use, has good psychometric properties, and offers an acceptable alternative to the CTS-R. Finally, chapter seven examines whether assessors require training in how to use the ACCS, concluding that simply reading the ACCS manual may be sufficient to achieve acceptable levels of reliability and usability. The results from the thesis are then drawn together in the final concluding comments in chapter eight, which discusses the findings within the broader context of the assessment of CBT competence.

The overarching aim of this thesis was to contribute towards the translation of a laboratory paradigm into a clinical intervention: that is, to develop a positive Cognitive Bias Modification (CBM) technique using mental imagery into an internet-based computerized intervention for people with clinical depression. Preliminary studies using an imagery-based CBM to modify interpretation bias in depression have shown significant effects of the CBM in alleviating depressive symptoms. We know very little, however, about the mechanisms underlying the beneficial effect of imagery-based CBM in depression. A particular focus of the current thesis was to explore the effects of imagery-based CBM on variables that were thought to contribute to symptom improvement: mental imagery, emotion and behaviour. Experiment 1 explored these effects in a sample of mildly depressed individuals, using a CBM paradigm in which participants were required to generate mental imagery in response to positive, negative or mixed (control) combinations of picture and word cues. Participants assigned to the positive imagery condition showed mood improvements as well as enhanced behavioural performance (fishing game task) and reduced cognitive bias compared to participants in the two other conditions. Further, positive imagery was rated as increasingly vivid as they went along with the training. Study 2 explored the possibility that the behavioural task (i.e. a fishing game) used in mildly depressed individuals to detect CBM-induced differences in behaviour could be associated with behavioural differences between individuals with various and clinical levels of depressive symptoms. The hypothesis was tested that in a sample of individuals with minimal to severe symptoms of depression, behavioural performance on the fishing game would be inversely related to the severity of their depressive symptoms. As predicted, participants with higher depression scores performed less well on the fishing game task than those with lower scores, and this association remained when controlling for other variables such as state mood. Experiment 3a and 3b constituted the first two pilot studies exploring the feasibility of delivering imagery-based CBM over the internet to individuals with clinical depression. In Experiment 3a, the imagery-based CBM was developed into an internet-based intervention involving 6 sessions of CBM that participants completed in their own home over a week. The Oxford Imagery Generation (OxIGen) program was piloted in a small sample (N = 6) of clinically depressed individuals, and qualitative data were collected to assess experience of the intervention. As a result, refinements were made to improve the intervention and enhance engagement. In Experiment 3b, the finalised version of the OxIGen program, which involved 12 sessions of online CBM completed over a month, was piloted in a small sample (N = 8) of individuals with clinical depression. Results showed high levels of acceptability and adherence. Three of the four participants allocated to the positive imagery version of OxIGen showed reliable levels of symptom improvement. The exploration of the effects of OxIGen on mental imagery, bias and behaviour provided a mixed picture. For example, the predicted change in vividness for positive future imagery and negative interpretative bias was only found in two of the four participants from the positive imagery group. Finally in Experiment 4, the effects of OxIGen on positive future imagery and behaviour were examined as part of a wider clinical trial involving a large sample (N = 150) of individuals with clinical depression. The larger scale of this study allowed a sufficiently powered test of the prediction that the intervention would lead to changes in specific features of imagery (i.e. vividness and likelihood of positive future imagery) and increases in behavioural activation. Further, the hypothesised link between positive future imagery and optimism was tested. The results examined whether the OxIGen intervention can induce changes at different levels of psychological functioning (i.e. emotional, cognitive and behavioural). It is discussed that the combined action of these changes may reinstate a positive feedback cycle that ultimately leads to symptom improvements. Existing resources are largely insufficient to combat the major health problem of depression. The development of a promising laboratory paradigm towards a clinical intervention is an important step towards the development of short and inexpensive forms of treatment that can be delivered to the hands of the many people who need help.

The theme of this project was synthesis and the thesis encompasses knowledge generation and knowledge translation. Systematic review methodology was employed. The initial two systematic reviews compared antidepressant medication and cognitive-behaviour therapy for the acute treatment of depression. A further comparison of a combination of the two interventions with each treatment on its own was also conducted, with the bulk of the evidence favouring the psychotherapy. Moving to the topic of knowledge translation, the main theme of the thesis, the barriers, facilitators, and interventions impacting on systematic review uptake were identified. The evidence from these three systematic reviews, using diverse methodologies, was then combined to identify the interventions that overcame specific obstacles and built on highlighted facilitators in order to improve the uptake of evidence from systematic reviews. Juxtaposing barriers and facilitators alongside effectiveness studies in this final, mixed-methods systematic review allowed a number of interventions to be recommended. The synthesis also allowed strategies to be highlighted that required further development. Interventions with a statistically significant effect such as educational visits, summaries of systematic reviews, and targeted messaging, addressed a wide range of the identified barriers and facilitators. These interventions were recommended. Promising uptake strategies requiring further development were also identified. Furthermore, large gaps in the evidence base regarding systematic review utilization were highlighted. Fewer of the facilitators identified as part of this project, such as the medico-legal protection provided by systematic reviews, appear to have been built on in order to increase review uptake. Finally, all the preceding evidence was drawn on in order to develop a proposal focused on improving the uptake of evidence from systematic reviews and meta-analyses. This doctoral project offers a menu or range of evidence-based factors that can be considered by organisations and researchers when planning strategies aimed at increasing the uptake of pre-appraised, synthesized evidence.

