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Rational Emotive Behaviour Therapy (REBT: Ellis, 2001) represents the original cognitive behavioural therapy (eBT) model of psychopathology. Although there is much empirical support for the basic theory of REBT (see David, Lynn, & Ellis, 2010), the model has never been tested in the context of posttraumatic stress responses to adverse life events. The first empirical chapter of the thesis investigated the construct validity of the Attitudes and Belief Scale 2 (ABS-2: DiGiuseppe, Leaf, Exner, & Robin, 1988). This chapter employed traditional confirmatory factor analysis and confirmatory bifactor modelling to investigate the psychometric properties of the ABS-2. Results indicated that a bifactoral model conceptualisation was found to offer an adequate representation of the underlying factor structure of the scale. Based on these results, an abbreviated version of the ABS-2 with superior psychometric properties was thus constructed. In the second empirical chapter confirmatory bifactor modelling and composite reliability analysis were employed to investigate the psychometric properties of the Profile of Emotional Distress (PED: Opris & Macavei, 2007). The PED was designed to capture the qualitative distinction between dysfunctional emotions, as predicted by REBT theory. Results indicated that the PED does not capture the distinction between functional and dysfunctional negative emotions, however a bifactor model inclusive of a single general distress factor, and four method factors was found to be an acceptable fit of the data. The third empirical chapter utilised structural equation modelling to test the organisation of the irrational beliefs in the prediction of posttraumatic stress responses. A model consistent with the predictions of REBT theory was found to be a good fit of the data and explained a large percentage of variance in each symptom class of posttraumatic stress. The fourth empirical chapter provided the first piece of empirical evidence that generalised irrational beliefs impact upon posttraumatic stress symptoms via trauma-specific irrational beliefs; a frequently hypothesised relationship which had hitherto remained untested. Results of structural equation modelling offered support for this core hypothesis. Subsequently, the fifth empirical chapter investigated the impact of trauma-specific irrational beliefs in the prediction of reporting posttraumatic stress symptoms while controlling for a number of important sociodemographic factors. Binary logistic regression ~ .. ~ ... analysis was employed and found that three irrational belief process positively predicted belong to the strongly symptomatic group. Finally, the sixth empirical chapter employed sequential moderated multiple regression analysis to determine if rational beliefs could positively moderate the impact of irrational beliefs of posttraumatic stress symptoms. Rational beliefs were found to exert a negative, direct effect on posttraumatic stress symptoms, and to lessen the impact of irrational beliefs on posttraumatic stress responses.

The concept of Complex Posttraumatic Stress Disorder (CPTSD) (Courtois & Ford, 2009) or Disorder of Extreme Stress Not Otherwise Specified (DESNOS) is one that has attracted debate and controversy. Is it a separate entity from Posttraumatic Stress Disorder (PTSD), already in DSM IV? (American Psychiatric Association, 2000; Courtois, 2008; Ford, Courtois, Steele, van der Hart & Nijenhuis, 2005; Korn & Leeds, 2002;). Perhaps as a result of this diagnostic difficulty, attempts to establish effective treatment approaches have been scant. This is surprising considering the amount of people with CPTSD-symptoms within psychiatric populations (Courtois, 2008). A consensus of research suggests that CPTSD exists as a separate diagnostic entity to PTSD and that treatment is best attempted through a transtheoretical approach which uses empirically-supported protocol-based treatments within the wider context of a three-phase meta-model. This involves a focus on the client achieving emotional self-regulation skills and a secure attachment within the therapeutic relationship before more specific trauma-focused work is attempted (Courtois, 2008; Korn & Leeds, 2002; Pearlman & Courtois, 2005; Resick, Pallavi & Griffin, 2003).

Despite a high proportion of the population experiencing traumatic events within their lifetime, the number of individuals who go on to develop posttraumatic stress disorder (PTSD) is comparatively small; herein highlighting the importance of individual differences in imparting risk and resilience towards the development and maintenance of PTSD. Existing literature illustrates that biological and ecological factors are important in predicting PTSD development, with pathological vulnerabilities excepting their effects at pre- peri- and post trauma stages. Whilst cognitive and emotion based models of PTSD account for the role of a minority of known pre-trauma risk factors, individual differences in peri- and post trauma processes are held as critical to the development of PTSD. The broad range of risk factors implicated in the empirical literature, and necessity of traumatic exposure to PTSD, implicates the utility of a diathesis-stress conceptualisation of PTSD development. The current thesis employed an analogue VR-trauma paradigm to investigate the respective importance of vulnerability factors at each stage, in the prediction of analogue PTSD symptoms (memory problems, startle responses, re-exposure fear habituation), whilst measuring affective and electrophysiological concomitance. Findings supported the importance of peri-traumatic responses in the prediction of PTSD, where present, showing increased predictive capacities over pre- and post-trauma factors. Biological and ecological factors also illustrated important predictive associations, with genetic SNPs implicated in reflex startle and cardiac responses towards intrusive memories. Moreover, peri-traumatic HR decelerations and accelerations mediated the association between pre-trauma factors and cued recall inaccuracy and intrusion severity respectively. Results support existing cognitive and emotional models in their emphasis on peri-traumatic processes but suggest the added utility of a diathesis stress conceptualisation of the development of PTSD, in highlighting the importance of pre-trauma biological and ecological risk and resilience factors.

