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Clinical education has important implications for learners, patients, and wider healthcare systems. It also has implications for clinicians who provide this role, particularly regarding their practice and wellbeing, though there has been little interest to date in investigating this from the educator perspective. This thesis used qualitative methodology to clarify and deepen our understanding of the lived experience of being a clinical educator. Paper One presents a systematic review and thematic synthesis of the experiences of clinician-educators from a range of clinical backgrounds. Databases were searched and 23 papers were identified for inclusion. Four analytic themes were generated: (1) Emotional Weight: students are a heavy burden; (2) Relationship & proximity: a journey from dependence to independence; (3) Personal enrichment: knowledge, validation, and meaning; and, (4) Community and systems: networks of support. Providing clinical education is a challenging role that has the potential to enhance the personal and working lives of clinicians when appropriate support is provided. Conditions required for effective educational experiences are highlighted by this review. Paper Two is an empirical investigation into the experiences of eight General Practitioner educators who facilitate Clinical Debrief, a model of case-based learning, for small groups of medical students. Results from semi-structured interviews were analysed using Reflexive Thematic Analysis and four themes were developed: (1) Personal enrichment: psychological "respite" and wellbeing; (2) Professional enrichment: Clinical Debrief as a "two-way" door; (3) Becoming a facilitator: a journey from insecurity to security (and back again); and, (4) Relationships in teaching: blurred boundaries and multiple roles. The implications of these findings for individual GPs, their patients, and the wider healthcare system, are discussed. Finally, Paper Three presents a critical reflection of the research conducted in this thesis. Pertinent issues from the process of conducting the research are discussed and the implications and relevance of the work are considered alongside personal reflections.

The aim of this thesis was to understand more about the intimate relational impacts of female Chronic Pelvic Pain (CPP), to contribute to intervention approaches for this prevalent and difficult to treat condition. Paper one reports a narrative synthesis of twenty-seven qualitative investigations in this area, to clarify the nature of relational distress associated with female CPP. Themes identified pertain to dominant societal discourses that influence couples' experiences, disruptions across domains of sex and intimacy, planning for and having children, work, social and domestic life and attempts to manage such disruptions. Implications for future research across different contexts and addressing relational difficulties within healthcare settings are highlighted. Paper two presents a qualitative inquiry using grounded theory to produce a novel conceptual framework for understanding how women with CPP perceive, experience and manage difficulties within their intimate relationships. The resulting theory, derived from thirteen in-depth interviews, identifies two core concepts: 'Dreading sex and physical intimacy' and 'being bound by lifestyle constraints'. These themes permeated women's experiences in which dominant societal narratives negatively influenced self-concept and emotional experience, compelling women to find another way to manage CPP within their relationships. This resulted in two interactive cycles, influenced by women's internal psychological conflict and partners' responses; one leading to distancing and the other to bonding for couples. Findings provide deeper insight into the intimate relational impacts of female CPP and the role of open communication in relational adjustment. Implications for early relational intervention and education for clinicians are discussed. Paper three provides an overview and critical appraisal of the processes involved in conducting the research. The researcher's reflections on decision making and research processes, methodological rigour, reflexivity, strengths, limitations and the overall research contribution are presented. This paper concludes with personal reflections on the project.

The aim of this thesis was to examine emotion regulation and experiences of shame in individuals who engage in nonsuicidal self-injury (NSSI). The thesis is presented as three separate papers. Paper One is a systematic review of Experience Sampling Methodology (ESM) studies examining associations between NSSI and nonsuicidal self-injurious thoughts (NSSIT) and momentary emotional states. The results indicated that negative affect generally increases prior to, and reduces following, NSSI. Fewer studies were available regarding positive affect, specific emotional states and NSSIT. Paper Two presents a mixed-methods empirical investigation of shame in individuals who self-injure. Participants completed baseline measures, followed by two weeks of ESM diary entries. Personalised qualitative interviews were then conducted to discuss their experiences of shame recorded in their diaries. Thematic analysis suggested that shame is experienced as a social and relational emotion, this finding was present across all themes. Themes included shame being associated with feelings of failure, being trapped, dangerous or contaminated, and hidden or exposed. The phenomenology of shame and coping with shame also emerged as themes. The results indicated that although NSSI could occur as a response to shame, shame was more often triggered by others' response to NSSI. Finally, Paper Three presents a critical appraisal of Papers One and Two and the research process overall. Further detail on the methodology used and decision-making processes that occurred during the research process is provided, and strengths and limitations are discussed. The researcher's overall reflections on the project are included at the end of this paper.