It is now widely accepted that the experience of pain is subject to cognitive influences that may determine the severity of subjectively perceived pain. Many of these top-down factors rely on memory-based processes, which in turn are related to prior experience, learned beliefs and behaviours about pain. As such, memory for pain heavily contributes to the physical pain experience. We posit that pain memory is bidirectional in that following each painful event a trace is stored and that these traces in turn may modify future pain perception prospectively. The following body of work explores aspects of what we have termed a memory template for pain. The results of these chapters taken together, examine these bidirectional aspects of short-term memory for pain employing a recall pain task. Specifically, we explore how, after an acute pain event, a short-term mental representation of the initial event persists. We show that during this time, sensory re-experiencing of the painful event is possible. Furthermore, we investigate aspects of recalled pain, namely intensity and vividness. Data suggests that the intensity and the vividness of this mental representation are determined by the intensity of the initial stimulus, as well as the time-to-test delay. We identify regions that characterise short-term memory for pain. Following on from studies in motor and visual imagery, we explore how pain imagery in the form of recall may affect subsequent pain perception. Our results demonstrate that the inclusion of pain-related imagery preceding physical pain events reduces affective qualities of pain. Testing healthy, naïve subjects, we replicate the effect observed in studies using attention management and imagery strategies, which normally require extensive training. Finally, in a cohort of neuropathic pain patients we show significant reductions in white matter connectivity between areas responsible for working and prospective memory. Collectively, these studies emphasise and elucidate the role of short-term memory of pain in physical pain perception. Acting both retrospectively and prospectively, cognitive reinforcement can increase or decrease the subjective feeling of pain, and therefore manipulating how pain is recalled may have therapeutic potential.

The need to provide effective Cognitive Behavioural Therapy (CBT) treatments in routine clinical practice necessitates effective methods of CBT training, which are scalable and can be disseminated in populations without ready access to specialist trainers or large scale funding. This thesis seeks to add theoretical and empirical guidance to the development of evidence-based CBT training. The first chapter reviews the current literature on effective CBT training, and suggests theoretical and methodological guidance for future research on evidence-based training practices. Cohort studies (Chapters 2 – 4) examine data from former trainees for guidance on accurate CBT competence measurement and effective CBT training components. The fifth and sixth chapters report randomised-controlled trials examining the effects of internet-based training (IBT) on therapists’ competence and patient outcomes (Chapter 6). Findings from the literature review (Chapter 1) and Chapter 2 suggested the need for training effectiveness trials using treatment trial methodology, which includes ‘blind’ observer ratings of therapist behaviour as the measure of competence. Chapter 3 found that extensive training led to significant improvement in competence for trainees with a range of individual baseline characteristics. Since such extensive training is not accessible to the majority of practicing therapists, Chapter 4 examined which elements of extensive training were perceived by trainees as having the greatest positive effect on competence; thus providing empirical guidance in planning more scalable forms of training, such as IBT. Findings from the first four chapters provided guidance in planning the two randomised controlled trials outlined in Chapters 5 and 6, resulting in rigorous empirical data showing significant positive effects of IBT on therapists’ competence and on their patients’ clinical outcomes. Finally, the results of this thesis are related to the framework for developing evidence-based training, which was suggested in Chapter 1 and suggestions for future research are made.

Catechol-O-methyltransferase (COMT) metabolises catechol-containing compounds, including dopamine. The aim of this thesis was to investigate whether COMT is involved in hippocampal function. This thesis also explored the role of functional polymorphisms within the COMT gene in the pathogenesis of schizophrenia and schizophrenia-related phenotypes. First, as part of a study investigating the role of COMT in schizophrenia, human hippocampal COMT mRNA levels were shown to be neither altered in schizophrenia or bipolar disease, nor affected by COMT genotype. Hence, functional COMT polymorphisms do not appear to operate by altering gross COMT mRNA expression. Importantly, this study showed that COMT is expressed in the human hippocampus. Second, the role of COMT in hippocampal neurochemistry was explored by studying the effect of pharmacological COMT inhibition on catecholamines and metabolites in rat hippocampal homogenates, and extracellularly, using microdialysis. Both demonstrated that COMT modulates hippocampal dopamine metabolism. Thus, hippocampal COMT is of functional significance with respect to dopamine. Third, the effect of COMT inhibition on hippocampus-dependent behaviour was investigated. The results suggested a memory-enhancing effect of pharmacological COMT inhibition on hippocampus-dependent associative and non-associative forms of short-term memory in rats. In contrast, acute COMT inhibition appeared to have no effect on behavioural correlates of ventral hippocampal function i.e. anxiety-like behaviour. In summary, the expression of COMT mRNA in the human hippocampus, as well as the effect of COMT inhibition on rat hippocampal neurochemistry and hippocampus-dependent behaviour provide evidence for a functional role of COMT in the hippocampus. Moreover, changes in COMT activity alter hippocampal dopamine metabolism, which could be a potential mechanism for the role of COMT in hippocampus-dependent short-term memory.

Patients with both depression and anxiety show an increased tendency to deploy attention towards negative information. Cognitive models of the illnesses predict that these negative attentional biases are causally related to the symptoms of the disorders. Consistent with this, modifying attentional bias using either antidepressant medication or simple, computer based training tasks has previously been associated with altered symptomatology in both non-clinical and clinical populations. The current thesis aimed to investigate the mechanisms by which attentional bias training tasks alter attention. The investigations were conducted within an experimental neuroscience framework which has previously been successfully deployed in studies of antidepressant medication. The thesis then sought to use these initial results to improve the basic understanding of attentional control processes and, ultimately, guide the development of novel treatment strategies. The initial studies of the thesis characterised the behavioural and neural effects of attentional bias training. Behaviourally, a high degree of generalisation of the training effect was found across a range of emotional stimuli. Neurally, training was found to alter activity in a network of prefrontal regions known to be involved in the control of attention. Further analysis, utilising a computational learning model, suggested that the attentional control systems identified in this study could be understood in terms of expectation based processes. These studies therefore indicated that, in contrast to the predominately limbic effects of antidepressant medication, training initially altered the response of frontal control circuitry. The later studies of the thesis investigated possible strategies for extending the use of attentional bias training. Firstly, combining training with antidepressant medication was found to produce an interference effect on emotional memory suggesting that administering both interventions concurrently is likely to erode their cognitive impact. Lastly, attentional bias training was found not to alter attention in patients with bipolar disorder, with the results of the study indicating that standard assessments of attentional bias in this clinical population are likely to be unreliable. Overall, these studies indicate that attentional bias training may be used to alter the top-down control of attention to emotional information and suggest that such effects may interfere with the bottom-up effects of antidepressant drugs. More generally the work demonstrates the utility of using a cognitive-neuroscientific framework to explore the mechanisms and impact of novel therapeutic strategies.