The first paper is a review of Imaginal Exposure treatment for Post-Traumatic Stress Disorder (PTSD). There are still questions around the effectiveness and acceptability of exposure treatments for PTSD, and whether different forms of exposure such as Imaginal Exposure (lE) are equally as effective as other psychological treatments for this presentation. Such knowledge may prove useful for services and clinicians who want to utilise an effective and acceptable treatment. This review summarises and evaluates empirical literature on lE treatment for PTSD. Numerous methodological limitations were raised , however evidence suggests that lE treatments are effective in the treatment of PTSD, including some co-morbid difficulties such as depression and anxiety. Nonetheless, lE is not always as effective when compared to other PTSD treatments or 'combination' treatments, and cannot yet be recommended by itself for more complex PTSD presentations or Type-II trauma. Acceptability of lE was not determined in any of the studies, although dropout rates (a potential marker 0 acceptability) were similar to other PTSD treatment studies. The findings also support the Emotional Processing Model as a potential mechanism in exposure treatment. Clinical, service and research implications are discussed. The second paper aimed to produce a shorter version of the Supervisory Relationship Questionnaire (the Short-Supervisory Relationship Questionnaire: S-SRQ) that retained its reliability and psychometric validity. Two hundred and three UK trainee clinical psychologists completed a series of on line questionnaire including the developed S-SRQ. A Principal Component Analysis identified three components of the S-SRQ: 'Safe Base', 'Reflective Education' and 'Structure'. The S-SRQ (three subscales, 18 items) has high internal reliability, adequate test-retest reliability and good convergent, divergent, and predictive validity. Certain supervisor and supervisee characteristics were associated with higher supervisory relationship (SR) scores. Findings also support aspects of existing S models. The S-SRQ is a promising measure for use in clinical, training and research settings.

Females are more than twice as likely to have a diagnosis of Post-traumatic Stress Disorder (PTSD) making PTSD particularly relevant to female mentally disordered offenders (MDOs). Female offenders have been observed to report higher levels of trait anger and anger expression compared to males. Exploration of the relationship between anger and PTSD is in its infancy among MOOs. This study investigated gender differences in the levels of PTSD and anger and in the relationship between PTSD and anger in a sample of 66 MOOs using a cross sectional design. Participants completed self- report measures of posttraumatic symptomatology, trait anger, anger expression, depression, anxiety and social desirability. Results indicated that PTSD was particularly prevalent among female MOOs, which was independent of potential con founders, however none of the participants had received a formal diagnosis. A gender difference was found on the measure of trait anger in the univariate analysis but did not remain significant when controlling for confounding variables in the multivariate analysis. A gender difference was not found on measures of anger expression in the univariate and multivariate analysis. Consistent with previous research a positive relationship was found between PTSD symptomatology and trait anger, and this correlation remained significant for males and females separately. A positive relationship was found between PTSD symptomatology and anger expression, however this correlation remained significant for females only. However, a gender difference between the relationships of PTSD and trait anger and PTSD and anger expression was not found. The limitations and strengths of the study are outlined, and the clinical, theoretical and research implications of the findings discussed.

Interpersonal violence in adulthood adversely affects large numbers of people around the world; its deleterious physical and psychological consequences are well documented. Over the past 18 years, research has broadened its focus to the full range of potential sequelae including posttraumatic growth (PTG). The first paper presents a systematic review of the literature addressing PTG in survivors of interpersonal violence in adulthood. The evidence reviewed suggests that growth is experienced by around 70% of survivors, and is by no means a universal phenomenon. Findings point to the therapeutic relevance of cognitive-behavioural therapy and developing individuals' social support networks. Implications for future research are discussed with an emphasis on factors associated with PTG. The second paper presents an empirical study of factors related to PTG and posttraumatic stress disorder (PTSD) in female survivors of intimate-partner violence (IPV). The internet-based questionnaire study employed an international sample of 200 women. While there may be some overlap in PTG and PTSD, the current finding suggest that the two trauma outcomes may be separate constructs. Although cross-sectional, findings draw attention to the importance of positive, post-trauma variables such as coping self-efficacy and social support in facilitating PTG and protecting against PTSD. Future longitudinal research is required to investigate the pattern of PTG development over time and the clinical utility of PTO for this population.

Research has suggested that incidences of traumatic experience may cluster within the population, suggesting that individuals may suffer from similar, multiple experiences (Menard, 8andeen-Roche, & Chi lcoat, 2004). Also, differences in trauma type and exposure have been shown to exist between the sexes. Given that different traumatic experiences have consistently been shown to influence psychopathological disorders in both males and females (Kessler et al, 1995; Breslau & Wilcox, 2004; Breslau, Chilcoat, Kessler, & Davis, 1999; Tolin & Foa, 2006), the current thesis aimed to identify distinct groups of females and males within the population characterised by unique profiles of trauma hi story. The present research investigated exposure to traumatic events by adopting a 'person centred' latent class approach. Latent class analysis (LCA), multinomial logistic regression analysis, and confirmatory factor analysis (CFA) were utilised to test a series of hypotheses using data from The National Comorbidity Survey. In chapter two, three latent classes of traumatic exposure were identified for both sexes. For females a low risk class, a medium risk class and an interpersonal trauma class were identified; for males a low risk class, a situational trauma class and an interpersonal/violence class were identified. In chapter three multinomial logistic regression analyses were adopted to identify situational, environmental and clinical risk factors associated with each of the six trauma classes. Traumatised females and males had significantly high associations' with parental psychopathology variables, parental behaviour variables, domestic violence and household/loss factors. It appeared that pre-trauma risk factors were significantly related to latent class membership. In chapter four, multinomial logistic regress ion analyses were used to identify associations between each of the latent classes of trauma and a range of psychopathological disorders. Significant associations were found between the male and female trauma classes and all psychopathological disorders. Extremely high associations were evident for diagnoses of psychosis and PTSD. In chapter five confirmatory factor analyses were utilised to investigate the underlying symptom dimensions of PTSD in both sexes. In addition a multiple indicators and multiple causes (MIMIC) model was used to predict variation in the latent dimensions of the King, Leskin, King, and Weathers (1998) PTSD model using the six trauma classes. All trauma classes in each sex had significant associations with each of the symptom dimensions of PTSD. These findings add to the growing body of research supporting associations between diverse traumatic experiences and diverse psychological outcomes. It is recommended that, based on the current findings, clinicians and practitioners should demonstrate care and consideration when evaluating clients who present with trauma. Full trauma histories may afford better opportunities to deliver more successful and informed treatment interventions, while discrimination between the sexes in terms of trauma risk, occurrence and outcome may aid recovery and care

