Search

Background: Team formulation is an increasingly popular practice within Clinical Psychology. However, the extant literature is limited to a small body of peer-reviewed research which employs unstandardised definitions and reports varied implementation of team formulation in practice. The absence of a consistent understanding and practice of team formulation complicates both the identification and evaluation of key processes that enable workable team formulation practice. Describing practice-based instances where Clinical Psychologists have experienced workable implementation allows for identification of the key characteristics of this practice as well as an understanding of the factors that might help/hinder implementation. Aims: In the context of Clinical Psychology practice in the UK, this study aimed to: 1. Characterise the perceived forms, functions, and outcomes of team formulation 2. Understand whether/how team formulation is evaluated 3. Identify factors that may support/obstruct perceived 'best practices' in team formulation - based on practice-based examples of successful and unsuccessful implementation Method: We conducted an online survey of 49 UK Clinical Psychologists with experience of involvement in team formulation in practice. Participants were asked to describe two detailed examples of team formulation in practice. Further, participants answered questions regarding team formulation implementation and evaluation. Professional membership networks, social media, and snowballing were used for recruitment. Responses to free text questions were analysed using Framework Analysis. Results: Seven types of team formulation with different functions were found based on examples form practice. These had varying foci and key features. Further, evaluation was targeted at three levels: (1) Service-level indicators; (2) Team formulation indicators (quality, perceived effectiveness and staff experience); and (3) Service user-level indicators. However, issues of specificity, sensitivity and validity were noted for reported measures/methods. A number of factors perceived to support and obstruct team formulation were identified and were common across team formulation types. Managing teams' distress within team formulation sessions was an important factor for successful implementation. Factors such as the group structure, managing difference, the level of collaboration and engagement, and linking the team formulation to meaningful changes to practice were also highlighted as factors supporting workable implementation. Conclusion: This study highlights specific team formulation functions and forms which could be used to standardise practice. Further, proposed common factors that facilitate workable implementation across team formulation types are provided. This study offers an understanding of workable team formulation in practice, however, there remains a dearth of understanding about "effective" team formulation. Future research should focus on validating and testing the identified helpful factors to further our understanding of team formulation process-outcome links.

Nurses working in acute mental health services are vulnerable to occupational stress. One main stressor identified has been the challenging behaviour of some service-users (Jenkins & Elliott, 2004). The impact of challenging behaviour is far reaching. It affects the health and safety of staff, service-users and carers, negatively impacts the overall experience of care (Beech & Leather, 2005; NICE, 2014; 2015) and can increase risk of abuse, isolation and neglect of service-users and increase stress and strain amongst caregivers (Emerson, Robertson, Gregory, Hatton, Kessissoglou, Hallam, & Hillery, 2000; Rose, Nelson, & Hardiman, 2016). Challenging behaviours, in particular incidents of violence and aggression, are a complex manifestation of a combination of characteristics. Challenging behaviour has been found to be the term most often cited as the reason for the use of restrictive interventions on incident forms (Ryan & Bowers, 2006). The use of unnecessary restrictive interventions has been widely criticised, particularly following the Winterbourne View Inquest (DoH, 2012) and national guidance states that it should only be used as a last resort to manage imminent risk (NICE, 2015a). A number of political drivers have attempted to end the use of unnecessary restrictive interventions (Mind, 2013). However, a Freedom Of Information request (FOI) made by Norman Lamb MP has found that the use of physical restraint on inpatient wards remains high. The central aim of this research was to explore how qualified mental health nurses construct the challenging behaviours they experience on the wards, and how they talk about its management. A number of studies have explored how staff account for their treatment decisions and have shown how dominant practices are enabled and maintained through language (Harper, 1995; Parker, Gergaaca, Harper, McLoughlin & Stowell-Smith, 1995). This research is informed by a critical realist stance. Semi-structured interviews were used to elicit talk about challenging behaviour and its management with seven voluntary participants, all inpatient mental health nurses recruited from the acute and PICU Wards of two NHS mental health hospitals. Interviews were analysed using discourse analysis, informed by both discursive psychology (Potter & Wetherell, 1995) and Foucauldian discourse analysis (Foucault, 1979) approaches. It was found that staff drew on a dominant biomedical discourse which acted to legitimise restrictive interventions and marginalise psychosocial and emotional constructs and approaches. Systemic discourses were also drawn on to both justify and criticise the use of coercive approaches and to position both staff and service-users as disempowered. Thus, challenging behaviour and restrictive interventions could be argued to represent tools for both groups to recover control.

Background Trauma exposure is common throughout the world, yet only a small minority of people in the population develop post-traumatic stress disorder (PTSD). Increasingly research has demonstrated that adverse life events (e.g., relationship breakdowns) that do not meet PTSD diagnostic criterion, can produce effects comparable to major trauma causing significant psychosocial impairment. Existing trauma therapies recommended by National Institute of Clinical Excellence (NICE,2005) are limited to Trauma-focused Cognitive Behavioural Therapy (TF-CBT) and Eye Movement Desensitisation Reprocessing (EMDR). Whilst both therapies have achieved evidence-based status having accumulated a large body of research supporting their use, their tolerability and longevity of effects remain questionable. Brain Work Recursive Therapy (BWRT) is a new addition to the psychotherapy arena. Not yet subject to controlled research, the positive claims regarding the effectiveness of BWRT are limited to anecdotal evidence. Yet, BWRT appears to share procedural elements compatible with EMDR, namely dual taxation of working memory (WM) which is a key mechanism considered to influence outcome in EMDR. However, questions remain regarding if, and how, BWRT works, therefore, this current study is considered an important piece of work towards the efficacy and evidence development of this nascent therapy. Method This exploratory study utilised a multiple single-case experimental design (n=6) and implemented a psychosomatic, mixed-method approach. An A-B-C design was adopted which included baseline, intervention, consolidation and two follow-up phases, at one month and two months post-intervention for each participant to evaluate the stability of any effects. Results Four participants showed reliable and clinically significant reduction in traumatic stress symptomology from pre-intervention to 1-week post-intervention, which were maintained or further improved at subsequent follow-ups. Overall, concurrent improvements were also found on measures of psychological distress and Quality of Life. In-session ratings of memory vividness and arousal decreased markedly following the introduction of recursive loop(s), offering potential support for the WM account of dual taxation. All participants experienced a rise in parasympathetic activity and a decrease in heartrate (HR) at the end of treatment, indicative of arousal reduction which was coherent with reductions on self-reported arousal ratings. Furthermore, four participants showed an increase in heartrate variability (HRV) variables from pre- to post-treatment. Qualitative findings revealed five participants had found BWRT helpful and considered the intervention responsible for change. In particular, limited exposure to the trauma memory and the immediacy of improvement experienced by participants was cited as positive aspects of the therapy. Conclusion To conclude, this was an exploratory study offering the first controlled research of BWRT. The results demonstrated an overall improvement with both psychological tests and HRV measures. Despite the limitations identified with regards to measurement, these initial case series findings offer support for the effectiveness of BWRT for non-complex trauma; a finding that was substantiated by participants' qualitative reports. Future research recommendations include the use of additional physiological measurement, working memory assessments to determine the effects of working memory capacity on outcome and the use of dismantling studies to decompose the multi-components of this nascent therapy.

Background Waiting lists for clinical psychology services in the UK are long. A low-cost, transdiagnostic waiting list intervention could improve experiences and initiate processes of psychotherapeutic change. Guided Acceptance and Commitment Therapy (ACT) self-help holds promise in this regard - with evidence supporting its efficacy in other contexts - but has not yet been tested as a waiting list intervention. Moreover, research needs to explore underlying change-processes. Do outcomes (where present) follow the predictions of the Phase Model of Psychotherapeutic Outcome (PMPO), and are outcomes mediated by psychological flexibility, and its theorised sub-components, as posited by ACT? Method A multiple-baseline single-case experimental design was utilised to explore participant outcomes in psychological flexibility (and its theorised subcomponents), well-being, symptomatology, and life-functioning, during a 10-week phone-guided ACT self-help intervention. Analysis assessed levels of clinical/reliable change, and graphical plots of weekly scores were subjected to visual analysis utilising dual criterion and percentage of non-overlapping data methodology. Average percentage change on each measure was also calculated. Participants then engaged in a post-intervention change interview to triangulate results. Results Seven participants were recruited, with three participants completing the full 10-week intervention. Of the three who completed the intervention, two experienced clinically significant improvements in psychological flexibility, well-being, and symptomatology, and trends towards improvement in life-functioning, and the other participant experienced no significant changes in outcomes. The greatest average percentage improvement was in well-being, followed by symptomatology, then life-functioning - as predicted by the PMPO. However, visual analysis of weekly outcomes indicated a temporal order whereby symptomatology changed first. Links between psychological flexibility and outcomes were supported, with changes in psychological flexibility preceding or co-occurring with other outcomes, and indication that processes relating to "openness to experience" were most influential. Outcomes experienced by the four individuals who withdrew from the intervention were both supportive and counterintuitive to the main results; however, external life-factors, and the reduced number of completed weeks, reduce the generality of the results. All participants attributed outcomes to both life-events and the intervention and placed emphasis on the positive impact of the guiding phone calls. Feedback also indicated that the intervention requires adaptation to improve accessibility prior to future implementation. Discussion Results indicate that a guided ACT self-help intervention produces outcomes that are (1) evidenced to predict later therapeutic results, (2) partially follow the temporal predictions of the PMPO, and (3) are likely mediated by changes in psychological flexibility (in particular "openness to experience"). The utility of the single-case experimental design has been supported, however, its limitations need to be considered when generalising results. Future research should continue exploration into ACT processes, and the application of guided ACT self-help interventions in such populations.