Selective mutism is a rare anxiety disorder that affects less than one percent of the population. This study will research the types of treatments, their effectiveness, and their effectiveness over time. Through a meta-analysis it was determined that modular cognitive behavioral therapy produces the best outcomes when it comes to reduction of symptoms. Integrated behavioral therapy produced the best results when looking at maintenance of treatment outcomes.

The following autoethnographic dissertation examines my personal experiences of trauma,abuse, and violence. Drawing on journals, memories, and artifacts from my life, I useself-reflection to illustrate the impacts of trauma on my childhood and adulthood. My traumaticexperiences of sexual abuse, childhood violence, and emotional abuse are situated within broadersociocultural contexts of masculinity, Hispanic culture, and social norms. This study illuminatespossibilities for healing and transformation for myself and others with shared traumaticbackgrounds. It calls for trauma-informed education, masculinity, and resiliency. Evocativelysharing my traumatic life events provides an accessible window into often silenced experiences,bearing witness to injustice while offering empathy, connection, and hope. This dissertation isavailable in open access at AURA (https://aura.antioch.edu/) and OhioLINK ETD Center(https://etd.ohiolink.edu/).

This study sought to identify dimensions of a song that might suggest its clinical relevance to the music therapy method-variation of song discussion as employed with adolescents with behavioral health needs. Additionally, I aimed to explore how those dimensions of a song interact with an individual and their unique clinical profile and thus may contribute to indications and contraindications for the use of this method-variation in treatment. Because much of the published literature on song discussion points to its efficacy, it seemed fitting that the next step would be to detail the various salient aspects of a song that a music therapist must give attention to when evaluating its relevance for a discussion experience. I carefully reviewed the music therapy literature on song discussion, reflected on my own process of choosing songs for discussion in my clinical practice with children and adolescents, and I consulted other music therapy professionals on their process of choosing song material for song discussion and incorporated this information into my considerations. In this report, I outline the 30 relevant dimensions I have identified as crucial to consider when examining a song’s potential for use in song discussion. The list of dimensions related to the lyric, musical, and nonmusical aspects of song selection for song discussion is intended to provide a general roadmap for music therapists and is not necessarily the ultimate or only resource that therapists may consult.

Social anxiety involves excessive fear when there is a perceived threat of negative evaluation (Wong & Rapee, 2016). Individuals with social anxiety tend to use maladaptive strategies to avoid negative evaluation, such as experiential avoidance (Asher et al., 2021) and limiting intimate self-disclosure (Alden & Bieling, 1998). Recent data suggest that individuals with social anxiety tend to prefer online communication to face-to-face communication (Kamalou et al., 2019). Other studies suggest that individuals with social anxiety experience similar levels of anxiety during online and face-to-face communication (Doorley et al., 2020). It is unclear how past findings generalize to videoconference communication or face-to-face communication with a protective face mask. The purpose of the current study was to compare how individuals experience unmasked videoconference and masked face-to-face communication. Sixty-four undergraduate participants with traits of social anxiety engaged in a 45-minute conversation task. Dyads were randomly assigned to complete the task in a masked face-to-face or unmasked videoconference condition and completed measures of state anxiety, perceived threat of negative evaluation, experiential avoidance, and self-disclosure intimacy following the task. Analyses suggested the unmasked videoconference condition was associated with greater state anxiety and experiential avoidance, whereas the masked face-to-face condition was associated with greater perceived threat of negative evaluation. There was no difference between the two conditions on the self-disclosure measures. The results indicate that masked face-to face communication and unmasked videoconference communication have different effects on psychological processes associated with social anxiety.

Attention is a cognitive process that, when stable, allows the mind to focus on relevant information. While attention can shift and fluctuate nonlinearly, research shows that a two-factor model can be used to capture the stability of selective sustained attention. Nevertheless, nonlinear dynamics of attention remain elusive under this two-factor model of attention. Hence, a one-sided focus on attentional stability undermines ways to control the processes of focusing and ignoring. To shed light on non-linear shifting in attention, I applied ideas from complexity science, a framework that anticipates such nonlinear phenomena. Specifically, I sought to apply a cusp model of selective sustained attention to explore the extent to which complexity science could be a useful approach to attention. The following demonstrates how a cusp model anticipates the presence of two orthogonal factors that align with those already identified in extant research on selective sustained attention. I also found that the empirical findings of selective sustained attention are conducive of fitting data to a cusp model. This research provides the first step in establishing a consistent framework for taking a dynamical complexity approach to the study of attention that inherently changes.