Aims and objectives. The aim of this study was to explore how clients perceived, and experienced NEST group therapy. Study design. A qualitative longitudinal design was adopted to explore the impact of treatment over time. Participants. Six participants, abuse survivors, five females and one male, aged between 25 and 61 years, all from Northern Ireland bar one who lived in the Republic of Ireland, volunteered to participate in the study. Data generation. Data was yielded from recorded semi structured interviews conducted with the six participants from two NEST groups, pre, middle and end of therapy and at three and six months post treatment, a total of thirty. For the purpose of verifying findings, focus group discussions were held and recorded with each group post interviews for the first four data collection phases, eight in total. Procedures. Ethical approval to conduct this study was obtained from NEST Board and the University of Ulster Filter Committee. Data analysis. Transcribed interviews and focus discussions were analysed using grounded theory (Strauss and Corbin, 1998) with the assistance of Nvivo 9. Results. The core category of the study "From the Pupa to the Butterfly, a new way of living, a new way of being" describes the metamorphosis of change r witnessed in participants. From pre NEST treatment when "My life was really nothing", positive changes were experienced by participants in several areas of functioning including emotional wellbeing "1 feel that I've got wings and it's just amazing", self esteem, "A sense of wholeness", cognitive "I have a new vision", coping capacity, "The eyes to the soul, I see, I know where I am going" and relational improvement "Reaching out to others". NEST had a positive and powerful impact on participants conceptualised in the category "NEST saved me, I got soul from NEST."

The possibility of positive psychological change following traumatic life experiences has now been well documented in the literature. This phenomenon is most commonly referred to as posttraumatic growth. Several theoretical models have sought to explain the development of posttraumatic growth, many of which have emphasised the important role of cognitive processing (Calhoun, Cann & Tedeschi, 2010; Tedeschi & Calhoun, 2004a). This thesis sought to further our understanding of the nature of posttraumatic cognitive processing and its association with psychological growth following trauma and adversity. A narrative review of the existing literature on cognitive processing and posttraumatic growth was conducted (Chapter 2) and suggested that cognitive processing might be best understood as comprising intrusive, deliberate and ruminative subtypes. Two cross-sectional studies and one longitudinal study were then conducted to develop and test this conceptualisation using samples of survivors of sexually traumatic experiences (Study 1; n = 123), trauma-exposed individuals recruited from trauma-focused websites and support forums (Study 2; n = 254), and trauma-exposed students from the University of Nottingham (Study 3; n = 174). The influence of these three subtypes of cognitive processing on levels of growth following adversity were also tested using the expressive writing intervention (Study 4; n = 24). Taken together, findings from the four studies supported the conceptualisation of cognitive processing as multidimensional, comprising intrusive, deliberate and ruminative subtypes that are differentially associated with posttraumatic growth. Results also provided consistent evidence to suggest that deliberate processing is especially important in the occurrence of growth following trauma and adversity. Unexpectedly, intrusive processing was not found to positively influence posttraumatic growth in the ways hypothesised by existing theoretical models. Implications of these findings with respect to both further research and clinical work with trauma survivors were reviewed in the final chapter.

There is significant research into childhood bullying and associated psychosocial difficulties in childhood. In contrast, research into the impact of childhood bullying in adulthood is sparse and predominantly quantitative. This study addresses this gap by exploring the lived experience of adults who were bullied as children. Semi-structured interviews were conducted and the data was analysed using Interpretative Phenomenological Analysis (IPA). Participants were six women and two men, aged between 27 and 57 years of age, who experienced bullying during their childhood and adolescent years. Four superordinate themes emerged from the interviews: "The impact on the self', "Interpersonal relationships", "The struggle for control, power and autonomy" and "Making sense of childhood bullying experiences in adulthood". This study's findings have been placed in wider context to existing literature. This study has also adopted an integrative theoretical framework for the interpretation of the findings in order to understand the mechanisms and processes involved in the experiences reported by participants. Therefore, suggestions can be made for psychological interventions and therapeutic exploration in clinical work with adult clients who experienced childhood bullying. The theoretical approaches used were developmental life span, humanistic, psychodynamic and cognitive-behavioural. Clinical implications, such as control relating to coping strategies and the potential for post-traumatic stress in adults who experienced childhood bullying, are also explored. Limitations of the study and recommendations for future research are discussed.

This study considers the history of trauma, both as a psychiatric concept and as a diagnosis, and its social and cultural representation from a transnational perspective after WWII. The intellectual evolution of trauma was determined by various medical, social and cultural variables, institutions, and people who wielded influence in the postwar world order as well as diverse local contexts. This thesis focuses on the globalisation and localisation of such concept and diagnosis shaped by international and local mental health experts at the World Health Organization and the National Taiwan University Hospital. Through the efforts of these experts, trauma not only became one of the most globally diffused psychiatric diagnoses, but also a hyperbole appropriated by Taiwanese psychiatrists to account for extreme forms of social suffering. Studies have criticised the universality and the Anglo-American-centred approach to the history of traumatic psychiatry. Scholars have also begun to explore transnational histories of psychiatry by systematically comparing or tracing the diffusion routes of psychiatric topics. Their methods of enquiry and problems solved, however, differ. My research analyses a disparate collection of evidence at the level of international organisations and from local aspects, allowing not only a critical reconsideration of trauma in the trend of global medicine, but also its reception, contestation and appropriation in the non-Western contexts. Guided by the works of medical historians, literary critics and cultural anthropologists, this project combines archival research with oral history interviews to challenge the existing historical accounts of trauma, and provide evidence of the limited capacity of globalised psychiatric norms and their reception and appropriation beyond the imagination of world citizenship. It argues that such scientific artefacts were not only produced through mutual reference between Eastern and Western experiences, but also measures of instrumental rationality employed by postwar internationalists to engineer their modernity in the Global South.