Background: Involvement with psychotropic medication is not traditionally viewed as an aspect of the clinical psychologist's job, and there are currently no professional guidelines advising on a role. International research suggests that psychologists are likely to encounter a variety of opportunities to become involved, and are frequently (indirectly) involved in the process of prescribing and managing of clients' psychotropic medications. There is a lack of research into psychologists' involvement with psychotropic medication in the United Kingdom (UK), but given the widespread use of psychotropic medication similar opportunities and practice may occur. The collective clinical psychology profession is also taking an increased stance against biological approaches towards mental health, such as issuing guidance on use of diagnosis and promoting movement away from its use. The question remains as to whether the professional movement with diagnosis extends into any role with psychotropic medication, be this a critical stance or any other. Aims: This study aimed to explore whether clinical psychologists in the UK have a role with their client's psychotropic medication by exploring forms of involvement undertaken, and decision-making behind involvement. Method: A mixed method design was employed; 147 clinical psychologists took part in an online survey, and 11 respondents were interviewed. Descriptive statistics, logistic regression, and thematic analysis were used to analyse the quantitative and qualitative data respectively. Results: Results suggest that clinical psychologists are engaging in various forms of involvement with medication on a regular basis, often with intent to influence prescribing based on their agendas. A thematic map was created identifying a process by which clinical psychologists weigh up factors prior to deciding to have involvement in order to establish their rationale, and then flexibly navigate their approach and actions. This all occurs within the context of professional uncertainty and conflict, under dominant societal narratives around epidemiology of mental health difficulties and the effectiveness of medication. Following involvement, participants reflected on their strategy which led them to consider future approaches. Conclusions and Recommendations: Findings echo previous international research; clinical psychologists recruited in the study are regularly engaging in roles with their client's psychotropic medication. This is despite lack of guidance from professional bodies, no professional position statement, and minimal (or no) teaching during training. To the author's knowledge this is the first study to explore the topic area within the UK. Study findings are considered important due to uncovering the extent to which involvement forms part of the role, which was previously unknown. Findings translate into two main clinical implications: 1) supporting the idea of training on psychotropic medication for clinical psychologists, and 2) professional guidance to inform clinical psychologists' practice.

Background. The evidence base that has been established for hearing persons has demonstrated that experiences of hallucinations and delusions are shaped by the individual's context and the culture of their local community (e.g., Kent & Wahass, 1996; Stompe et al., 2006;Yamada, Barrio, Morrison, Sewell, & Jeste, 2006). The Deaf community has a distinct culture to the general British population, carrying with it different beliefs and social rules for living. However there is no research exploring the specific content and themes of hallucinations and delusions for deaf persons despite an understanding that; a) the content of these experiences reflect individual context and culture for hearing persons; and b) the personal meaning ascribed to these experiences (i.e., content reflecting their local culture and community) is necessary to understand the individual's feelings, distress and associated behaviours (Chadwick, Birchwood, & Trower, 1996; Strauss, 1991). Study Aims. The aim of the current study was to explore d/Deaf adults' experiences of hallucinations and/or delusions within the context of unique experiences of being d/Deaf and Deaf culture. Method. Multiple Sequential Functional Analysis (MSFA), a structured case study approach was used to track the developmental nature of hallucinations and/or delusions in a sample of three d/Deaf men from a secure specialist Deaf service. Multiple data sources were collected for each individual; participant interviews, file reviews and interviews with a professional. The data was triangulated to develop MSFA sequences of the individual case histories. An across-case analysis was also conducted of the MSFA sequences that intended to identify common themes that were shared across the participants. Thematic analysis was used as a structured approach to identifying shared themes in the across case analysis. Results. The analysis identified two key findings. Firstly, unique experiences of being deaf and Deaf culture appeared to shape the content and themes of delusions with regards to delusions of grandeur. The second important finding was that there was a lack of information regarding the content of hallucinations for all the participants despite access to 113 documents in the file review process. It was therefore not possible to analyse how the content and themes of hallucinations were shaped based on the individuals learning history and unique experiences of being d/Deaf. Conclusions. The lack of content specificity indicates a clear clinical implication that we need to better understand how to support d/Deaf individuals in psychiatric services to understand and communicate their inner experiences. The significance in understanding the personal meaning of hallucinations for clinical interventions is acknowledged within hearing mental health (e.g. Chadwick et al., 1996) yet there appears to be barriers in accessing this information for d/Deaf persons in secure psychiatric services.

Background: Psychological formulation is a central process in many contemporary evidence-based psychological therapies. Formulation is also considered a core competency of clinical psychology training and practice and is heavily referenced throughout professional standards and guidelines. Despite the significance of formulation in clinical psychology and within wider mental health professions, there is limited evidence to show that formulation benefits the client or improves outcomes in therapy, including the working alliance and measures of distress. Considering the status of psychological formulation, further research is required to examine whether formulation impacts outcomes in therapy. Aims: The key aims of this study was to investigate whether (1) formulation impacts on working alliance and (2) there is a relationship between formulation, working alliance and psychosocial outcomes. To address these research questions, the study delivered a CBT intervention, incorporating 'product' and 'process' formulations to adults experiencing low mood. Method: The study used a repeated single-case A-B, mixed methods design. The design included a non-treatment baseline phase (A), measuring weekly symptoms of low mood and was followed by the intervention phase (B), which consisted of eight weeks of CBT focussing on low mood. The CBT intervention incorporated two 'product' formulations (in session 3 and 7) and 'process' formulations, which were delivered throughout. Participants and the therapist completed weekly measures at the end of each session, which included measures of working alliance, depression and well-being. Change interviews were also undertaken at the end of therapy to triangulate results. Data analysis mainly included visual analysis, simulation modelling analysis and clinical/reliable change. Results: Seven participants were recruited, with five participants completing the full eight week CBT intervention. The analysis showed a slight relationship between formulation and working alliance, although evidence was not robust enough to confirm whether formulation directly impacts working alliance. The results showed mixed findings in terms of the relationship between formulation, working alliance and psychosocial outcomes measured. Although over half of participants showed an improvement in depression and two improved in wellbeing, it was not possible to attribute these changes specifically to formulation. Discussion: This study contributes to a dearth in the literature surrounding the impact of formulation on outcomes in CBT. The findings discussed are mixed and although tentative conclusions can be made that formulation, particularly the product formulation may have contributed to elements of the working alliance, it is not possible to state that formulation directly impacted on the working alliance. The study also highlights the complexity of psychotherapeutic research and the challenges of disentangling processes to draw conclusions on what variables contribute to changes in outcomes. The utility of single-case designs enables researchers to study complex therapeutic processes using a scientific methodology, ultimately bridging the gap between research and clinical practice. This study provides a platform for future research into formulation and should further consider some of the limitations discussed, e.g., does the accuracy of process formulations mediate the working alliance, is it possible to separate the working alliance from the process of formulation.

Public speaking anxiety (PSA) is a common problem, and in some cases can lead to significant social and occupational difficulties. While exposure therapy combined with cognitive restructuring is currently the most effective treatment available, approximately 25% of individuals fail to respond. Acceptance and Commitment Therapy (ACT), a third-wave behavioural approach predicated on supposed different mechanisms of change, may have additional benefits to more traditional interventions, and may be more acceptable to those individuals with PSA who find exposure based therapy too difficult. A multiple single-case design was used to examine the effects of a self-help ACT intervention for PSA on self-reported, implicit, imaginal, and in-vivo outcomes, across six replications. All participants reported a reduction in speech anxiety, with evidence of reliable change in three cases. The four participants who reported an increase in willingness to approach a feared public speaking scenario, also completed an in-vivo voluntary speech task. Triangulation of quantitative (daily and weekly measures) and qualitative data (change-interview) indicate that mindfulness (self-as-context and present-moment awareness) may be a key mechanism of change in ACT for individuals with PSA. The findings offer support for ACT delivered in a self-help format to treat speech anxiety, however, further research is needed to generalise these findings and examine the long term effects.

Attitudes towards sexual offenders have been widely studied in forensic psychology and criminology research over the past 25 years. At present, however, studies examining these views are predominantly descriptive in nature. That is, self-report questionnaire measures are typically distributed to different groups (e.g., general public samples, and members of different occupational categories), with the resultant between-groups differences being reported in research papers. While these studies have provided some interesting findings, the results gained from them fail to inform researchers about the psychological mechanisms that underpin views about this offending population. The overarching aim of this thesis was to begin to fill this knowledge gap. That is, a range of studies were designed to use robust experimental methods, within validated theoretical paradigms, in order to examine some of the potential constructs that influence people’s attitudes towards sexual offenders. Chapter 1 presents a review of the current state of the field in relation to attitudes towards sexual offenders, with gaps in current knowledge being identified. In Chapter 2, the theoretical framework within which the empirical aspects of the thesis operate is set out. Key constructs in this section include dual-process cognition, and our reliance on implicit (i.e., non-conscious) mental processes when making decisions. Chapter 3 builds upon criticisms of one measure of attitudes towards sexual offenders in order to reconceptualise its use into one of an outcome measure. This is then used throughout Chapters 4, 5, and 6 as a measure of sentencing and risk judgements, in order to examine the effects of various experimental manipulations. Studies presented in Chapter 4 found that heuristic-based processes based around the principles of availability appear to influence decision-making about sexual offenders at the macro (political) level, but not at the micro (individual) level. Instead, individual participants’ attitudes and judgements about sexual offenders were dependent on different primes relating to the representativeness (Chapter 5) and affect (Chapter 6) heuristics. Chapter 7 offers a discussion of the empirical findings presented at earlier points of the thesis, and outlines opportunities to develop further work into the heuristic-based nature of attitudes towards sexual offenders. The work contained within this thesis is original, in that well-validated theoretical models are used to begin to examine the psychological mechanisms that may underpin attitudes iii towards sexual offenders. The apparent dual-process nature of such views calls into question some previously-expressed calls within the literature that presenting fact-based information about sexual offenders may lead to improvements in societal attitudes. Instead, it may be that more indirect and emotional methods may be required to achieve such aims. Towards the end of the thesis, clear opportunities for further work are set out, as are some of the potential implications of this research.