Cognitive Behavioral Therapy (CBT) for drug addiction is an effective treatment strategy, as a monotherapy and in combination with other therapies and treatment strategies. This phenomenological qualitative study described the struggles of adults diagnosed with opioid use disorder (OUD) and their experiences with how CBT strategies moved them to the contemplation stage of change in a residential treatment program. In the contemplation of change stage, the adults acknowledged that their opioid addiction behaviors are problems that need to be addressed, beginning with motivational interviewing. Utilizing the Cycle of Change Model (Prochaska and DiClemente), the Cognitive-Behavioral Theory (Aaron Beck), the Social Learning Theory (Albert Bandura), and the Theory of Planned Behavior (Icek Ajzen), this study sought to uncover the recovery process of patients with opioid addictions and analyzed the factors that influenced their addictions and behavior changes in CBT treatment. Interviews and focus group discussions were used to collect qualitative data, and thematic analysis was applied to develop a model to understand the effectiveness of CBT and persistence in recovery from opioid addiction. This model, derived from the theory of planned behavior, was grounded in the qualitative data and was significant in understanding the phenomenon of change, and how the change process was integrated into the lives of people addicted to opioids. Specifically, the model reflected the effectiveness of CBT in moving adults struggling with opioid addiction from the precontemplation stage of change where they did not see or acknowledge opioid addiction as a problem, to the contemplation stage of change where they were aware and acknowledged that their addictive behaviors may be problematic.

This study addresses the concept of religious doubt concerning those who embrace the Christian tradition, i.e., those who embrace the words and works of Christ, specifically the reality of the Resurrection, as true and efficacious for both salvation and spiritual formation. The existential crisis of doubting these truths is a consistent and significant issue addressed in both religious and secular circles driven by the desire to help the individual overcome the emotional distress associated with this phenomenon. This study is designating doubt that creates an existential crisis as emotional religious doubt (ERD), i.e., it is a species/variety of doubt that requires a specific approach for better treatment/counseling. Few studies, however, have addressed the species/varieties doubt concept and the significance of these designations to help both the counsellor and individual better navigate the anxiety produced by ERD. This study examines the literature surrounding religious doubt, the use of cognitive therapy (particularly REBT methodology), the importance of divine revelation as an epistemic axiom for the emotional religious doubter, and brings into question ability of REBT to produce long-term effects in the life of a believer. In doing so, it has argued that the best methodology for dealing with ERD requires the proper understanding and implementation of divine revelation as an epistemic axiom within the cognitive therapy approach of Rational Emotive Behavioral Therapy (REBT).

This study examines the social and cultural considerations in accessing mental health treatment in The Gambia, West Africa. Participants were recruited from The Gambia for a qualitative study that included semistructured interviews (N = 17). A team of analysts identified five themes. The results highlighted social and cultural conceptualizations of mental health and mental illness, sociocultural determinants of health, interventions, barriers to care, and the legal framework to support mental health change. These findings are important for counselors to understand different perceptions of mental health and mental illness and the associated stigma. Furthermore, several opportunities for advocacy in The Gambia have resulted from this study.

The central research question that informed this study asks: How do attachment and creativity focused counseling interventions encourage connection between an adolescent and their parent or caregiver? The research study centered on two mother and son dyads that participated in six weeks of a therapeutic intervention. The modality utilized an attachment and creativity focused approach created by the author. Data was collected through a post intervention semi-structured interview with the parent (adult). Data was transcribed and evaluated with an interpretive phenomenological approach. Six themes were identified by a team of researchers. The findings have implications for clinical practice with parents and adolescents presenting with a trauma history. In addition, the modality with an attachment and creativity focus could be further evaluated. This dissertation is available in open access at AURA (https://aura.antioch.edu) and OhioLINK ETD Center (https://etd.ohiolink.edu).

Spirituality is an essential and deeply embedded part of Black Americans’ psyche. The counseling field has largely overlooked the roles of spirituality and religious beliefs in the development of the consciousness of this demographic. In the treatment of Black Americans, particularly Black churchgoers, this can be a serious oversight. The purpose of this DMin action research thesis is to provide sufficient intradisciplinary integrative spiritual teaching to effect holistic coping strategies for Lake Providence’s Mid-Week Bible Study Service members. The goal is to bring healing through an intradisciplinary integrative teaching approach utilizing psychology, theology, and spirituality. If the members of Lake Providence’s Mid-Week Bible Study Service receive intradisciplinary integrative teaching, then holistic coping strategies could be created. This research was conducted utilizing Participant Response Questionnaires. Ten members of the Lake Providence Missionary Baptist Church who attend the Mid-Week Bible Study Service were chosen to form the sample group. Gathered data was reduced to create recurrent themes of spiritual relationship, transformation, faith, the Holy Spirit, and storytelling. Results demonstrated that a pedagogy addressing integrative techniques utilizing cognitive and narrative therapeutic approaches along with an emphasis placed on spirituality provided spiritual and psychological revelation and a behavioral assist for the interviewees. The desired influence of this thesis project is to add to the underrepresented literature on the impact spirituality has on the cognitive behavior of Black American churchgoers relative to affecting holistic life outcomes.

The Impact of Creative Arts on Meaning Reconstruction and Loss Adaptation in Widowed AdultsDani Baker-ColeAntioch University SeattleSeattle, WAIn counseling, helping grieving clients find meaning after significant loss is a unique, multidimensional, and lengthy process. This is particularly true in Western societies, where antithetical linear grief models, supported by hegemonic expectations to move on after loss, add exhausting pressure to speed up an individual’s natural grieving process. For that reason, this study examined how creative arts interventions such as using traditional art media and expressive writing, combined with postmodern, nonlinear, culturally sensitive bereavement models, help individuals explore their loss narrative to make meaning and adapt to loss. Specifically, this study examined the impact of a switch from traditional art media to expressive writing via a grief meaning reconstruction dependent variable. A quantitative, single subject multiple baseline model was used. Results suggested that such a switch had an impact. This dissertation is available in open access at AURA (https://aura.antioch.edu) and OhioLINK ETD Center (https://etd.ohiolink.edu).