Traumatic and life threatening events can have a profound impact on the physical and psychological wellbeing of those who experience them. Limited research has been conducted into the impact upon partners of people who have experienced trauma and subsequent Posttraumatic Stress Disorder (PTSD). This study aimed to explore such experiences. Six partners of service users awaiting or undergoing treatment for PTSD at a specialist Trauma Service were interviewed. The data was analysed using Interpretative Phenomenological Analysis (Smith et al, 2009). One final, overarching theme was developed from the data: participants experienced trauma and PTSD as an ongoing journey of loss and gain. Their journeys were characterised by striving and struggling to make sense of the trauma and its ensuing consequences, whilst also grappling with the identities of themselves, their partners and relationships shifting over time. Participants navigated their journeys in the context of external resources and support from friends, family, colleagues and professionals. The results are discussed in relation to existing literature and limitations of the study are highlighted. Further research is recommended to investigate and inform how clinical and non-NHS services can provide appropriate and culturally-sensitive support to families of people with PTSD.

Resilience literature has recently seen an important shift in focus from the identification of individual characteristics that seem to contribute to positive adaptation to a focus on how these characteristics appear to work together cumulatively to result in such adaptation. There is a paucity of research though that conceptualises post-trauma resilience as an interactional and transactional process or adopts a culturally-sensitive perspective. This study therefore sets out to consider some of these gaps by qualitatively investigating the processes underlying resilience from an ecological, developmental and culturally-sensitive perspective in an adult population that have endured high levels of psychological trauma. Refugees were the population of choice given the proportionally high levels of exposure to traumatic events present within this population. Moreover, the study of the resilience process within the experience of refugees hailing from certain cultural backgrounds such as Eritrean is remarkably scarce. Six in-depth interviews were conducted with Eritrean refugees who have sought asylum in Malta. Subsequently, in the theoretical sampling stage, an additional seventh interview was conducted with one of the original participants. Themes garnered from a constructivist grounded theory data analysis high light the role in resilience of a variety of psychological processes including responding to external messages critically and analytically and striving to maintain existential well-being. Additionally, analysis pointed towards the role of contextual factors such as religious practices and cu ltural norms and indicated the presence of a set of transactional processes between these two aspects. Finally. a theoretical model was developed attempting to capture how these processes operate in conj unction to lead to post-trauma resilience in Eritrean refugees. Following a discussion of this study's limitations, suggestions detailing how future research can help enlighten areas that were only partially examined by this research, were provided. Finally, implications for theory and practice were discussed in view of providing suggestions for resilience-based interventions for refugees exposed to traumatic events.

Threat based risk factors previously found to be associated with PTSD were investigated in a clinical population of treatment seeking individuals. Building on previous research, within evolutionary psychology, this study conceptualised experiential avoidance, shame and self-critical processes as activators of an individual’s threat based affect system, following a trauma. These processes may play a central role in the sense of ongoing current threat found in PTSD sufferers. The concept of self-compassion was also investigated; this concept has been implicated in regulating threat based processes and moderating threat based responses. This study hypothesised that individuals higher in levels of self-compassion would demonstrate lower levels of PTSD symptomatology and that levels of self-compassion would moderate the effect of each threat based risk factor on PTSD symptom severity. Correlation and hierarchical multiple regression analyses were conducted and all hypotheses were either fully or partially upheld. An interesting and unexpected moderation effect was found between self-criticism and self-compassion. It was expected that self-compassion would fully moderate the relationship between self-criticism and PTSD symptom severity, however, results show that self-compassion only moderated this relationship when the level of self-criticism was low. This suggests that the interaction between self-criticism and self-compassion is more complex than originally thought. Implications of the findings as well as ideas for future research are discussed.

Early clinical observations and more recent clinical studies have identified that individuals with Posttraumatic Stress Disorder (PTSD) commonly experience difficulties with anger and anger expression. However, no exploration of this relationship has been undertaken in samples of mentally disordered offenders (MDOs), despite the high levels of PTSD and anger-related difficulties identified within this population. The current study explored the relationship between PTSD and anger in a sample of 44 mentally disordered male and female offenders. Participants completed self-report measures that examined posttraumatic symptomology, trait anger, anger expression and alexithymia. Results indicated that PTSD was prevalent within this sample although no participants had received a formal diagnosis. PTSD was tentatively related to trait anger, although this was no longer the case when the effect of gender was taken into account. PTSD and anger expression were also related, although PTSD did not predict anger expression when trait anger was controlled. Alexithymia was found to be predictive of trait anger. The findings indicate that a diagnosis of PTSD should be considered in samples of MDOs. Furthermore, interventions aimed at addressing anger and anger expression in the context of PTSD might be effective. Treatments for anger might also be effectively supplemented by addressing emotion regulation skills.