Background. Non-epileptic attack disorder (NEAD) is one of the most common differential diagnoses to epilepsy. Due to the impact of misdiagnosis, research has focused on improving differential diagnosis by identifying factors distinguishing the two populations. These factors, though non-specific and common place comprise much of the understanding of the aetiology of NEAD. Theories which adequately explain the processes by which attacks develop and are maintained are lacking. Although it is agreed that psychological processes underpin NEAD, therapeutic approaches targeting specific processes are under developed. In light of the limitations of currently employed structural approaches, a functional approach may improve understanding of possible mechanisms underpinning NEAD development and maintenance. Aim. This study aimed to use Multiple Sequential Functional Analysis to explore whether behavioural principles of learning, applied to detailed life histories, can be used to understand the developmental pathway of non-epileptic attacks. Method. Three adult participants were recruited from outpatient Neurology clinics in the East Midlands, UK. Clinical interviews were conducted using a biographical format to collate detailed information around all aspects of the participant’s histories, current situation, and non-epileptic attacks. To improve the hypotheses made, interview data was triangulated with data from an interview with a relative and a file review. The MSFA was conducted according to the principles of radical behaviourism and applied functional analysis. Data was utilised in the analysis based on the pragmatic truth criterion of functional contextualism. Results. The results are three detailed functional analytic case studies that track the development of non-epileptic attacks for each participant from formative experiences to their current attack experiences. The results demonstrate that functional analytic principles can be used to understand the developmental pathway of NEAD in these three adults. Though the participants had very different experiences and presentations, an across-case analysis identifies that attacks have similar functional values for these people. Issues including avoiding/reducing stress and emotional suppression appear to be important factors in the development and maintenance of the behaviour. Discussion. The findings that non-epileptic attacks hold functional value for this group of people, supports the theorised roles of avoidance and secondary gain in the developmental process. The findings have important implications for future research. A strength of the present methodology is that it identifies subtle differences in the learning histories, which has implications for the development of assessment and treatment approaches for those with NEAD.

Background: Obesity rates are growing globally along with the associated health and economic consequences (Caballero, 2007). However, weight loss is difficult, highlighting the need to address the psychological challenges of obesity (Wing & Phelan, 2005). Obesity is linked with emotional eating (Torres & Nowson, 2007). Therefore, interventions which may tackle emotional eating may address obesity. This study evaluated the effectiveness of an Acceptance and Commitment Therapy (ACT; Hayes, Strosahl & Wilson, 1999) intervention which has been considered helpful for this clinical problem. Method: Six participants engaged in a five week guided self-help ACT intervention. Utilising an AB single case experimental design (SCED) and follow-up, participants completed a range of implicit, explicit and behavioural assessments; targeting areas such as emotional eating, psychological ACT processes (referred to hereafter as ACT processes), Body Mass Index (BMI), and daily recordings of calorie intake and mood. Reliable and clinically significant changes were calculated on self-report measures. Simulation Modelling Analysis (SMA) examined the relationship between mood and calorie intake across baseline and intervention phases. Results: Half of the sample no longer met the criteria for “emotional eating” at follow-up. On the self-report measures, all participants “recovered”1 on at least one ACT-specific process, whilst two participants “recovered” from emotional eating. There was some evidence of temporal precedence whereby changes in the ACT processes occurred, prior to, or alongside, changes in emotional eating. SMA revealed a decrease in emotional eating in the intervention phase compared to the baseline phase for some participants. Inconsistencies were found between the implicit and explicit measures of emotional eating. Postintervention, four participants lost weight, three of whom maintained the weight loss at follow-up. All participants reported benefits from ACT. Discussion: Given the current obesity epidemic and the associated adverse consequences, finding an effective intervention for weight management is critical. This study resulted in four important findings; (a) ACT proved promising for some participants in reducing emotional eating and shifted the ACT process 1 Achieved both reliable and clinically significant change (Davies & Sheldon, 2011). 3 variables in a positive direction; (b) There was some evidence that ACT processes mediated changes in emotional eating. This has important theoretical implications as it indicates that mindfulness, defusion, values and acceptance influence emotional eating. Although theories have hypothesised this to be the case, this study provides empirical support. However, more single case research is required to demonstrate the replication of effect prior to refining weight management interventions; (c) Improvements in emotional eating measures did not reduce weight in all cases. This suggests that ACT alone, or in its current modality, may not be sufficient for behavioural change. It is suggested that more intensive input may be needed, or that ACT may make a useful adjunct to standard behavioural interventions. Nevertheless, in terms of cost-effectiveness, the brevity and modality of this intervention is a promising start, and (d) There were mixed findings regarding the impact of the intervention on the implicit emotional eating measure; correspondence with the explicit measure occurred for some participants. The utility of implicit measurement in targeting attitudes, behaviour or initial responses in this sample is questionable.

Background and aims: In the UK, the illegal use of anabolic androgenic steroids (steroids) among recreational gym-users has been increasing alongside a growth in the number of steroid-users accessing harm reduction services. Steroid-misuse has therefore become a public health concern. This study explored first-hand experiences of steroid-users’ attitudes towards and motivations for using steroids. It also explored whether and how societal and individual pressures as well as barriers and facilitators influence steroid-users’ decisions to use steroids. One key aim was to develop a Theory of Planned Behaviour (TPB; Ajzen, 1988; 1991) questionnaire. This study also examined the application of TPB variables (attitudes, subjective norms, perceived-behavioural-control and their respective underlying beliefs) to account for the variations in intention to use steroids. Finally, the study explored the differences between steroid-users and non-steroid-users in terms of the TPB variables (i.e., differences in explanation of actual past or current behaviour, and predictions of future intentions within a steroid-user group), as well as their underlying beliefs towards steroids. Methodology: This study used a cross-sectional mixed methodology (exploratory sequential design). The study utilised the TPB theoretical framework and consisted of two phases: (I) A qualitative exploration of steroid-use, leading to the development of a TPB questionnaire and (II) The use of the developed TPB questionnaire to investigate participants’ future intentions concerning steroid-use or non-use.188 adult male recreational gym-users (113 steroid-users and 75 non-steroid-users) participated in this study. Participants were recruited from various online social media (e.g., Facebook, bodybuilding forums) and from Addaction within Lincolnshire, where paper copies of the questionnaire were available. Results: Findings from phase one led to the development of the TPB questionnaire as well as providing novel insights to explain reasons for steroid-use (e.g., reduced natural testosterone levels, self-protection) accounted for outside the TPB framework. During phase two, hierarchical multiple regression revealed that a positive attitude towards steroid-use among users is the most 3 important contributing factor for explaining future intentions to use the drug. Findings from the two individual logistic regressions and between group comparisons highlighted that steroid-users’ attitudes towards steroid-use and perceived-behavioural-control (i.e., a higher level of positive control and factors that enabled steroid-use) were higher than non-users. Non-users’ normative beliefs (i.e., a perceived increase in negative social pressure and disapproval from significant others) were higher than users. Conversely, users perceived a positive outcome of steroid-use whereas non-steroid-users perceived an increased negative outcome of steroid-use for behavioural beliefs. Finally, independent t-tests identified particular beliefs and factors that the groups differed on (e.g., non-users mostly reported unfavourable consequences of steroid-use). Conclusions: This study provides evidence that the application of the TPB can be useful in understanding an individual’s future intentions concerning steroid-use or non-use. The TPB could be used in future research as a template for the development of harm reduction, awareness and education programmes. Furthermore, it may be applied within clinical practice by supporting healthcare professionals to develop specific interventions to target the TPB variables in order to help reduce the use of the drug.

This study sought to explore how men experienced their transfer from prison in the criminal justice system, to being detained indeterminately in mental health services, under the Mental Health Act, for treatment and rehabilitation. An exploratory qualitative method using thematic analysis was adopted throughout the research process. Eleven participants were recruited with each participant engaging in one semi-structured interview. The data was collected and analysed employing a six-stage process, following the guidelines by Braun and Clarke (2006). Four main themes were constructed, with some themes consisting of smaller subthemes: Shifting Identities, Understanding and Negotiating, Engaging with Therapy, and Making Sense of Time. The core of the thematic analysis constructed suggests that individuals found that the process of transfer had a direct impact on their perception of self, causing shifts in identity. The main features which supported their view of self was that of ‘being a patient’ in a system; a system which held power to make important evaluations about them as individuals. This linked directly to a second theme where participants described a process of familiarisation and adaptation to their environment. This was constructed as a strategy which supported participants to set up assumptions and expectations about being detained for treatment in a high secure hospital. The process of transfer and adjustment was underpinned by existing hierarchies of power. This research offers a unique contribution to the current literature by illustrating that the process of transfer has a significant effect on individuals, highlighting the need to support individuals to make sense of this process and their new environment. Given the limitations of the study future research incorporating a wider constituency of participants, including those who may have moved on from high secure services would add useful insights into this experience. The clinical implications suggested by the study include the need for psychological therapy in this setting to focus more upon the impact of transition, with wider consideration by clinicians of the impact of social identity on the process of treatment and rehabilitation for this population.