The aim of the study was to explore the lived experience of counselor education and supervision students who reported experiencing symptoms of imposter phenomenon (IP). The population included counselor education and supervision students in their first year of their program, with a sample of convenience (N = 4). The method used in this study was an interoperative phenomenological analysis. Data analysis revealed four major themes: (a) counselor education students express self-doubt, lack of confidence and concern about competence, (b) students rate different levels of competence in counselor education and supervision roles, (c) instructor feedback impacts student perceptions of competence, and (d) counselor education students report hope or observation that imposter phenomenon can get better. This is important for counselor education because this research has findings and implications that may serve future research. The findings in this study imply that CES students, like other populations studied, also wrestle with IP. Given the lack of research into IP among CES students as a specific population, this research may help to establish its existence. This research may be important in bringing awareness to this issue, paving the way for more in-depth research into this topic. This dissertation is available in open access at AURA (https://aura.antioch.edu) and OhioLINK ETD Center

Psychotherapy process researchers seek to determine what mechanisms internal to the patient drive the improvement patients experience from therapy. Many of these studies focus on cognitive behavioral therapy (CBT) for depression. There are many unanswered questions remaining about CBT processes; this dissertation contains three papers that aim to provide evidence relevant to these questions. All three papers utilize session-to-session data collected from patients with a diagnosis of depression who received cognitive behavioral therapy. The first paper examines the alliance-outcome relationship and provides evidence suggesting that the alliance and depressive symptoms may have a reciprocal relationship. The second paper assesses positive affect and negative affect in CBT for depression. Results show that both positive and negative affect change over the course of treatment and predict depressive symptoms. The third paper is a study of clinician ratings of patients’ likelihood to respond to the active ingredients of CBT. Ratings of therapists following the first session, but not ratings of assessors at intake, moderated the relationship between each form of adherence and symptom change. Patients given lower ratings (easy patients) had a stronger relationship between adherence and greater symptom change, with this relationship reversing such that adherence was related to less robust symptom change for those with the highest ratings (challenging patients). Depressive symptoms, working alliance, and change in affect at the first session predicted therapists’ ratings. Taken together, the findings of these three studies are an initial step in answering key questions about how psychotherapy achieves its effects and for whom it is most effective. We conclude by discussing methodological considerations that we, and other researchers, can take into account in future studies of psychotherapy processes, such as operationalizing outcome using specific depressive symptoms to obtain results that are more specific and generalizable, and measuring a broader array of outcomes beyond symptom change.

As the graying population increases worldwide, the World Health Organization (WHO) estimated that dementia and related illnesses will almost triple by 2050. There has been an ongoing global effort with a worldwide quest to prevent the disease and find treatments. While there has been ongoing optimism to find a cure, dementia is a disease that lacks awareness and understanding, causing stigmatization and barriers to diagnosis and providing care. Although there is abundant data on dementia and its effects in the current study, various organizations have adopted siloed and ambiguous dementia care approaches. Hence, the current research studied the extensive literature as preliminary work, followed by interviews with providers who had a multitude of experiences working with individuals with dementia and their families. An exploratory research method was used to gather the lived experiences of 25 medical providers who have treated individuals with dementia, recommending the best approaches to improve the individuals' quality of life from the providers' perspective. The study incorporated open-ended interviews with the 25 participants to better understand the current challenges in care treatment for individuals with dementia and a proposed dementia care pathway that enhances the patient quality of life. A collaborative partnership between the government, private organizations, and a ready workforce in hospitals and clinic settings is needed for a successful dementia care pathway. Although dementia will likely not be cured, through partnerships as discussed in this research study and a supportive society significant progress can be realized.

The article offers information on the impact of increased personal responsibility on marriage using cognitive-behavioral intervention. Topics include effect in the personal responsibility for one's self and one's marriage has on marital satisfaction, goal of sustaining relationship and improving relationship quality and satisfaction.

Precision treatment for depression may be one method of improving interventioneffectiveness, especially among brief, self-guided interventions. Brief interventions are acost-effective alternative to accessing psychological services (Karyotaki et al., 2017;Powell et al., 2020), but suffer from high dropout rates (Torous et al., 2020). If content istailored so the most relevant concepts are presented earlier, treatment may be quicker inits effectiveness. One method of personalizing treatment is in skill strengths. However,research is currently mixed on whether clients benefit most from skills in which they aremore (i.e., capitalization; Cheavens et al., 2012; Fluckiger et al., 2016) or less (i.e.,compensation; Miller et al., 2005; Straumann et al., 2006) experienced. This studyinvestigates whether pre-treatment skill use moderates the effectiveness of a brief, selfguided, CBT skills-based intervention on depressive symptoms. Participants (n = 291;68% female; 67% White) consisted of undergraduate students who were randomized tocoping skill modules (i.e., behavioral, cognitive, interpersonal, mindfulness). Participantswatched module-specific educational videos and completed worksheets over three weeks.Participants completed measures on coping skill use, depression symptoms, and theirappraisal of the intervention, with depression symptoms being re-assessed each week.There was a small, significant reduction in depressive symptoms for participants in allmodules during the intervention. No differences were found between modules, nor wasiiiequivalence testing able to suggest statistical equivalence in effectiveness of reducingdepressive symptoms. Pre-treatment skill use did not moderate rate of improvement.However, there was a small, significant, correlation between pre-treatment skill use andappraisal of an intervention emphasizing that skill, suggesting individuals expect greaterimprovement when taught familiar skills. This suggests expectations of treatment successmay serve as a mechanism underlying the capitalization hypothesis. Further, thesefindings highlight the need for better assessments of coping skill aptitude and betterunderstanding of the relationships between coping skills within an individual.