This thesis explored the views of patients with a low grade glioma (LGG) and their relatives in relation to their experiences of diagnosis, adjustment and support using qualitative methodologies. This thesis has been prepared in paper based format and comprises three papers: 1) a systematic literature review, 2) an empirical study and 3) a critical reflection of the research process. The systematic review (Paper 1) is a thematic synthesis of patients' and relatives' views, beliefs and experiences of being diagnosed with a LGG, associated treatments and their support needs. Ten studies were included, involving 114 patients with a LGG and 39 relatives. A thematic synthesis derived three main analytical themes: 1) feelings of uncertainty, 2) changing identities around 'illness,' and 3) adjusting to a new normality. The importance of including and supporting relatives was emphasised. In light of these findings, clinical implications were reported that aimed to improve the experience of being diagnosed with a LGG, encourage the sharing of explicit and detailed information to reduce uncertainty and improve the subsequent support provided to both patients and relatives. The empirical paper (Paper 2) explored the relational aspects involved in the adjustment process from the perspective of patients living with a LGG. Semi-structured interviews were conducted with seven patients. Their views and experiences of the relational aspects involved throughout their journey from initially seeking medical attention to living with a LGG today were explored. Interpretative Phenomenological Analysis (IPA) revealed three sub-ordinate themes: 1) double burden of threat to self and others, 2) double burden of reciprocal protection and 3) the role of others as facilitators of adjustment. Participants highlighted the facilitative role others played in their adjustment process. Attachment theory appeared to be a useful framework for understanding the relational aspects involved in adjustment to a LGG. Clinical implications were provided to support clinicians to engender attachment security to ensure patients feel connected and held by clinicians providing their care. Paper 3 is a critical appraisal of the research process. As well as sharing the researcher's reflections this paper considers the challenges faced by the researcher and the strengths and limitations of the research. This paper also provides an overview of the clinical implications and suggested areas for future research.

This thesis presents an in-depth qualitative exploration of the family relationships of individuals with fibromyalgia and consists of three separate papers. Paper one presents a qualitative systematic review and thematic synthesis that sought to understand how women with fibromyalgia experience and understand family relationships. Data from 27 studies were thematically synthesised and five analytical themes were identified: 1) The impact of fibromyalgia on women and family life: "there was nothing left of me, just pain, what if I can't take care of my children", 2) A changing view of the present and future self: "How can you love me now, if I'm not the person I was", 3) Searching for understanding and support in the midst of an invisible contested illness: "I'm having a bad day and you need to understand what that means", 4) Hidden pain and feelings: "I don't want to give up ... I don't want to show people that I am in pain", and 5) Accepting and moving towards the future-self: "he decided that he is going to be there forever, no matter what". A changing view of the self, relational difficulties, and communication barriers may have implications for well-being and family adjustment. In light of these findings it appears that treatment approaches with an increased focus on interpersonal difficulties and communication skills could be beneficial. Paper two presents an empirical study that explored the romantic relationships of individuals with fibromyalgia who remained distressed or disabled by their pain despite receiving tertiary-level treatment in a multidisciplinary pain management programme. Seventeen semi-structured interviews were conducted and analysed using inductive thematic analysis. Three core themes were identified: the relational impact of fibromyalgia, factors contributing to relational distress, and moving towards the future. Results demonstrated that fibromyalgia can lead to changed relationships, interpersonal difficulties, and relational tension. However, participants generally struggled to adapt to and accept these changed circumstances. A range of potential contributing factors were identified including a perceived lack of communication, understanding, and support. It therefore appears that treatments with a specific focus on relational difficulties, partner support, and communication skills may enhance therapeutic outcomes for some. Paper three presents a critical appraisal of the work conducted within this thesis and the researcher's personal reflections on the research process. The critical consideration of the work encompasses the planning, methodology, and implementation of the systematic review and empirical study. The implications of the work and dissemination plans are also discussed.

Every year, approximately 800,000 people die by suicide, with an estimated 20 times this figure making a suicide attempt. Developing an understanding of variables associated with suicide risk is important in improving clinical intervention and contributing to prevention. This thesis aims to enhance understanding of suicide by exploring psychological factors associated with suicide ideation and behaviour, including attachment and emotion regulation. Paper one is a systematic review of quantitative empirical research findings, exploring the relationship between emotion dysregulation and suicide ideation and behaviour in adults. Nineteen papers were identified through a systematic search. Results indicated that there was a positive association between emotion dysregulation and suicide ideation and behaviour. However, this was not always present when controlling for other psychological variables. Studies were critically evaluated and a narrative description of findings was presented. Clinical implications and recommendations for future research were discussed. Paper two is an empirical study exploring the relationship between attachment insecurity and suicide ideation and behaviour. Emotion regulation was considered as a potential mediator and betrayal trauma as part of a moderated mediation model. Sixty-seven participants completed self-report questionnaires measuring adult attachment, emotion regulation, suicide ideation, betrayal trauma, depression and hopelessness. Avoidant attachment was associated with suicide ideation. Emotion regulation did not mediate the relationship between attachment insecurity and suicide ideation and behaviour. Findings were considered in light of limitations. Clinical implications and directions for future research were discussed. Paper three is a critical appraisal of papers one and two. Reflections on the research process were provided, including further discussion regarding implications, as well as evaluation and justification of key decisions.