Over the past 15 years psychological therapy for people with Intellectual Disabilities (ID) has been increasingly advocated (e.g., Linington, 2002) and successful treatment outcomes of psychological therapies for this population have been highlighted in a number of studies (e.g., Beail, 1998). However, the processes underlying these successful treatments are uncertain and some authors argue that success could be attributed to person-centred counselling rather than the specific approach adopted (e.g., Beail, 1998). Current literature highlights a substantial gap and an increasing need for research that identifies conditions under which the effects of therapy are optimised for people with ID through the exploration of barriers and facilitators to positive therapeutic change. This thesis explored the experiences of Clinical Psychologists (CPs), their clients with an ID and the client’s carers, with regards to the perceived barriers and facilitators to positive therapeutic change. Furthermore, this research aimed to develop a cohesive understanding from the multiple perspectives of the topic area. A triadic case design was utilised in which two triads of the CP, clients with ID and carers were nested by one CP. Therefore one ‘case’ constituted one CP, two of their clients (with ID) and two carers. Three of these cases were recruited and therefore this study had 15 participants and as the CPs were interviewed twice (once regarding each client separately) 18 interviews were completed. Thematic analysis was deemed to be an appropriate methodology to address the gap in qualitative research with people with ID. This methodology allowed the exploration of participant’s accounts whilst enabling the flexibility that is required to accommodate the varied abilities of people with ID. From the analysis of the transcripts of the 18 semi-structured interviews, five super-ordinate themes and one central theme were identified based on their frequency and salience from participants across all three participant groups. The first super-ordinate theme, ‘what the client brings’ encapsulated a number of factors related to the client that participants perceive to be initial barriers within therapy, namely, the ID itself (e.g., communication skills, memory) and the client’s engagement in therapy. A second super-ordinate theme that the client also brings to therapy is their ‘wider system’. This theme encompasses the facilitating role that a wider support network can play and also the barriers that the wider system can bring with regards to the negative influence of others on the client. A third super-ordinate theme related to ‘therapy factors’ that are generally perceived to be facilitators to overcome the barriers that clients bring to therapy. This included therapy adaptations and the therapeutic relationship. The fourth super-ordinate theme, namely ‘the mental health GP’ encompasses the concept that psychologists are required to coordinate the often extensive wider system of people with ID and this is because participants felt that in order to benefit from individual therapy, all of the client’s needs must be met, including physical health needs and ensuring that the client lives in an appropriate environment. Given the four super-ordinate themes noted above, all of these concepts foster the fifth super-ordinate theme ‘systemic dependency’. The mere presence of an ID means that naturally people are more dependent on others. As a result, therapy factors including the therapeutic relationship and adaptations to therapy (e.g., increased longevity of therapy) can foster strong attachments which can facilitate an unhelpful level of dependency. Additionally, the client’s wider system can also become dependent on services to help them facilitate care and coordinate the numerous services involved. All of these super-ordinate themes maintain the concept of the ‘revolving door’ into services. Additional subthemes noted in the extended paper are examples of barriers and facilitators to therapeutic change that are considered to have an important impact on therapy but were only noted by one group of participants (e.g., clients) and thus did not contribute to cohesive understanding of multiple perspectives aimed for within the journal paper. For example, clients reported confidentiality to be a barrier and CPs reported attachment difficulties of clients to be a barrier. The results of this study offer the first explorations of conditions under which therapy can be optimised for people with an ID through the awareness of barriers and facilitators to positive therapeutic outcomes. CPs are shown to be skilled at overcoming barriers within therapy; however there appeared to be a process of facilitators creating more barriers within therapy and the phenomenon of the revolving door needs to be fully considered. Given the potential impact of funding constraints on the role of CPs and access to psychological therapies for people with ID, this has important implications for the way psychologists working within this population market themselves and further evidence their work.

Background: Research indicates that it is the non-therapeutic factors such as warmth, empathy, understanding and therapeutic alliance that are most effective at creating change. The use of the therapists’ own identities has been highlighted as a means of enhancing such non-specific factors. The literature suggests that 90% of therapists disclose something about themselves to clients; however therapist disclosure is a contentious issue. Furthermore, literature suggests that for therapists working with stigmatised or minority groups (e.g. sexual minorities) disclosure can be beneficial. Guidelines suggest that therapist disclosure of sexual orientation (TDSO) should be used judiciously, while others suggest that TDSO could be classed as the therapist displaying sexualised behaviours towards the client. Aim: This study aimed to understand the purpose of lesbian, gay, bisexual and trans (LGBT) therapists’ disclosing sexual orientation to clients, while exploring their perceptions and experiences of disclosure. Method: This study employed a mixed methods design. Purposeful sampling was used to recruit 53 participants from an international sample of LGBT therapists, through professional body listservs and an LGBT therapist directory, to complete an online survey. From this survey 17 participants were purposively sampled to take part in a semi-structured interview. Quantitative and qualitative analysis methods were utilised. Results: The findings highlighted that 81.1% of the online survey sample reported that they had disclosed their sexuality to a client, with the majority stating that they mainly disclosed to non-heterosexual clients and 73.6% of participants stating that they were not aware of any guidelines related to using TDSO. Chi-square test of independence found that there was no significant association between therapists’ awareness of guidelines and TDSO. A Mann-Whitney U analysis revealed that there was no significant difference between participants post qualification experience (years) and making a disclosure. Three main themes were derived from the qualitative analysis: 1) Function of 1415, RPV, UoN: 4194596, UoL: 12353909, Research Portfolio & Viva Page 10 of 202 disclosure; 2) Function of non-disclosure; 3) How disclosure happens, each of these themes have between two and five subthemes. Conclusions and recommendations: TDSO was shown to occur mainly with non-heterosexual clients. Disclosure was highlighted to facilitate the enhancement of the therapeutic alliance and create a safe, non-judgemental space for sexual minority clients. However, therapists expressed that concealing their sexuality was common when working with heterosexual clients because of fear of judgement and personal safety. Psychological effects were also noted due to therapists’ concealment. Disclosure was found to happen in various contexts, with direct verbal disclosures being one of many ways that sexuality was disclosed. It is suggested that supervisors and training courses need to acknowledge the psychological impacts of therapists concealing their sexual identity by showing an understanding of how concealment can lead to increased stress for professionals who are trying to maintain focus on the clients. Sexuality is seen as a key characteristic of being human and concealing it is like trying to conceal your gender or ethnicity. Future guidelines need to reflect the experience of non-heterosexuals working within a heteronormative society and understand the importance of therapists’ rationales for making disclosures.

Research into rape-supportive cognition has been hampered by methodological problems such as social desirability. The study of so-called implicit cognition has been dominated by explanations that the effects produced on implicit/indirect measures are mediated by associations held in memory. The Implicit Relational Assessment Procedure (IRAP; Barnes-Holmes et al., 2006) offers an alternative perspective. Derived from Relational Frame Theory (RFT, Hayes, Barnes-Holmes & Roche, 2001), here it is applied for the first time to study the malleability of implicit rape-supportive cognition, following a cognitive-restructuring task in university males. The relationship between implicit (IRAP) and explicit measures (the Acceptance of Modern Myths about Sexual Aggression scale (AMMSA) Gerger, Kley, Bohner & Siebler, 2007), and behaviour was explored (measured by a forced-choice task and ratings of the researcher). IRAP scores did not change following the intervention. Behaviour on the forced-choice measure was predicted by IRAP scores but not by scores on the AMMSA. Additional analyses into the predictive ability of the AMMSA and IRAP measure on behavioural measures (charity-box overall giving score and Researcher Rating Scale) were conducted. Findings from hierarchical multiple regression analyses indicated that the AMMSA predicted none of the variance whereas the IRAP predicted 12.4% and 11.5% of the variance respectively.

This thesis explores mental health nurses’ perceptions of boundaries with service users in acute mental health inpatient settings. This is against a backdrop of notions of recovery implying a relaxation of boundaries, but with an increasing dominance of concerns with risk. This thesis is divided into two sections, with the first part containing a journal paper that is ready for submission. The second section, an extended paper, is required to be read alongside the journal paper. The extended paper contains more detailed information that could not be presented within the journal paper. The journal paper concentrates on the main literature about recovery approaches and service users’ views about the relaxation of boundaries as part of their recovery, alongside barriers to the relaxation of boundaries within the acute mental health inpatient setting. It highlights the gap in the current literature which the thesis aims to address. In order to build a theory about what mental health nurses within the acute psychiatric setting perceive as boundaries with service users, a grounded theory methodology was used. This was used to analyse transcripts of semi structured interviews carried out with the mental health nurses. Three descriptive categories were constructed from the analysis relating to how mental health nurses perceive boundaries: the socially constructed nature of boundaries; the perceived need for boundaries; and enacting boundaries. Theoretical categories were constructed to embed the analysis in the broader cultural setting. The extended paper sets the research against a broader background about recovery approaches and the dominance of the discourse about risk aversion. It specifically explores boundaries in relation to recovery principles and risk, as well as factors that may hinder the relaxation of boundaries, such as stigma and othering. It offers additional information about the methodology and analyses of the data. It has a detailed reflection and memos about the research process. The results section concentrates on factors that impact on mental health nurses perceptions of boundaries. The theoretical categories are presented which aim to account for the data gained, rather than to just describe it.