ADHD symptoms are associated with dysfunctional automatic thoughts that increase avoidance, impairment, and distress; however, little is known about factors that increase the likelihood of these thoughts. The current study developed an Experimental Vignette Measure of Automatic Thoughts for ADHD (VMATA-E), which was used to test how task-specific factors (Immediacy, Aversiveness, and History of Failure) and ADHD Status influenced automatic thoughts. This study systematically manipulated components of the vignettes, using a 23-1 between-subjects fractional factorial design. After randomization to an experimental condition, 320 participants read three brief vignettes and rated automatic thoughts in response to each one. EFA was used to develop the measure, convergent validity was examined via correlations. MANOVAs were used to examine main effects of task-specific factors and interaction with ADHD status. The VMATA-E demonstrated a three-factor structure which supports the stability of negative (NAT), rationalizing (RAT), and adaptive (GOAT) thoughts found in prior work. Task-specific factors of Immediacy and Aversiveness were found to have effects on NAT and GOAT. Compared to non-ADHD participants, individuals with clinically significant ADHD symptoms reported higher levels of dysfunctional automatic thoughts and lower levels of adaptive automatic thoughts (i.e., GOAT), even after controlling for prior mood disorder diagnoses. In contrast to expectations, there were no interactions between ADHD status and any task-specific factor. The findings of the current study have theoretical and practical implications for research on the role of automatic thoughts in ADHD-related impairment.

Adult individuals seeking non-pharmacological, therapeutic support for situationalmental health challenges have emerged as a population group that is unrecognized andunderserved by the mental healthcare system in the US. Music therapy is known as abeneficial treatment modality for these individuals, but accessible treatment methods forthis group of consumers is narrowly represented in music therapy literature. This caseexploration was conducted to gain insight into the experiences of one member of thispopulation as she engaged in a series of music therapy sessions involving reflexive,participant-led therapeutic music experiences facilitated by a supportive music therapist.The clinician, who was also the primary investigator in this study, employed researchmethods based in transcendental phenomenology during collection and analysis of rich,descriptive data. The research process ultimately resulted in synthesis of the essential,structural elements of a phenomenon that emerged organically from the participant’stherapeutic process. The essence of the phenomenon, Therapeutic Change, is defined bythe intersection of Awareness, Control, and Connection within the therapeutic space. Theresearcher discusses implications of these findings and makes recommendations fordevelopment and future implementation of a new, integral model of music psychotherapythat emerged as a result of this work, called Insight-Oriented Music Facilitated Psychotherapy (IMFP). The researcher believes the ethical application of IMFP willempower and inspire music therapy clinicians to expand their services to meet the mentalhealth treatment needs of this emergent group of consumers.

Pilot Study: a) 21 Generalised Anxiety Disorder (GAD) patients were treated double-blind with either diazepam or placebo for 6 weeks. This active treatment period was preceded by one-week single-blind placebo 'wash-in', and followed by two-week single-blind 'washout'. Results showed that diazepam used in moderate doses for 6 weeks produced anxiety recurrence and withdrawal symptoms. b) 10 GAD patients were randomly allocated to Cognitive-Behaviour Therapy (CBT) and compared with the above diazepam and placebo groups. All treatments were balanced for degree of Psychologist/patient contact. At cessation of active treatment CBT superiority was indicated. Post-Study psychotropic prescription and psychological treatment were assessed at 12 months follow-up. The CBT group had the lowest incidence of subsequent treatment interventions. Main Study : 101 GAD patients were randomly allocated to diazepam, placebo, CBT, CBT + diazepam, and CBT + placebo, and treated over 10 weeks. Outcome measures at end of treatment and at 6 months follow-up revealed the superiority of all CBT treatments; especially CBT alone, and CBT + diazepam. Diazepam was more effective than placebo. CBT + diazepam, and diazepam groups showed no anxiety recurrence during graded withdrawal. Secondary Study : 205 long-term benzodiazepine users were matched for age and sex with controls. Inspection of medical case notes showed that benzodiazepine users had higher rates of previous physical illness, GP attendance, and non-psychotropic drug prescription. Differences emerged between anxiolytic, hypnotic, and anxiolytic + hypnotic benzodiazepine users in age, history of physical illness, and previously prescribed medication. Tertiary Study : 44 long-term benzodiazepine users were interviewed. The incidence of psychological ill-health and social problems was lower than expected. Patients were dependent on medication, and reported concern if their medication were to be stopped. Nevertheless 40% considered stopping benzodiazepines. Results from the above studies are discussed in relation to clinical management of GAD, and current concerns about benzodiazepine dependence and withdrawal.

A distinction has often been drawn between "process" and "outcome" studies in psychotherapy research, but interest in outcome implicitly underlies virtually all research in psychotherapy, there being little point in studying what happens in treatment if these events do not, in some way, relate to outcome. In addition, since an integrative measurement of change appears to be promising in psychotherapy research (e.g. Bloch and Reibstein (1980), Cartwright et al (1963), Mintz et al (1979), Strupp and Hadley (1977), Truax and Carkhuff (1967), among others), the emphasis of the present study was on the perceptions of change by the main participants in therapy, namely the patients and therapists. Therefore, the present study was initiated in an attempt to integrate process and outcome measures of patients' and therapists' experiences of group psychotherapy into a longitudinal study, following the participants from the start of the therapeutic contact through to termination, and six months after termination. Bearing these considerations in mind, the aims of this research were to investigate: a) patients' and therapists' expectations and perceptions of themselves and each other before they commence therapy, and b) patients' and therapists' perceptions of themselves and each other throughout treatment, in relation to outcome. The research design employed was a repeated measures design using interviews, psychological tests (Rotter's Internal-External Control Scale, the Treatment Expectancies Questionnaire, and several semantic differentials), and observation of the participants in the group psychotherapy situation. The main findings of the current research can be summarized as follows: 1. patients' expectations of the role the therapist played in t.heir treatment and what they thought their impending therapy would consist of, influenced their perception of the initial stages of therapy and their participation in treatment. 2. therapists felt there was a lack of congruence between what they thought it was realistic to achieve with their group patients and what they would really like to achieve; their expectations of the patients' participation and gain from group therapy being modified considerably as a result of ongoing treatment. 3. prior to therapy, patients and therapists had differing expectations of what the process of therapy would involve; however, during therapy, patients who came to share similar perceptions of the group process as their therapists, successfully completed treatment. 4. patients became more Internal in the responses to Rotter's Internal-External Control Scale as a result of treatment (p < .OO5), although there were no significant differences between terminators and non-terminators or between males and females. 5. responses to the Treatment Expectancies Questionnaire indicated that patients showed a preference for a more behaviourally oriented treatment regime at the end of group therapy, compared to pre-therapy (p < . 01). 6. the semantic differential data indicated that patients who successfully completed treatment viewed themselves more positively in terms of their attitude towards self and what they felt capable of achieving, attributing this, at termination to the "potency" of the group. 7. it is tentatively suggested that it may be possible to identify the potential terminator prior to commencing therapy, based on his expectations of therapy in general and his treatment in particular. It is suggested, given the numerous limitations of the current study, further research be initiated to validate the present results.