Approximately 800,000 people die by suicide every year. Moreover, for every fatal outcome approximately 20 people attempt to take their own life. Therefore, increasing our understanding of the vulnerability factors and acute states that trigger suicide and related behaviours is vital in improving suicide prevention efforts and initiatives. This thesis aims to contribute to the evidence base by examining attachment in relation to suicide-related outcomes and, specifically, the role of psychological mechanisms in this relationship. Paper one is a systematic review of quantitative empirical research investigating the role of psychosocial mechanisms in the attachment-suicide relationship. Fifteen papers were identified, most of which carried out mediation analyses. Studies were extremely heterogeneous and there was limited overlap with respect to the psychological mechanisms under investigation. However, there is preliminary evidence that suggests a range of predisposing, precipitating and crisis-state factors mediate the association between attachment styles and suicidality. Studies were critically evaluated and findings were discussed in the context of a developmental model of suicide. Areas for further exploration are considered and clinical implications discussed. Paper two is an original empirical study investigating the mediating role of reflective functioning between adult attachment and suicidality. Sixty-seven participants completed self-report questionnaires measuring adult attachment, suicidal ideation, reflective functioning, depressive symptoms and hopelessness. Mediation analyses did not support an indirect effect of either attachment dimension on suicidal ideation via mentalization impairments. However, a direct relationship was established between avoidant attachment and suicidal ideation. Findings are considered in light of the limitations and cross-sectional methodology. Future research directions are recommended, and clinical implications outlined. Paper three is a critical reflection that aims to provide insight and reflections on the research process. Explanations and justifications of key decisions are offered, and reflections are made in respect to the study design, methodology, recruitment, data analysis and personal experiences of the researcher.

This thesis investigates the behavioural phenotype, especially social functioning, in mucopolysaccharidosis type IH (MPS IH) and reviews research in social information processing in developmental genetic disorders in general. MPS IH is a developmental genetic disorder that causes severe physical symptoms and intellectual disabilities. Paper 1 presents a systematic literature review that aimed to review research on social information processing in genetic developmental disorders. Searches identified 23 articles and a quality assessment classified 15 of these as high quality. These articles were included in the review. The results showed that social information processing was impaired in sex chromosome aneuploidies, Turner syndrome, neurofibromatosis 1 (NF1), and Williams syndrome (WS). The findings suggest that problems with social information processing are part of the phenotype of several different developmental genetic disorders. In addition, social outcomes were lower than those of control children or in comparison to norms in NF1, deletion syndromes and WS. Thus, it is important to consider the potential social impairment in children with developmental genetic disorders when planning the care of these children and their families. Paper 2 is an empirical study investigating the behavioural phenotype in MPS IH with particular focus on social functioning and sleep. Participants were 22 children with MPS IH (mean age 9 years 4 months). Nine control children with intellectual disabilities were recruited as well, but due to the small size of the control group, the scores of the children with MPS IH were compared to questionnaire norms instead of the control group. The results indicated that 23 percent of children with MPS IH scored in the severe range on social functioning difficulties. Thus, children with MPS IH were more than 30 times more likely to score in the severe range than typically developing children. Children with MPS IH did not exhibit significantly more behaviour problems, but they scored higher than the norms on social, thought and attention problems and rule-breaking behaviour. They were also markedly impaired in all the competence areas (social, activities, school). The results indicate that these problems are part of the behavioural phenotype in MPS IH. They should therefore be considered in the design of clinical care of individuals with MPS IH and their families in terms of support and follow-up and for example facilitation of ASD diagnoses where appropriate. Paper 3 is a critical appraisal and reflection on the research process of both the literature review and empirical study, considering issues such as the quality ratings used in the literature review and the reasons for the small control sample in the empirical study. The implications of the decision to use norms rather than the control group as a comparison are discussed. This paper also considers the significance of the findings for the research in the field and the clinical care provided to children with developmental genetic disorders, MPS IH especially.