Background: Stigmatisation negatively affects those being stigmatised. Anti-stigma campaigns suggest that biogenetic explanations reduce attributions of personal responsibility towards those with a mental illness. This study focused on one experience: Voice-hearing, which is associated with mental illness, namely schizophrenia, but may be considered to be a common experience, as at least 10% of the general population will hear voices at some point in their lives. There are multiple theories on the mechanisms that underlie voice-hearing experiences. However, each theory has strengths and limitations and there is limited empirical evidence to support the view that one theory is superior to others. The primary aim of this study was to test whether attributions, emotional responses and behavioural intentions towards voice-hearers were sensitive to differential conceptualisations of voice-hearing. The secondary aims were (a) to test attribution theory and identify attributions and emotional mediators that influence behavioural intentions and (b) to explore the extent to which various socio-demographic characteristics influence attributions. Methodology: 1,004 members of the general public were recruited using online resources. They completed self-report questionnaires online. Attributions, emotional and behavioural responses were measured using an adapted attribution questionnaire, which also contained questions related to familiarity. Results: Analysis of Variance (ANOVAs) found that four out of five attributions were not sensitive to conceptualisations offered. The attribution of personal responsibility was sensitive to conceptualisations. Responses from the biogenetic conceptualisation were significantly lower that the responses from the cognitive conceptualisation. There was no statistical significance between conceptualisations and (a) emotional responses (b) behavioural intentions, or (c) behavioural outcomes. Mediation analyses indicated that there was an indirect relationship between four out of five attributions and behavioural intentions, which were mediated by emotional responses. Fear was the strongest predictor of coercive behaviours and was negatively associated with helping behaviour. The construct ‘pity’ appeared to be viewed as a negative emotion, as results for this construct were similar to those of anger and fear. Correlation analysis demonstrated a small-to-medium sized relationship between behavioural intentions and behavioural outcomes, which was added to an adapted attribution pathway model. Additional analyses found that stressful life experiences produced neither a direct nor an indirect relationship with behavioural intentions and appeared to be the least stigmatising of the six causal explanations. Further correlation analysis found that professional familiarity was associated with a reduction in attributions of dangerousness. However, there were only small associations between socio-demographic variables and attributions. 1314, RIP, UofN:4149204, UofL:06075465 Research Project Resubmission Page 9 of 193 similar to those of anger and fear. Correlation analysis demonstrated a small-to-medium sized relationship between behavioural intentions and behavioural outcomes, which was added to an adapted attribution pathway model. Additional analyses found that stressful life experiences produced neither a direct nor an indirect relationship with behavioural intentions and appeared to be the least stigmatising of the six causal explanations. Further correlation analysis found that professional familiarity was associated with a reduction in attributions of dangerousness. However, there were only small associations between socio-demographic variables and attributions. Conclusions: These finding are unique in that they extend research into stigmatising attributions towards voice-hearers and extend attribution theory. The biogenetic conceptualisations lowered attributions of personal responsibility, but mediation analysis suggests that attributions of personal responsibility were positively associated with increased social distance and coercive behavioural intentions. These results have clinical implications as the differences between medical and psychological approaches reflect the different conceptualisations offered to service-users within mental health services. The least stigmatising conceptualisation appeared to be Family Intervention. This was the only conceptualisation that utilised a bio-psycho-social model, Future research should focus on whether, in practice, this would be the least stigmatising conceptualisation used within mental health services. Further consideration should be given to its use in future anti-stigma campaigns.

Background: An estimated one in ten adolescents living in the community will engage in deliberately self-harming (DSH) during their lifetime. This perplexing behaviour is of growing clinical concern and appears to be increasing in prevalence, yet continues to be without definitive understanding. There are multiple theories on the underlying mechanisms of DSH, however, there is limited empirical evidence to support these theories. The present study aimed to investigate whether Young’s schema theory could provide a comprehensive framework to understand DSH in adolescents from the general community. This study aimed take a unique perspective on DSH by investigating the theorised unconscious cognitive constructs, known as Early Maladaptive Schema’s (EMS’s), which may underlie this behaviour. It also explored the relationship between EMS’s and psychopathology within this sample. Methodology: 252 adolescents recruited from internet forums and social networking sites completed a series of self-report questionnaires online. DSH was measured using the Deliberate Self-Harm Inventory. Early Maladaptive Schema’s were measured using an age downward version of the Young’s Schema Questionnaire-short form. The Brief Symptoms Inventory was used to measure psychopathology, and a demographics questionnaire was designed to gather pertinent additional information. Results: Correlational analyses indicated positive relationships between frequency of DSH behaviours and intensity of 13 of the 15 EMS’s. Despite no association found between the overall EMS score and general psychological distress, when each EMS was considered individually, relationships were found between the intensity of each of the 15 EMS’s and the general measure of psychological distress. Hierarchical multiple regression, controlling for gender and general psychopathology, indicated that the Emotional Deprivation, Vulnerability to Harm, Subjugation and Self-Sacrifice EMS’s accounted for a unique proportion of the variance in DSH behaviour. Conclusions: These finding are unique in that they extend the research into both DSH and EMS’s in adolescents. From the findings one could broadly conclude that, as Schema Theory states, DSH is a coping strategy used to manage unbearable memories, emotions, cognitions, and bodily sensations associated with EMS’s, with positive correlations between the intensity of the EMS’s and the frequency of DSH, and the intensity of the EMS’s and increased psychological distress. Further, during this time the EMS’s Emotional Deprivation, Vulnerability to Harm, Self-Sacrifice and Subjugation are more predictive of DSH than alternative EMS’s. When comparing these findings to the wider literature, one could conclude that EMS’s are unstable in adolescents, as those EMS’s causing distress in an individual’s adolescence may not continue to do so into their adulthood, yet the coping strategy may remain the same. This highlights the role of social, environmental and biological changes in the stability of EMS’s. The pertinence of these findings to adolescents who DSH, the overlap with broader psychological symptomotology, and its relevance to clinical practice is discussed.

Objectives: We examined the psychological consequences of termination of pregnancy for fetal abnormality (TOPFA). The impact of individual coping styles as well as a number of obstetric factors were assessed to determine their relevance in relation to the psychological impact of this event Additionally, when faced with health related decisions, individuals will have an idea about the level of input or control they wish to take (control preference).We aim to explore whether disparity between an individual’s control preference and their perceived levels of control in relation to a) their decision to terminate and b) by which method increased their levels of distress. Design, Setting & Sample: A cross-sectional cohort study was performed on a community sample of 122 women who had terminated a pregnancy for fetal abnormality. Methods & Outcome Measures; The construct of control preference for health related decisions was assessed in the context of a TOPFA. This, obstetric factors, social support, and coping style (predictor variables) were used to investigate psychological outcome on standardised questionnaires which measured depression, anxiety, grief, and post-traumatic symptoms. Four parallel hierarchical regression models were developed. Results: Termination of pregnancy for fetal abnormality is associated with a range of symptoms on standardised measures of psychological morbidity. Clinically relevant determinants included social support and a range of coping styles, namely: denial, behavioural disengagement, self-blame and acceptance (protective). Conclusion: Coping is a psychological construct of significant importance within the context of TOPFA. Behavioural disengagement, denial and self-blame all predict worse outcome. In contrast good social support and coping through acceptance predict better outcome on standardised questionnaires which measured depression, anxiety, grief, and post-traumatic symptoms.

Background: Unpredictability is identified as a major factor in Multiple Sclerosis (MS) and reported to be a “constant companion” for individuals living with MS. It is reported to be a factor of uncertainty, which is indicated to have a biopsychosocial impact on these individuals. However the impact of uncertainty is argued to diminish over time. Whereas, the lived experience of unpredictability is reported to be continual. Furthermore, unpredictability is argued to have a continual psychological effect on individuals with MS. However, unpredictability is an aspect that remains relatively unaddressed in the research. Qualitative research has been highlighted to be fundamental in exploring the individual experience of illness, providing rich detailed descriptions. In addition it has been instrumental in the development of services to meet the needs of these individuals. The significance of unpredictability in MS highlights the need for further exploration of lived experience of this aspect of the illness to support healthcare professionals and the development of services to meet the needs of these individuals. Aim: This study aimed to address the limited research examining unpredictability in MS, to develop a comprehensive understanding of how this aspect affects the lives of individuals with MS. Method: This study employed a qualitative design. Twelve participants were recruited through the MS Society, local advertisements and by a ‘snowballing’ sampling technique. All participants lived in England, had a diagnosis of MS, and were able to provide consent to participate. Individual interviews were conducted (7 face-to-face and 5 telephone interviews) using a semi-structured interview. Interviews were transcribed verbatim and analysed by the researcher using a thematic analysis (TA) approach. Results: Three main themes were derived from the analysis: 1) Challenges to meaning-making; 2) A wide picture of unpredictability; and 3) Surviving unpredictability. Each of the themes generated between two or three sub-themes. The themes told the participant’s story for living with unpredictability. Conclusion and recommendations: Unpredictability was reported to be a key factor of living with MS, yet it was challenging and difficult to understand. Participants described the wide reaching impact of unpredictability influencing them personally and socially. Pragmatic and psychological approaches were employed by participants to deal with unpredictability. The findings offer insight into the individual’s experience of living with unpredictability. It is argued the findings represent individuals who have reached a stage of acceptance with their illness and therefore may offer health professionals guidance around how to support individuals who have not been able to come to terms with the unpredictability of their illness. Furthermore, the findings highlight the wide reaching impact of unpredictability emphasising the importance of the family team. These findings may offer health professionals guidance around providing family education and support to help develop a cohesive network of support for the individual and the family experiencing the effects of unpredictability in MS.