The Impact of Resilience, Spirituality, and Self-Regulation on the Quality of Life of Adults with Opioid Use Disorder in the Gulf State of OmanAbstractByHAMED MUBARAK AL BATTASHISubstance use is currently recognized as a chronic brain disease and a significant public health concern. In Oman, the percentage of individuals seeking substance use treatment in 2017 increased by 44% when compared to 2016. A total of 64% of the individuals who reported substance use problems are below 35 years old. Easy access to alcohol and other substances, family histories of substance use, and traumatic experiences during childhood were some of the primary risk factors reported by individuals in Oman who are substance users.Individual and family self-management theory and the bio-psycho-social-spiritual model of addiction were used as theoretical frameworks to guide the development and implementation of the study. The study addressed the following aims: (1) explore the variability and extent of resilience, spirituality, self-regulation, and quality of life (QOL), (2) investigate the impact of resilience and spirituality on self-regulation, (3) examine the impact of self-regulation on QOL, and (4) assess how does self-regulation mediates how resilience and spirituality predict QOL.This descriptive, cross-sectional study utilized a convenience sampling technique to recruit 109 adult participants diagnosed with opioid use disorder or polysubstance use including opioids. The study was implemented in two treatment centers in Oman. Data xiiiwere collected using the Resilience Research Center-Adult Resilience Measure (PRCARM), Spiritual Involvement and Beliefs Scale (SIBS), Cognitive-Emotion Regulation Questionnaire (CERQ), Emotional Self-Efficacy Scale (ESES), and the World Health Organization Quality of Life (WHOQOL) Scale (WHOQOL-BREF). The SPSS 25 statistical package was used to analyze descriptive data and conduct various multiple linear regressions.The levels of resilience (M=58.77; SD=9.928), cognitive regulation (M=122.59; SD=17.991), emotion regulation (M=88.56; SD=13.300), and QOL domains (OverallQOL M=2.95; SD=1.100) (Overall health M=3.09; SD=1.085) (Physical M=41.90;SD=18.559) (Psychological M=39.12; SD=18.572) (Social M=37.43; SD=22.190)(Environment M=46.75; SD=16.067) were significantly low among this population. High levels of spirituality were reported (M=99.80; SD=12.051). Age, duration of substance use, substance severity, and mental illness comorbidity were significantly correlated with the QOL of this sample. The tested regression models reported different significant effects. This study’s findings filled gabs in current substance use literature and provided insights for practice and future research.

Adult adoptees may be blocked from feeling securely attached to their romantic partners and they may not even know it or what to do about it. The literature shows adult adoptees being overrepresented in insecure attachment styles, and not enough attention has been paid to the effect this has had on adoptees in their romantic relationships. In fact, no known study, to date, has provided an attachment-based psychoeducational approach for this marginalized population. The purpose of this introductory qualitative study was to explore the experiences and meaning-making of attachment, specifically related to adoption, for the adult adoptee and their romantic partner once they had attended a Hold Me Tight program (based on the principles of emotionally focused therapy). Semistructured dyadic interviews of three couples who identified as one partner being adopted were analyzed by using experiential thematic analysis. Results of this study demonstrated the need for the adult adoptee to vulnerably share their experiences of adoption-related attachment injuries with their partner. This sharing created new understandings, awareness, and a deeper connection for the couples. Themes included sharing adoption-related attachment burden with their partner, finding the reason for adoption-related attachment injuries, attachment in the adoptive parent relationship and transitions from birthmother to adoptive parents, adoption-related attachment injury of social stigma, and the adoptee’s negative view-of-self. These themes point to the need to promote attachment security for these unique couples through attachment-related education programs such as the one used in the study. One important finding was that avoidantly attached adult adoptees could lean into more securely attached behavior with their romantic partners after learning about their attachment through the HMT. The results of this study highlight a need for researchers, mental health professionals, families, and society to understand there may be a significant link between these couples and adoption-related attachment injury and support them in research, therapy, and understanding.