The aim of this thesis was to explore whether a training package based on Conversational Therapy is effective in enhancing empathy within Psychological Well-Being Practitioners (PWPs). The thesis is presented as four separate papers. Paper One is a narrative review of the literature on training empathy to psychological therapists, including other factors which are considered to enhance empathy. The review highlights that as empathy is a multi-faceted concept, different approaches are required to enhance certain elements. An apparent combination of experiential learning with feedback and clinical practice combined with clinical supervision is required for empathy to be enhanced. However, further research is required into the effectiveness of empathy training for qualified psychological therapists. Paper two is a qualitative study exploring the experiences of PWPs learning and putting into practice the skills taught within the training programme. Semi-structured interviews were conducted with fourteen PWPs. Data was analysed using a thematic analysis and themes were generated relating to PWPs experiences of the training and learning the techniques. The results suggest that learning more conversational and relational techniques supplemented PWPs current way of working. The training appeared to help increase their empathy and understanding of clients presenting difficulties. Some improvements to the job satisfaction and self-efficacy of PWPs were also apparent. Adopting the techniques did however pose some challenges, especially in relation to moving away from a PWPs current practice. Paper three is an empirical service evaluation of the effects of the skills training on clinical outcomes. The evaluation did not find any significant results, however findings relating to a reduction in non-attendance in sessions were promising. Possible explanations and interpretations of the findings are discussed alongside suggestions for future research. Paper four is a critical reflection of the processes involved in conducting the project. This paper provides further detail on the methodology and decision making processes which took place within the research, alongside considering the strengths, limitations, implications and suggestions for future research. This paper concludes with personal reflections on the thesis project.

The prevalence of Autism Spectrum Disorder (ASD) and its defining features has been increasingly investigated in genetic syndromes associated with intellectual disability, with syndrome specific profiles reported. The experience of catatonia and other movement disorders in people with ASD has been increasing highlighted within both research and diagnostic guidelines. However, these issues have not typically been investigated alongside other features of ASD within research into genetic syndromes. The first paper in this thesis provides a review of the literature on movement disorders in genetic syndromes associated with ASD, which focuses on the prevalence of reported movement disorders, the methods of assessment used, and the quality of research to date. An empirical study is reported in Paper 2. Within a cohort of individuals with Cornelia de Lange and Fragile X syndromes the prevalence of attenuated behaviour [autistic catatonia] is examined, based on parent/carer report, and the extent to which features of ASD predict later attenuated behaviour is investigated. Paper 3 provides a critical reflection on the first two papers as well as some wider considerations on undertaking research in this area. The results of both the literature review and the empirical study indicated that across a number of genetic syndromes (Angelman syndrome, Cornelia de Lange syndrome, Fragile X syndrome and Rett syndrome) attenuated behaviour [autistic catatonia] and/or movement disorders affect a substantial proportion of individuals. Furthermore, repetitive behaviours, one of the characteristic features of ASD, appear to predict later attenuated behaviour in Cornelia de Lange and Fragile X syndromesThe results presented in this thesis have important implications for the way services support individuals with specific genetic syndromes. Paper 1 confirms the high prevalence of movement problems in Angelman and Rett syndromes, and Paper 2 provides a new insight into movement problems in Cornelia de Lange and Fragile X syndromes. Movement disorders are reported to impact negatively on wellbeing and quality of life in people with ASD, and are likely to have a similar impact on the lives of people with genetic syndromes. Greater awareness and recognition of movement problems in CdLS and FXS is required, and although specialist services may already be aware of some of the above issues, there should be an increased emphasis on ensuring that community services are aware of the needs of individuals with genetic syndromes, including the implications of movement problems for support needs and quality of life.

Acute inpatient mental health nursing staff provide mental health care for individuals when they are most vulnerable and unwell. The therapeutic relationship can facilitate positive changes and recovery for individuals. Therefore, understanding nursing staff’s attitudes is paramount. In this thesis, the attitudes of nursing staff towards those experiencing mental health difficulties was explored. In the systematic review, the attitudes of European nursing staff supporting those experiencing severe mental health difficulties were synthesised and evaluated. A total of 14 cross-sectional studies met the inclusion criteria. The review identified that the role of personal experiences of mental health difficulties through friends or family members was shown to elicit more positive attitudes. Overall attitudes amongst nursing staff were varied, and factors that influenced these attitudes were less clear and consistent. The limitation of using cross-sectional questionnaires to explore attitudes was also discussed. Moreover, recommendations regarding further research priorities as well as clinical implications were identified. Nursing staff’s attitudes towards adults who were either ‘informal’ voluntary clients or those who had been admitted under the Mental Health Act (1983) to an inpatient ward were explored in the empirical paper. The attitudes of nursing staff have the potential to impact on the development of therapeutic relationships and therefore upon treatment outcomes. Repertory grid interviews were completed with twelve nursing staff. All staff made critical judgements about some of their clients; however, staff who used more dimensions to construe clients made less clear distinctions between clients and non-clients. The findings highlight the need for support mechanisms that enable staff to formulate clients’ difficulties and explore the complexity of interactions. The implications of these results are discussed, as well as future research directions. The final paper consists of a critical reflection of the research and the research process. This includes an evaluation of the decision making processes and discussion of the strengths and weaknesses of this research.