Introduction: Numerous accounts have been developed which portray sex addiction and the sex addict. These in turn have led to screening tools, said to be capable of accurately distinguishing the sex addict from non-addicts. However, there are a wealth of various, diverse and conflicting understandings of addiction, sexuality and sex addiction. Sex addiction also carries moral implications, leading some to argue the term is used as stigmatising label for those who deviate from a socially constructed sexual standard. Despite the clinical significance of the growing use of the term, to date there has been a dearth of research which has critically reflected on sex addiction as a concept, and the meaning for those who identify as sex addicts. Objective: This study aimed to explore a seminal text and screening assessment’s description of sex addiction; as well as sex addicts and nonaddicts’ own descriptions of their sexual behaviour and perspectives on sexual addiction; using a qualitative methodology sensitive to the adaptable and social and historical contextual aspects of discourse. Design: A primarily Foucauldian Discourse Analysis approach was taken in the analysis of data from text and semi-structured interviews. Method: Data was collected from the book “Out of the Shadows: Understanding Sex Addiction” (Carnes’, 2001), and the “Sex Addiction Screening Test – Revised” (Carnes, Green & Carnes, 2010), as well as from nine interviews conducted with men identifying as sex addicts and non-addicts from both the UK and USA. Results: The findings demonstrated three main discourses: A Loss of Control, ‘Good’ vs. ‘Bad’ sex, and a Cultural Imperative to Intervene in Sex Addiction. The study demonstrated expert, addicts and non-addicts talk about sex addiction show a number of similarities and some select distinctions. The ways in which sex addiction was talked about were complex and at times inconsistent. Scientific, psychological and moralistic discourses were commonly drawn on to position sex addiction as distinguishable from ‘normal’ sexual behaviour. Health and biomedical discourses were also drawn on to manage accountability, and to construct the sex addict as sick, naïve and disempowered. Correspondingly there was a reciprocal-construction of experts as credible and impartial in being able to identify sex addiction. These experts and wider society were necessitated to identify and protect against a projected exponential rise in sex addiction, catalysed by the advance and accessibility of Internet pornography. Discussion: The study offers new understanding on the discourses of sexual addiction and the subject positioning, actions and subjectivities it creates and restricts for those identifying as sex addicts. Those discourses identified correspond with contemporary discourses surrounding addiction and sexuality; though offer novel permutations which invite further research. The results of this study ascertain that there is a need for healthcare professionals to reflect upon the risks of uncritical acceptance and practice using the sex addiction label, given the breadth and diversity of discourses it encompasses.

Introduction: Diagnostic systems conceptualise different eating disorders as discrete entities, identified at a particular point in time. However, research shows there is much overlap between ‘anorexia’ and ‘bulimia’, and the most prevalent diagnosis is ‘Eating Disorder Not Otherwise Specified’ (EDNOS), when people fail to meet full criteria for other diagnoses (Fairburn & Bohn, 2005). When considered from a longitudinal perspective, eating disorder diagnoses and behaviours also tend to change over time, a phenomenon called ‘diagnostic crossover’. Although it is accepted that the prevalence of ‘diagnostic crossover’ in eating disorders is high (e.g. Eddy et al., 2002), the process through which it occurs is poorly understood. Authors have suggested that higher movement from ‘anorexia’ into ‘bulimia’ may represent an inability to maintain restrictive eating and have deliberated about a ‘natural course’ to the eating disorders. Although physiological and psychological effects of starvation suggest this may play a part (Polivy, 1996), some people avoid diagnostic crossover and others move from ‘bulimia’ into ‘anorexia’, which suggests additional factors are involved. Other researchers have proposed that clinical and personality variables such as low self directedness influence these transitions (Tozzi et al., 2005), but the results are inconsistent. Eating disorder therapies are underpinned by psychological models, but these are theorised on the basis of eating disorder diagnoses, which for the reasons above may be invalid, and ignore transitions between them. Although some theories acknowledge crossover (e.g. Fairburn, Cooper & Shafran, 2003), they fail to fully account for the process. Since anorexia binge-purge type, and therefore the acquisition of more eating disorder behaviours, is often associated with poorer outcomes (e.g. Carter et al., 2012, Favaro & Santonastaso, 1996, Herzog, Schellberg & Deter,1997), better understanding of the way eating disorders change over time could improve outcomes and quality of life for patients. Objectives:To investigate the experience of diagnostic crossover, which will be referred to as ‘eating disorder transitions’ to represent the phenomenon as a process rather than a discrete event. This aims to gain a better understanding of the process through which this occurs, and improve insight into the trajectory of eating disorders to further our understanding of them. Methods: Twelve people with a history of transitioning between ‘anorexic behaviours’ (more restrictive eating) and ‘bulimic behaviours’ (bingeing and/or purging) were interviewed about the experience. The results were analysed using ‘Thematic Analysis’. Results and Discussion: Participants’ eating disorders tended to focus on restrictive eating before cycles of bingeing and purging developed in a staged process. The effects of certain life experiences either triggered a change, or facilitated the emergence of these different eating disorder behaviours. When the expression of eating disorders was inhibited and underlying emotional difficulties remained, the eating disorder changed to a different form to compensate. Since participants continually valued being thin, bingeing and purging behaviours were evaluated much more negatively than phases of restrictive eating and led to risky behaviours. The findings suggest that attempts to change eating disorder behaviours without helping patients manage their underlying difficulties first should perhaps be avoided.

Overview Female Perpetrated Sexual Abuse (FPSA) remains a largely under-studied and poorly understood phenomenon, despite its growing prevalence. Traditional gender constructions in relation to victimisation and perpetration as ‘gendered’, may be stifling its recognition, and the recognition of those affected. Survivor’s perspectives on disclosure are crucial, given its known under-reporting, and how many people feel silenced. As research on FPSA is in its relative infancy, understanding the process of disclosing is particularly important in influencing professional and social change, and progression. Method Fourteen participants of equal gender distribution, who self identified as having been sexually abused in childhood by a female, were recruited online. The study was advertised via online survivor communities, survivor charities and forums supporting survivors. Participants were directed to a website designed by the Researcher outlining the study in its entirety. Participants then offered their consent to participation and contacted the researcher via the website. Telephone interviews were arranged and conducted with participants meeting eligibility, using a qualitative semi-structured interview protocol. Interviews were transcribed and systematically analysed using a qualitative methodology applying an Inductive Thematic Analysis approach (Braun & Clarke, 2006). Results Four super-ordinate themes relating to participants disclosing sexual abuse by a female were discussed, with one being a central and over-arching theme ‘Perceptions of Gender and Disclosure’, which influenced the three further themes; Perceptions of Gender and Disclosure; consisting of ‘social attitudes’, ‘gender roles’, ‘barrier to recognition’ and ‘barrier to disclosure’ o Decisions to Disclose; consisting of ‘relationship with the perpetrator’, ‘making sense of the experience’, effects of abuse’ and ‘readiness’ o Process of Disclosure; consisting of ‘experiences of services’, ‘contexts of disclosing’ and ‘nature of disclosure’ o Experiences of Disclosure; consisting of ‘perceived professional responses’ and ‘impact of perceived professional responses’. Conclusions Constructions of gender and narrow views of ‘perpetration’ and ‘victimisation’ appear to be stifling personal, professional and social recognition of FPSA. This lack of awareness and perceived cultural denial may be silencing survivors, and restricting their ability to disclose and process their experiences. The impact of gender appears to be two-fold and future research would benefit from exploring disclosure of FPSA for males and females exclusively, as their experiences and needs may greatly differ. The value of involving survivors in educating professionals and in widening awareness is discussed.

Background: Research indicates that although 50-60% of people who have had a traumatic brain injury (TBI) experience changes in sexual functioning, sexuality issues remain largely unaddressed in rehabilitation. Studies have investigated professionals’ perspectives about communicating about sexual issues with service-users2 post-TBI, with a number of barriers being identified. However, as studies have tended to use quantitative methodologies, it was felt that qualitative research would provide a richer understanding. Aim: This study aimed to explore professionals’ perceptions and experiences of discussing sexuality with service-users who have had a TBI. Method: This study employed a qualitative design. Purposeful sampling was used to recruit 24 participants from two local National Health Service (NHS) trusts, and from a national charity. Four focus groups were carried out with pre-existing teams of professionals, using a semi-structured interview schedule. Focus group data were transcribed verbatim and analysed using thematic analysis. Results: Six main themes were derived from the analysis: 1) Sexuality after TBI is a specialist issue; 2) Sexuality is a sensitive subject; 3) Practicalities of discussing sexuality; 4) Roles and responsibilities; 5) Dilemmas about risk and vulnerabilities, and 6) Organisational and structural factors. Each of these themes have between two and five subthemes. Conclusions and recommendations: In order that sexuality becomes accepted as an integral part of holistic rehabilitation, it is recommended that a more proactive approach is taken. It is recommended that sexuality is incorporated into assessments, and that written information is available for service-users. Support for professionals is also needed in the form of the development of policy, on-going training, and supervision.