Objectives: Posttraumatic stress disorder (PTSD) is a universal phenomenon, but evidence suggests psychological processes involved within its aetiology and maintenance have cultural variations. Leading PTSD models agree that autonomous appraisals are central to PTSD but give little consideration to the influence of culture. However research suggests individuals from cultures with primarily independent self-construals make more autonomous (e.g. control, responsibility) appraisals for everyday events. This could have significant implications for PTSD models. This study's objective was to assess cultural differences in everyday appraisals and provide a novel examination of cultural differences in appraisals of trauma. Design: A total of 90 participants (49 Independent, 41 Interdependent) were recruited from the community. A 2 (culture; Independent vs. Interdependent) x 2 (memory: everyday vs. trauma) mixed design was utilised. It was predicted that the Independent group would show elevated autonomous appraisals for the everyday memory. The trauma condition was exploratory. A correlational analysis of the relationship between appraisal patterns and PTSD symptoms was also conducted across cultures. It was hypothesised that a negative association would be observed between elevated PTSD symptoms and autonomous appraisals in Independent but not Interdependent cultures. Results: Cultural differences were reported for several appraisals themes, however methodological limitations prevented firm conclusions regarding control and responsibility appraisals. Cultural differences also emerged in the relationship between trauma appraisals and posttraumatic symptoms. Some unexpected relationships arose, but as anticipated, the Interdependent group's psychological well-being correlated with interpersonal appraisals rather than autonomous appraisals typical within Independent cultures. Conclusions: This study highlights the complex relationship between culture and PTSD. The central findings support claims that whilst PTSD is a universal phenomenon, the appraisal themes involved may not be. There is a clear need for further research to clarify these initial findings and where necessary develop culturally appropriate assessment measures, models and interventions for PTSD.

The field of traumatic stress recognises that the impact of traumatic events can extend beyond those immediately exposed. However, in the past decade, research has been dominated by Post-traumatic Stress Disorder (PTSD) with less focus on how the greater majority, who do not develop PTSD, accommodate traumatic experiences into their lives. The Foreign and Commonwealth Office (FCO) has approximately 4,800 diplomat officers serving in 170 countries. Officers may be exposed to a disaster while on a short-term posting overseas, i.e. of two to four years duration. Adopting Charmaz's (1990) social constructivist approach to grounded theory, this qualitative study aims to explore how a disaster event is experienced from the perspective of the spouses of these British diplomats. Semi-structured interviews were conducted with ten participants. The analysis led to a theory, captured in an emergent model, of the temporal pathway of the lived experience of a disaster event for the spouses of British diplomats. It can be described as follows: Locating Multiple Self-Aspects at the Point of Disaster; Encountering Disaster; Immersion; Dissonance; Consequences; Disaster Endures. The core category - Incorporating Disaster into the Self-Concept- occurred in each phase of the model. The results may be helpful for both clinicians and policy makers working with this population. 23

A growing body of research has indicated that the levels of suicidal behaviour are particularly heightened among individuals with Posttraumatic Stress Disorder (PTSD). Two theoretical models of suicide, the Cry of Pain Model of suicide (CoP; Williams, 1997) and the Schematic Appraisals Model of Suicide (SAMS; Johnson, Gooding & Tarrier, 2008) have proposed that perceptions of defeat and entrapment are key components of the psychological mechanisms which drive suicidal behaviour. The SAMS has also emphasized the importance of psychological resilience factors for preventing suicide risk. Resilience to suicide has been recently defined as a set of appraisals which buffer the impact of risk factors on suicidal behaviour. The first aim of this thesis was to investigate the role of perceptions of defeat and entrapment in suicidal behaviour in those with full or subthreshold PTSD. The second aim of this thesis was to obtain empirical evidence for the presence of resilience factors to suicidal behaviour in PTSD. Initially, a comprehensive narrative review and a meta-analysis were conducted to examine the magnitude of the association between various forms of suicidal behaviour and a PTSD diagnosis and the role of comorbid depression in this association. Both, the narrative review and the meta-analysis demonstrated a strong positive association between suicidal behaviour and PTSD, and supported the mediating impact of comorbid depression in this association. A re-analysis of a previous dataset of individuals with PTSD was also pursued to establish the relevance of negative perceptions/appraisals to suicidal behaviour in those with PTSD. Next, three empirical studies were designed to investigate the utility of perceptions of defeat and entrapment in explaining suicidal behaviour in those with full or subthreshold PTSD. The outcomes across the three studies supported the hypothesis that defeat and entrapment represent the proximal psychological drivers of suicidal behaviour in PTSD and fully account for the suicidogenic effects of negative self-appraisals and PTSD symptoms. Two additional empirical studies were conducted to examine resilience factors to suicidal behaviour among individuals with full or subthreshold PTSD. The first of these studies provided evidence that high levels of perceived social support buffered the impact of PTSD symptoms on suicidal behaviour. The last study supported the efficacy of a resilience-boosting technique, the Broad-Minded Affective Coping procedure (BMAC), to enhance the experience of positive emotions and improve mood amongst individuals diagnosed with PTSD. Together, the current results support the SAMS' postulation concerning the role of perceptions of defeat and entrapment in the emergence of suicidal behaviour in PTSD and highlight the importance of boosting resilience as a means of targeting suicidal behaviour in those with PTSD. Clinical implications of these findings are outlined throughout the thesis.

The experience of positive personal growth, termed posttraumatic growth (PTG), following significant illness events, has become increasingly prominent as a topic of interest. The evidence indicates that higher levels of PTG are associated with numerous positive health-related outcomes, including reduced physical complications and increased survival. Based on such findings there have been recent efforts to incorporate PTG into cognitive-behavioural clinical interventions. Such efforts appear theoretically justified, with the prominent model of PTG emphasising a central role of cognitive processing in the development of growth. The first paper presented here critically reviews recent evidence pertaining to the relationship between cognitive processing and PTG. Whilst the literature appears to support the role of cognitive avoidance, positive reappraisal, and threat appraisals in the development of PTG, there are mixed conclusions and significant limitations to existing research. The evidence base needs substantial development, a greater theoretical foundation, and improved conceptual clarity before it provides sufficient empirical grounding upon which to develop clinical interventions. The second paper presented here focuses specifically upon stroke survivors. Within the stroke literature there remains a heavy pathology-focus and little attention has been paid to positive outcomes, which may lead to a biased understanding of post-stroke adjustment. The empirical paper reports on a cross-sectional survey study investigating PTG and its correlates in 87 stroke survivors. The findings extend the highly limited evidence base indicating the possibility of PTG after stroke. Higher levels of post- stroke PTG were associated with social support and positive appraisal patterns. The findings also justify further research into the role that demographic and stroke-specific factors play in the development of post-stroke PTG. Clinically, the pattern of associations found indicates that stroke rehabilitation should incorporate a greater psychosocial focus in order to promote positive outcomes.