Major depressive disorder (MDD) is considered the current leading cause of disability worldwide (Friedrich, 2017), yet the recovery process in MDD, including neurobiological underpinnings, clinical features and optimal approaches to treatment remains ambiguous. Current definitions of recovery are disputed and involve measures considered subjective in nature, such as thresholds for questionnaires and clinical interviews of symptoms and their duration (De Zwart and Jeronimus, 2019; Fava et al., 2007; Keller, 2003, 2004). Symptom-based measures, although informative of clinical presentation, are not informative of neurobiological underpinnings that may persist even when symptoms are reduced. Indeed, even after treatment, persistent residual symptoms, impairments in quality of life, and vulnerabilities for future return to more severe psychopathology persist (Gotlib and Hammen, 2008; IsHak et al., 2011; Judd et al., 1998a; Kennedy et al., 2004; Kennedy and Foy, 2005; Kennedy and Paykel, 2004). Without assessment of neural mechanisms of recovery in MDD, efforts toward developing novel treatment approaches that are able to address neural processes of illness and to provide sustained remission are slowed. The following collection of studies provide neural and clinical insights into MDD recovery and relate findings to potential treatment approaches that are optimized to individual differences in symptoms and neural functioning and able to address neural vulnerabilities to provide sustained remission. In pursuit of individualized treatment selection in MDD, study one involved a meta-analysis of prior prognostic fMRI studies of response to cognitive behavioral therapy (CBT) or a selective serotonin reuptake inhibitor (SSRI) in MDD. Study one also reported on the application of resulting meta-analytic regions (subgenual and perigenual anterior cingulate cortex) in a confirmatory MDD sample. Although regions showed some predictive potential in the confirmatory sample, when predicting SSRI response, effects were inconsistent with prior studies, suggesting methodological confounds may hinder ready translation. In an assessment of the course of MDD, the second study documented depression symptoms and quality of life across 9-14 years after acute treatment (CBT or SSRI) and found that persistent residual depression symptoms and quality of life deficits were common. In light of the normality of chronic symptoms and impairment, the third study evaluated neural features of treatment (CBT) resistance in MDD within the context of neural mechanisms of change. The third study found a vermis-centered cerebellar cluster that was unresponsive to CBT, whereas prefrontal and parietal cortical regions were responsive, providing support of prior theories that CBT directly affects cognitive control and cortical regulatory processes in contrast to salience-driven subcortical functioning (Clark and Beck, 2010; DeRubeis et al., 2008; Frewen et al., 2008; Mayberg, 2003). In consideration of findings, clinical recommendations that pertain to treating residual symptoms and associated neural features toward asymptomatic remission are provided. Future research directions are also provided regarding neuroscience informed precision medicine, current therapy and medication practices, and the larger picture of MDD chronicity broadly.

Thousands of children are adopted both domestically and internationally every year. Many of these children come from institutional or foster care and suffer from complex trauma, abuse and neglect, which negatively affect their transition and attachment with their adoptive families (Van Der Kolk, 2005). If left untreated, these effects can last into adulthood, impairing a person's ability to form secure relationships throughout their lives (White, 2014). The purpose of this research is to explore the use of virtual play—especially play therapy—to help adopted children in Pennsylvania work through these past traumas so they can form healthy attachments with their adoptive families. As a result, treating complex trauma in these children requires treatment that addresses the whole child: 1) safety, 2) relationships and 3) self-regulation and management (Purvis, 2013). Up until this point, most interventions are behavioral-based and revolve around the caregiver and family, such as attachment parenting and Trust-Based Relational Intervention (TBRI) training (Chobhthaigh, 2019). However, few studies focus on adopted children and their use of play, and no studies have been published that revolve around the use of virtual play to treat adopted children with trauma.

Background and Objectives: Patient memory for psychological treatment contents is a promising transdiagnostic mechanism of change, but there is little consensus concerning its measurement. We investigated the relations between memory support, patient memory for treatment, and treatment outcome using a novel measure called the Conceptualization Task.Methods: Patients from a randomized controlled trial comparing cognitive therapy-as- usual to cognitive therapy plus the Memory Support Intervention (MSI) for adults with depression (N = 171) completed the Conceptualization Task and existing measures of memory for treatment. For the Conceptualization Task, patients read clinical vignettes and provided written responses to assess three facets of conceptualization ability: identifying contributing factors to psychopathology, making intervention recommendations, and providing a rationale for intervention recommendations. Higher scores were given to responses reflecting accurate memory for the theoretical model and change strategies used in treatment. Results: The Conceptualization Task was associated with select existing measures of memory for treatment. Therapist use of strategies from the MSI that involve patients constructing new ideas and connections about treatment contents (termed “constructive memory support”) predicted better Conceptualization Task performance. Patients providing more treatment- consistent intervention recommendations on the Conceptualization Task reported better treatment outcome. Yet the Conceptualization Task did not predict independent variance in outcome above existing measures of memory for treatment, suggesting that the task is too similar to previous measures. Conclusions: Memory support interventions may be improved by placing more emphasis on constructive memory support and reinforcing practical treatment contents (e.g., change strategies) over conceptual treatment contents (e.g., the theoretical model).

Background The purpose of this two-part descriptive study was to evaluate an online training course designed to introduce direct care workers to the Tovertafel, a multi-sensory technology device, and provide information about how to facilitate interactive game sessions with older adults who have dementia. While direct care staff are often an integral part of multi-sensory interventions, a review of previous studies indicates that staff training is often under-reported in the literature. Ensuring that direct care workers are comfortable with new practices or technology is crucial to their success, as they are usually the staff who implement new programs. Research suggests that staff members who have been trained using consistent methods are more likely to understand the intended activities and results, which increases the success of the program. Methods In Part One of the study an interactive online training course was created using constructs of the New World Kirkpatrick Model (NWKM). A convenience sampling of undergraduate students enrolled in academic programs offered by the College of Health and Human Services at a midwestern university were invited to participate in the training and complete an online survey. Additionally, students enrolled in three recreation therapy courses at the same university were assigned to complete the activities. Following course completion, an online survey obtained ratings of engagement (i.e., aesthetics, ease of use, novelty, and involvement), relevance, and knowledge/skills gained from the training. In Part Two of the study, undergraduate recreation therapy students were invited to practice using the Tovertafel games and provide input on their experiences. A survey was created using constructs of Social Cognitive Theory to measure perceptions of behavioral capability, self-efficacy, expected outcomes and reinforcing attitudes. Results In Part One, 72 undergraduate students participated in the online training course and subsequent survey. The majority were white (83.3%), non-Hispanic (81.9%) females (88.9%). Most participants agreed or strongly agreed (median=4) with positive statements related to engagement with the course. Statements about relevance to their intended career were rated even higher (median=5). Wilcoxon signed-rank tests for matched pairs revealed statistically significant improvements on self-reported pre-post knowledge/skills scores (p