The number of people with learning disabilities (LD) who become parents is rapidly increasing, as opportunities widen for people with LD to participate in all aspects of society. However, parents with LD continue to face negative attitudes and potential discrimination from both professionals and the wider community, based on erroneous assumptions, stemming from eugenic principles. This thesis investigated the experiences of parents with LD, with regard to the assumptions they encounter or perceive from the professionals who support them. Although previous research has established the continued existence of negative attitudes amongst professionals, no research has considered the awareness and impact of such assumptions from the perspective of the parents themselves. Thematic analysis was deemed an appropriate methodology to address the gap in qualitative research with this population, a method which allowed investigation of parents’ experiences while providing the flexibility to accommodate the particular abilities of people with LD. Semi-structured interviews were conducted with ten parents with LD, whose children remained living at home with them following an assessment of their parenting. Following analysis of interview transcripts, four overarching themes were established, based on their frequency and importance for participants. In the first super-ordinate theme, parents attributed a number of negative attitudes to professionals, at times based on directly expressed assumptions by professionals, but most often inferred without direct experience. A second related, but distinct theme was parents’ experiences of treatment by professionals. The instances of negative treatment parents described may have led to the attribution of assumptions by professionals. However, it is equally possible that parents’ pre-conception of professional assumptions influenced the way they experienced professional treatment. A third theme related to the impact of both inferred professional assumptions and treatment on parents, particularly in terms of emotional consequences and willingness to engage. Given that parents were all aware of negative assumptions, a final theme considered the extent to which parents internalised negative assumptions and applied them to themselves. Additional themes in an extended paper highlighted examples of good practice, leading to a number of recommendations for professionals working with parents with LD. For all ten parents, the importance of constructive and empowering professional relationships, as opposed to paternalistic and disempowering treatment based on outdated assumptions was emphasised. These results represent the first exploration of parents with LD’s awareness and experience of negative assumptions and stigma, and have clear implications in terms of professional approaches to working with parents with LD.

Introduction: This study investigates the experiences of individuals with autism spectrum conditions (ASC) as they experienced transition into employment in the UK. The high prevalence of ASC has led to increased social and economic pressures (Gerhardt & Lainer, 2010), with the estimated yearly cost to the UK for each individual at £90,000 (Knapp, Romeo & Beecham, 2007). Employment may help to reduce economic pressures, benefit individuals and society (Howlin, Alcock & Burkin, 2005). Individual gains in cognitive functioning (García-Villamisar & Hughes, 2007), quality of life and self-esteem (Eggleton et al., 1999) may be experienced. However, individuals with ASC tend to find transitioning to employment difficult, due to implicit characteristics associated with the condition (Berney, 2004). Transitions represent challenges to individuals’ social identity and self-concept, require behaviour change and may contribute to distress (Liddle, Carlson & McKenna, 2004). These factors may be exacerbated in individuals with ASC due to their difficulties with social and behaviour change processes (American Psychiatric Association [APA], 2010). Transition and employment support strategies have been shown to facilitate successful employment for individuals with ASC (Howlin et al., 2005). The National Institute for Health and Clinical Excellence ([NICE], 2012) propose how best to support people with ASC, based on the synthesis of available evidence. However, the evidence lacks in consideration of individuals’ experiences and psychological theories of support and transition. Considering these perspectives may facilitate service users to influence effective service provision, through disseminating their views and experiences of transition to work by means of a rigorous qualitative study. Method This study investigates the experiences of 10 participants with ASC during their transition to employment settings in the UK and aims to provide them with a platform to express their experiences and views of this process. An inductive thematic analysis methodology (Braun & Clarke, 2006) is used to explore semantic information obtained from retrospective interviews relating to the experiences of transition to work and identify frequent and salient themes within the data (Buetow, 2010). Results Analysis identified three main themes that were particularly salient and frequent for the interviewed participants: Diagnosis; comprised of subthemes ‘Access to support’, ‘Identifying with ASC’, ‘Other-understanding’ and ‘Delay in diagnosis’. Barriers to transition; comprised of ‘Socio-economics’, ‘Physical accessibility’ and ‘ASC characteristics’. Transition support; comprised of ‘Emotional needs’, ‘Clear guidance and honest feedback’, ‘Practical support’ and ‘Social integration’. Discussion Thematic analysis facilitated investigation into the experiences of 10 participants with ASC as they transitioned to work. Participants’ difficulties and needs were reflected in the existing evidence base and aims of current legislation and guidance, but short-comings in the delivery of these were also highlighted. In addition, a unique insight into both the positive and negative emotional impact of transition to work for individuals with ASC was obtained. Psychological models of support and transition are considered in relation to the experiences of transition and associated challenges to self-concept. Potential support measures for more effective and less distressing transition to work are discussed.

Background. Studies which have found high rates of intimate partner violence have identified that women use as much, if not more, partner violence than men. Research studies into the aetiology of female partner violence have identified a number of related risk factors but there is no single theory which adequately explains the processes by which partner violence develops and is maintained in the learning histories of females. Treatment and risk assessment options for this group are under developed and it is critical that research is undertaken to understand this phenomenon in order to provide effective interventions in the future. Study aim. This study aims to use a multiple sequential functional analysis to explore whether behavioural principles, when applied to the developmental histories of females, can be used to understand the trajectory of partner violence across the lifespan. Method. Three female participants were recruited from Probation and Forensic Psychology services in the East Midlands, UK. Clinical interviews were conducted with participants using a biographical format to collate detailed information around all aspects of female’s histories, current functioning and index offending. For accuracy, interview data was triangulated with data from professional interviews and file review. The multiple sequential functional analysis was conducted according to the principles of radical behaviourism and applied functional analysis. Data was utilised in the analysis based on the pragmatic truth criterion of functional contextualism. Results. The results are three detailed functional analytic case studies that show the development of partner violence for each participant from formative experiences to the current index offence. The results demonstrate that functional analytic principles can be used to understand the developmental pathway of partner violence in a small group of females. Synthesis of the three case studies identifies that violence and inciting violence in a male partner has functional value for these women and that issues such as power and control are important factors in female use of partner violence. Other factors of commonality are history of childhood and adulthood abuse, gendered belief systems, inferred insecure attachment style and borderline personality traits. Discussion. Power and control were significant factors in these women’s learning histories, both in terms of the victimisation and abuse they had suffered but also in their own use of violence and coercive behaviours. The findings that partner violence and inciting partner violence holds functional value for this group of women is controversial and directly contrasts with the feminist literature. This has important implications for future research and clinical implications. A strength of the current methodology is that it identifies subtle differences amongst learning histories, which has implications for development of individualised treatment planning and risk assessment for this under represented group.

Aim of the study The psychosocial outcome of anoxic brain injury following cardiac arrest is a relatively under researched, but clinically important area. The aim of the current study was to add to the limited existing literature exploring the psychosocial outcome for cardiac arrest survivors, but specifically explore if there is a greater impact on psychosocial outcome in individuals experiencing anoxic brain injury as a result. Methods A range of self report measures were used to compare the quality of life, social functioning and symptoms of anxiety, depression and post traumatic stress of individuals with and without anoxic brain injury following cardiac arrest. Measures of subjective memory and executive difficulties were also used to investigate whether psychosocial difficulties were associated with subjective cognitive difficulties. Participants took part in the study between six months and four years post cardiac arrest. A MANOVA was used as a primary method of analysis. Results There was a significant multivariate difference between the two groups; with individuals with anoxia reporting more psychosocial difficulties than the nonanoxia group. Participants in the anoxia group had more social functioning difficulties and more anxiety, depression and post traumatic stress symptoms. There was no significant difference in self-reported quality of life between the two groups, although better quality of life was associated with better social functioning and fewer anxiety, depression and post traumatic stress symptoms. Although there was no significant difference between the two groups in regard to self-reported cognitive difficulties, fewer reported difficulties were also significantly associated with better quality of life, better social functioning and fewer anxiety, depression and post traumatic stress symptoms. There was no significant association with psychosocial outcome and time since cardiac arrest and no significant gender differences. Conclusion As the first known study to compare outcome for cardiac arrest survivors with anoxia with those without, the results suggest psychosocial outcome is worse for individuals with anoxia. Individuals with anoxia experience significantly more social functioning difficulties and symptoms of anxiety, depression and post traumatic stress. It is suggested that the difference is due to a combination of neuropsychological, social and psychological factors resulting from anoxic brain injury following cardiac arrest, however further research is required to explore the contributing factors in more depth.

Gay Irish men over 55 grew up in the 1950s and 1960s when homosexuality in Ireland was illegal, the Catholic Church was an unquestioned dominance within society and the heterosexual family was seen as the basic unit of the Catholic state. The power of the Catholic Church, homophobia and repressive laws combined to create an atmosphere that made many people unable or unsafe to admit their sexuality. Gay men constructed their identity under a cloak of secrecy and negotiated any identity threat and conflict between their multiple identities alone. Evidence suggests that gay and lesbian individuals with religious identities face greater social and psychosocial challenges due to their identity configuration. Furthermore, the challenges faced within identity construction, and the obstacles of threat and conflict, have shown to affect an individual’s mental health. Using the interpretive lens of Identity Process Theory (IPT) the present study used a qualitative design to explore how older gay Irish men (over the age of 55) understand and construct their sexual identity and investigate the strategies they used. Semi-structured interviews were conducted with seven older gay men to explore their experiences, perceptions and understanding of being an older gay person in Ireland and the UK. Thematic analysis identified three themes i) experiences of sexual awareness and identity conflict; ii) the dilemma of ‘staying in ‘ vs. ‘coming out’; iii) dealing with identity conflict. The results suggested that many men faced challenges and barriers to constructing a stable identity. Religious and cultural experiences played a central role in Irish men’s identity acquisition and how they made sense of it. The results show ways in which identity conflicts were created and how the men developed strategies to minimise these conflicts. The study has implications for professionals working therapeutically with sexual minority clients. Recommendations are provided for improved understanding of sexuality issues concerning minority clients within therapeutic work. Health practitioners need to be willing to engage in discussion about the effect that religious and cultural influences have on a client’s well-being, as this will help support patients, reduce psychological distress and improve therapy outcomes.