Research on the interpersonal impact of Post Traumatic Stress Disorder (PTSD) is a developing area. The work presented here builds on this growing dimension of PTSD research. A narrative literature review examines the development of the concept of PTSD, the existing research on the interpersonal impact of trauma, and alternative approaches to treatment. It highlights a clear need to consider a more systemic way of working by broadening our perspective of PTSD wider than the just the individual. The research paper presented uses Interpretative Phenomenological Analysis (IPA) to explore couples' experiences of their relationship surrounding a trauma. The research identified themes of; losing the person you love; isolating versus needing support; PTSD affects roles, responsibilities and dynamics; and the dyadic nature of moving on from trauma. A critical review of the design and process of research is presented followed by the ethics documentation for the application and approval of the research.

This study aims to explore resiliency and its relation to dissociations (healthy & unhealthy) and, examine psychoanalytic work within an inter cultural framework. Four factors are identified, elaborated and contextualised as necessary for good therapeutic intervention in working with people who endured trauma: 1) the sense of self 2) the psychic space 3) the listening other 4) healthy dissociations. The literature review is organised to explore psychoanalytic concepts relevant to the research question, and provide a foundation upon which theory and practice can be coherently linked following the clinical vignettes and discussion throughout the thesis. Two case studies! are used to illustrate and discuss the central hypothesis that healthy dissociation is an indicator of resiliency, made possible through the access to and development of the four key factors. The clinical data is presented from a relational perspective, with the view that childhood trauma and patient experiences during the developmental processes is a dual narration playing a significant role in the capacity for resiliency. Three issues specifically will be addressed: 1) the characteristics commonly associated with trauma and with resilience 2) the creation of an intra-psychic and secure state of mind with reference to Freud and contemporary psychoanalytic thinking, specifically Object Relation Theory 3) the relevance between resiliency and psychological health or lack of it The effect of trauma in adult life and its relation to earlier experiences is discussed, indicating that people with good enough environment during developmental process can dissociate healthily, therefore better managing the effects of trauma, whereas those who experienced interruptions during this developmental phase may collapse psychologically. Through the course of psychoanalytic psychotherapy, however, people can be helped to develop stronger psychic space and a better sense of self through the containing provided by the listening other: the therapist.

Surviving subarachnoid haemorrhage (SAH) patients' experience significantly reduced health-related quality of life (HRQoL) in both the short- and long-term, as well as mysterious symptoms of fatigue and sleep dysfunction. Patients’ family members and friends - who often act as their informal carers - can also experience psychosocial disability. The cause for these poor outcomes remains unknown. Traditional explanations focusing on the neurological sequelae associated with SAH or the characteristics of the illness are not satisfactory; nor are attempts to explain family members' difficulties on the basis of carer burden. The hypothesis which is tested in this thesis is that post-traumatic stress disorder (PTSD) may be abnormally high in both the SAH patient and 'significant other' (SO) population and that this may explain their outcomes. SAH patients are known to be at risk of suffering from PTSD, but it is unknown if this explains their outcome. In terms of patients' SOs, they are known to experience psychiatric symptoms and I suggest these could be caused by their development of PTSD, but this has never been examined. In Part One (Chapter 2-5), I focus on patients' outcomes. Before examining my PTSD hypothesis, I present a meta-analysis (Chapter 2) I conducted of studies which have tried to explain patients' outcome using neurological factors. I conducted the meta-analysis as a tendency for prior studies to be underpowered and use unreliable statistics could have meant that the actual importance of traditional factors was obscured. The results of my meta-analysis however did not support this possibility and instead showed traditional neurological variables did not explain patients' outcome. With this in mind, I then present a longitudinal study (Chapter 5) in which I examined one of the largest prospective series of SAH patients to establish PTS D's explanative importance. Using regression analyses, this study showed PTSD was the best predictor for patients' mental HRQoL - the domain most persistently impaired. It also helped predict patients' physical HRQoL. Moreover, PTSD was linked to sleep problems and may therefore cause fatigue. Crucially, to establish the cause of PTSD, logistic regression was performed. This showed that maladaptive stress coping strategies were the best predictor for PTSD development. In Part Two of the thesis (Chapter 6), I present my longitudinal study of one of the largest prospective samples of SOs. All SOs were assessed with a diagnostic PTSD measure and coping skills were assessed. An elevated incidence of PTSD was found in both the short- and long-term. Although SOs' PTSD did not impinge on the recovery of the SAH patients being cared for, given that it is important to ensure SOs continue caring, regression results are presented which show the cause of SOs' PTSD was (at least in the short- term) due to the use of maladaptive coping strategies. The overarching conclusion is that the elevated incidence of PTSD in SAH patients and SOs helps explain why they experience psychosocial disability. In the final part of the thesis (Chapter 8) the clinical and theoretical implications of this conclusion are considered, such as that teaching patients and their SOs more effective coping skills might prevent PTSD and psychosocial disability.

Background: Differential relationships of the dimensions of psychopathy with external factors indicate that psychopathy can be conceptualised as a multifaceted syndrome comprised of distinct subgroups of psychopaths (Blackburn, 1988). However, it is not known whether similar subtypes of psychopathy exist across cultures. The research question which this thesis sought to answer was: Do subtypes of psychopathy exist among murderers, and if so, might the prevalence of these subtypes differ across cultures? Three aims were addressed: i) to compare the trauma histories, dissociative experiences and psychopathic features of British and South African men convicted of murder and the associations among them; ii) to test potential aetiological models of psychopathy; and iii) to explore whether subtypes of psychopathy could be identified among men convicted of murder. Method: Participants were 120 adult male prisoners serving sentences for murder. Sixty participants were British and incarcerated in prisons in England and 60 participants were South African and incarcerated in South Africa. Trauma, dissociation and psychopathy were measured using the Trauma History Questionnaire (THQ; Green, 1996), the Dissociative Experiences Scale (DES; Carlson & Putnam, 1993) and the Psychopathy Checklist-Revised Second Edition (PCL-R; Hare, 2003a), respectively. Results: South African participants reported significantly more traumatic and dissociative experiences and possessed more psychopathic features than their British counterparts. Structural equation modelling (SEM) analyses of the entire sample revealed that trauma was positively and directly related to the behavioural features of psychopathy, whereas trauma was positively and indirectly related to the affective features of psychopathy via the partial mediating role of dissociation, suggesting that subtypes of psychopathy may exist among murderers. In addition, cluster analyses identified subtypes of psychopathy, two of which parallel variants of primary and secondary psychopathy described in the literature. Conclusions: Dissociation may mediate the relationship between trauma and psychopathy among individuals who have experienced high levels of trauma, suggesting that there may be a threshold or a ‘cut-off’ level at which witnessing or experiencing trauma becomes detrimental for one’s psychological health. The prevalence of certain subtypes of psychopathy may differ across cultures. Findings have theoretical implications as well as implications for the treatment and risk assessment of offenders.

Background Post Traumatic Stress Disorder (PTSD) describes a cluster of symptoms that commonly occur as a reaction to a traumatic event. Hallmark symptoms are intrusive memories of these events. Such intrusive re-experiencing in the initial aftermath of trauma is a common experience and is believed to be part of normal adaptation. However in some individuals these symptoms will persist with often devastating consequences. Little is known about factors which might determine differential presentation following trauma. Evidence suggests that characteristics of early intrusions, including whether they are experienced as distressing or not, are predictive of PTSD. A factor implicated in such a negative experience is maladaptive appraisal of the trauma event and its aftermath (Ehlers & Clark, 2000). Studies have shown relationships between maladaptive trauma-related thoughts and beliefs (such as those measured by the Post Traumatic Cognitions Inventory (PTCI; Foa, Ehlers, Clark, Tolin, & Orsillo, 1999) and level of post-traumatic psychopathology. Method This study directly manipulated these potentially maladaptive cognitions, using Cognitive Bias Manipulation (CBM) techniques, with the intention of altering the quality/quantity of intrusions following an analogue trauma experience. Participants completed negative or positive training designed to alter trauma related beliefs, before experiencing distressing films. In the week following the laboratory session, participants completed diaries recording quantity and quality of their film related intrusions. Results Intrusion number was not influenced by CBM training condition, but the distress experienced during the intrusion was, with positively trained individuals experiencing less distress. CBM training succeeded in influencing both degree of distress from intrusions and the post-film scores on the PTCI, which were themselves correlated with participants' distress. Conclusion This study is the first of its kind to show that it is possible to manipulate appraisal of trauma-related beliefs, and furthermore that such an intervention affects analogue trauma symptoms. Implications for clinical application are discussed.

There is growing evidence to suggest that post-traumatic stress disorder (PTSD) can occur in a minority of people after an acute life-threatening illness such as myocardial infarction (MI), cardiac arrest (CA), cerebrovascular accident (CVA) and haemorrhage. To date, there has been no attempt to link these research findings with psychological models of PTSD. The purpose of this literature review was to investigate whether Ehlers and Clark's cognitive model (2000) is a useful framework for conceptual ising illness-related PTSD. The introduction describes the search strategy used, the diagnostic criteria for PTSD and the prevalence of illness-related PTSD. Ehlers and Clark's cognitive model of PTSD (2000) is outlined and the rationale for using this particular model is explained. The relationships between each component of the model are then discussed with regard to the illness-related PTSD literature and the evidence to support the use of the cognitive model within a medical population is critically evaluated throughout. Methodological limitations are discussed as they arise, with common problems being discussed more fully at the end. A small modification to the model is proposed, to account for the impact of medical symptoms on the PTSD experience. Finally, the clinical implications of the review are discussed.

Individuals who suffer a traumatic medical event, such as diagnosis of life-threatening illness or invasive treatment, are now recognised as at significant risk of posttraumatic stress disorder (PTSD) and PTSD symptomology (DSM-IV, (American Psychiatric Association, 1994)). Yet, these individuals also have the opportunity to transform their negative experience into a positive, life-changing experience; a process known as posttraumatic growth (PTG) (Tedeschi & Calhoun, 1996). Given this apparent dichotomy, this review attempts to integrate the literature on these phenomena, to identify the common variables involved in producing these outcomes. Published studies were included if they focused on adult medical populations (of 18 years and above) and assessed predictor variables of either PTSD or PTG. Exclusion criteria applied to studies were; articles where samples included family and carers, studies that implemented interventions, qualitative studies and studies without objective, standardised psychometric measures. A total of 27 studies were included in this review (18 PTSD; 9 PTG). Similarities and dichotomies in the literature were found, indicating that both phenomena may be inextricably linked. In general, sociodemographic and medical variables showed inconclusive patterns of prediction. Instead psychological and interpersonal factors, namely personality and coping styles, were found to have a consistent influence on outcomes. Methodological limitations and recommended future directions in the research are discussed, as are the implications for clinical practice.

Objective. Previous empirical studies provide support for the development of posttraumatic stressed is order following traumatic brain injury. This study investigated the nature of intrusive symptoms experienced by people with traumatic brain injury and explored the relationship between the severity of brain injury, PTSD symptomse, motional adjustment and appraisals. Method. Twenty four patients with traumatic brain injuries who had no explicit memory for the accident were interviewed using the CAPS and were asked to complete four questionnaires on PTSD severity, posttraumatic cognitions and emotional adjustment. Results. A descriptive analysis of participants' reports indicated a considerable number of intrusive symptoms among the sample with intrusions relating to the accident, waking up in hospital and preoccupation regarding the changes in people's lives following TBI. Correlations provided no evidence for an association between PTSD severity and severity of brain injury. The findings suggest that negative posttraumatic appraisals are associated with severity of PTSD type symptoms as well as with emotional maladjustment in this client group. Conclusions. It is suggested that PTSD models can be useful in understanding the mechanisms involved in the posttraumatic reactions and difficulties of emotional adjustment following traumatic brain injuries. This has serious clinical implications that need to be examined further.

All human experiences have an effect on the brain, and in the form of memories and cognitive biases, affect the response of the individual to future events. When people experience traumatic events the brain is sometimes impacted in extreme ways, with major consequences for the individual in the form of psychiatric illness. This study is concerned with examining the way in which the prior experience of traumatic events affects the processing of simple stimuli under experimental conditions, in order to understand better the types of cognitive biases involved in psychiatric illnesses. The study used a well-established computerized test of selective attention, inhibition of return (IOR), and a newer task involving facial expressions and gaze cues. A review of the use of the IOR paradigm in different adult psychiatric disorders was conducted in order to aid interpretation of the findings. The mental health status of the participants was described by use of a number of standardized questionnaires. Participants were people in contact with Adult Mental Health services who had experienced trauma, including those with Posttraumatic Stress Disorder (PTSD), Psychosis and other psychiatric diagnoses. Results were compared with a healthy control group. Despite small sample sizes and heterogeneity within the groups, the study indicated that significant trauma can be associated with different types of mental health problem, and that different mental health problems are associated with different types of cognitive processing difficulty. The Psychosis group showed a lack of inhibitory processing, which is likely to be associated with increased distractibility, and, for example, lack of the ability to follow a train of thought. This is different from the distractibility seen in PTSD, which can be characterized as a tendency for attention to be captured by a salient stimulus without appropriate subsequent disengagement.

This client study of a 23-year old woman begins by exploring post-abortion distress in context with hypnosis, and identifies particular themes across symptoms that indicate that hypnosis may be an appropriate adjunct to therapy for this problem. For treatment a three-phase framework was used as proposed by Brown (1995) for PTSD. Symptom changes were monitored throughout the course of therapy in a multiple-baseline design. The client also completed pre- and post-therapy questionnaires. The therapeutic outcome is described with reference to data collected from weekly monitoring and from written feedback regarding the client's own feelings about the therapy. The results indicate that the therapeutic interventions improved specific symptoms as well as general mental health and it is concluded that hypnosis may be a particularly appropriate adjunct to therapy for post-abortion distress.

This thesis set out to investigate some of the variables associated with, and the processes and mechanisms of, positive change following trauma and adversity, or adversarial growth, in diverse populations. A systematic and comprehensive review of the literature (Chapter 2) identified the state of knowledge, and pointed to a number of salient directions for future research. Some of these directions were pursued in the subsequent empirical chapters. Five empirical chapters (Chapters 3 –7) examined a range of variables and processes in adversarial growth, using a variety of populations. Using two large student samples, it was found that emotion-focused coping mediated the association between subjective distress and adversarial growth, and that emotional intelligence was a potentially key variable in the role of emotions in adversarial growth (Chapter 3). A longitudinal study of people who had been severely traumatised and were suffering chronic psychological distress revealed that the experience of positive change predicted lower psychological distress and negative change six months later (Chapter 4). Vicarious processes in adversarial growth were investigated in therapists, and it was shown that the working alliance may be a core channel through which the process of vicarious growth operates (Chapter 5). Extending this focus on vicarious processes, in two samples of disaster workers, and funeral directors, it was shown that psychosocial variables were more salient in their associations with adversarial growth than professional experience variables. Specifically, the role of cognitive processing was emphasised, together with an exploration of the novel area of death attitudes (Chapter 6). A more explicitly existential focus, using three samples of churchgoers, members of the general population, and funeral directors, addressed the role of Yalom’s ultimate existential concerns and adversarial growth. Negative death attitudes were shown to be consistently associated with more negative changes and fewer positive changes, but the associations with negative changes were mediated, in some instances, by the presence of meaning in life and satisfying close relationships, consistent with theoretical predictions. Further, aspects of the organismic valuing theory of growth through adversity were tested, and broadly supported (Chapter 7). The concluding chapter (Chapter 8) reviewed the main findings from the thesis, identified ongoing questions from the literature, and indicated salient directions for research, including an emphasis on the clinical applications of adversarial growth.

In 1999, Tarrier, Sommerfield and Pilgrim (1999) demonstrated that individuals with PTSD showed a poorer treatment outcome if they lived with relatives who were high in Expressed Emotion (EE). However, no exploration of how this effect was mediated was made at the time. The current study is an initial exploration into the possible links between Expressed Emotion and PTSD. Possible variables linking the two concepts were identified through an examination of the theoretical models of both EE and PTSD. These variables were then measured in a one off interview session with individuals prior to the onset of treatment. The EE level of their key identified relative was also calculated during the session through a measure which examines the individuals' perception of their relatives' behaviour. The findings demonstrated an association between the perceived level of EE of the relative and the cognitions about the world and the cognitions regarding self-blame held by the individual with PTSD. As this was only an exploratory study, findings were not specific enough to guide more theorising as to the links between EE and PTSD. However, the findings did suggest useful avenues of further research.