Prediction of violent recidivism is an essential component of forensic in-patient assessment and treatment. The significant impact of violent recidivism upon individual victims, families and our wider society is clear. In addition, high numbers of re-admission, coupled with potential for prolonged periods of detention following revision of the Mental Health Act, present high financial costs to already limited High Secure services. With unacceptable levels of post discharge violent crime reported, increasing demand is seen for the identification of valid and reliable violence risk markers. However, recent violence risk research appears to have moved towards community follow-up studies, which hold limited utility for improvement of in-patient assessment and treatment. As such, this study set out to conduct violence risk marker research with males with Major Mental Illness in a High Secure hospital. Consideration of the existing violence risk marker research revealed positive yet inconsistent findings with regard to anger and neglect surrounding the study of frontal lobe deficits. The utility of two measures of frontal lobe ability, specifically related to reasoning and decision-making, in addition to anger expression and control, were investigated as violence risk markers for patients with Major Mental Illness. 39 male adult in-patients were assessed using the Wisconsin Card Sorting Test (WCST), the Iowa Gambling Task (IGT) and the second edition of the State-Trait Anger Expression Inventory (STAXI-2). Finally, participants’ scores on the Violence Risk Scale (VRS) were used to quantify predicted risk of violent recidivism. It was hypothesised that poorer performance on the frontal lobe measures, higher anger expression index scores and lower anger control scores, would be associated with higher violence risk scores. In addition, it was hypothesised that poorer performance on the frontal lobe measures would be associated with poorer outward anger control. Finally, it was hypothesised that these frontal lobe and anger variables would be found to be significant predictors of violence risk score. Correlational analysis revealed that the Anger Control-Out and Anger Expression indices from the STAXI-2, as well as WCST total score, significantly correlated with Violence Risk Scale score in the hypothesised directions. Following linear multiple regression, WCST total score and the Anger Control-Out index score were found to significantly and independently contribute to the subsequent Violence Risk Scale predictive model [F(2, 36)=8.175, p <.01]. Discussion embeds these findings within the context of previous literature. Strengths and limitations of this study are discussed, as well as suggestions made for future research directions. Recommendations are made for new frontal lobe screening procedures, as well as the modification or refinement of existent treatments. Finally, an extended paper is presented in complement to the journal paper. This contains additional information relating to the research context which was beyond the scope of the journal paper. Extended methodological factors are addressed, with additional findings provided. This extended paper concludes with further discussion offered and a reflective commentary drawing focus upon the research process. Examples of materials used within the study and evidence of ethical approval can be found within the appendices of this portfolio.

Introduction: There are a number of theories proposed in order to attempt to understand the behaviour of sexual offenders. A common theme that they all cover is that of the impact of thoughts and beliefs on behaviour. However, existing measures of cognitions are explicit in their nature and therefore easy to respond to in a socially acceptable way. There has recently been a move towards using implicit measures in order to increase “honest” responding to overcome this. Such measures have been utilised with sex offenders, in order to empirically investigate the process of offending as proposed by a number of theories. There is as yet no universally accepted explanation of the beliefs that sexual offenders hold about children, whether they are pre-existing and inform offending, or develop after offending in the context of justifying behaviour. The present study aimed to investigate the role of the post-offending context in the presence of ‘implicit beliefs’ using the Implicit Relational Assessment Procedure with staff who work with offender relating to children and sex. Method: The Implicit Relational Assessment Procedure (IRAP, Barnes-Holmes, Barnes-Holmes, Power, Hayden, Milne & Stewart, 2006) was administered to 20 staff who work with sex offenders from the UK Probation Service, asking them to respond to Child-Sexual stimuli. The same measure was also administered to a non-offender control group (n=20) with no experience of working with sex offenders for the purposes of comparison. An explicit measure (Cognitive Distortion Scale, Gannon, 2006) was also completed by both groups. Results: The control group were unable to discriminate between children as being sexual or non sexual on the IRAP, whereas the staff group responses indicated that they view children as the opposite of sexual. The CDS results converged with the IRAP, with the control group scoring significantly higher on this measure than the staff group. Discussion: The results indicate that there is an impact of context on beliefs about children, and also that the presence or non-rejection of child-sexual relations is not necessarily indicative of a sexual offender. The results may also suggest some methodological issues with the IRAP, which are discussed.

Introduction: There are mixed findings about whether termination of pregnancy (ToP) is a significant life event that may trigger a negative psychological reaction in vulnerable women, or whether ToP is a minor life event (or not considered a life event) with minimal or temporary detrimental effects. The quality of studies exploring these issues varies substantially in terms of sample size, sample selection and validity of measures. Existing studies do not consider the role of discourse in the construction of ToP. This is significant because discourse has the potential to influence meaning, practices, and reported psychological distress. Objectives: This study employed a qualitative methodology to explore how discourse operates through power to produce a particular 'truth' of ToP and the effects of this. Design: A Foucauldian Discourse Analysis approach was taken using Berg's (2009) model to analyse the data obtained from the interviews. Method: Initially, a document analysis was performed where literature about ToP, produced by health organisations in the UK, was collected in order to contextualise health/legislative discourse. Next, discourse was collected from interviews conducted with six South Asian women recruited from community centres in Nottinghamshire and South Yorkshire. Results: Religious and cultural discourses were perceived to have validity and worth and produced effects- discursively and through practice which influenced how women understood, experienced, and responded to ToP. The discourses identified linked together using 'common-sense' ideas to produce a discourse of ToP. Discussion: The findings illustrate that taken for granted sets of ideas about who and what exists in the world help to impose bounds beyond which it is often very hard to reason and behave. When particular discourse becomes understood as common sense and 'true', these set limits to the cultural know-how of a particular social group. The clinical implications and the limitations of this study are considered and suggestions for future research are made.

Introduction: This thesis explored National Health Service (NHS) Mental Health (MH) Peer Support Workers’ (PSWs) experiences of transitioning from their own lived experiences of MH difficulties to supporting other people with their MH problems. Existing literature is scarce, particularly in the United Kingdom (UK). When it is available it oversimplifies the transitional process by failing to offer more than general descriptions of benefits and challenges to enacting the role. Aims: The purpose of the study was to explore how PSWs made sense of their experience of transitioning from their own lived experience of MH difficulties to providing a service to support others with their MH difficulties. Methods: Single-site ethical approval was gained to conduct the study in one NHS Trust. All PSWs within the service were approached by the Peer Support project coordinator. Semi-structured interviews were conducted with seven participants. Interviews were transcribed verbatim and analysed using an interpretative phenomenological analysis framework. Results: Analysis of transcripts yielded three superordinate themes. They were interpreted as interdependent with interrelating subordinate themes. The superordinate themes loosely reflected a time dimension of preconceptions before entering the role, actively making sense of the role in the here-and-now and future aspirations of the role. The first, fluctuating identities, detailed participants experience of a changing social self and a feeling of reconnecting, recovering and taking control. What constrained this were the difficulties with managing multiple identities. The second, PSW role, specified the understanding of what provided certainty in the role and where there was role vagueness and difficulties. Participants also detailed the complexities around boundaries and disclosures. Finally, organisational culture, outlined participants desire to change the NHS system. Supporting attitudes and barriers were described, at an individual, service, organisational and societal level. Discussion: The findings were compared to studies conducted in the areas of peer support, role transitions and identity. This research captured the complex and variable process of the transition, involving a number of inter-relating factors that impacted on an individual’s personal, interpersonal and collective identities. Participants highlighted the juxtaposition of the PSW identity being both emancipating and constraining whilst detailing the personal impact and attempted resolutions. Conclusion: The current research has clinical implications for the MH system, in that it has a role in practically supporting interprofessional working whilst addressing possible stigma attached to the PSW role. This research advocates for PSW training to be tailored to individual need, and flexible support offered throughout the process to both PSWs and the teams receiving PSWs. Finally, psychological interventions (e.g. self-narrative identity work), could help newly appointed PSWs to articulate and co-construct their identities during the transition; contextualising professional, personal and practice development. Methodological considerations are discussed, such as retrospective data collection, difficulty in recruiting a homogenous sample and the reliance on a specific transitional point. Suggestions for future research focus on the need for further longitudinal studies to better understand the enactment of the role. It may also be beneficial to explore the experiences of recipients of peer support and other professionals who work alongside PSWs.

The current study investigated the relationship between therapist and client attachment styles and perceptions of therapeutic alliance in a sample of inpatients with psychosis. A review of the literature found that attachment theory can provide understanding regarding the behaviour of clients with psychosis in therapeutic relationships, especially in inpatient settings. Working alliance can be measured as a representation of the therapeutic relationship and both client and therapist attachment styles contribute to the working alliance and can be measured in various ways. Research has suggested that for clients with psychosis diagnoses dissimilarity between client and therapist attachment styles indicated a better client rated working alliance. Given the low number of studies in this area and the relevance of attachment theory in working with clients with a psychosis diagnosis, this study aimed to investigate the relationship between therapist and client attachment styles and client perceptions of working alliance in therapy when clients had a diagnosis of psychosis. The present study hypothesised that clients’ with psychoses and therapists who were dissimilar in terms of attachment styles would predict better client perceptions of working alliance. The current study focused on clients with a diagnosis of psychosis because distress, trauma and interpersonal difficulties are prominent features of psychosis, which would influence individuals’ attachment behaviours and outline a role for attachment theory in understanding difficulties and tailoring treatments for this client group. The current research decided to focus on clients with psychosis in an inpatient setting to extend previous research which has mainly included clients in a community setting. Attachment theory can play an important role in considering the inpatient environment and how it can influence attachment behaviours. The present study was a cross sectional, within subjects design. Therapists and clients rated their attachment styles and working alliance. Most therapists rated their attachment style and working alliance with more than one client, therefore client data was nested within specific therapists. Using the Relationship Questionnaire (RQ) and Working Alliance Inventory (WAI), 46 pairs of therapists and clients recruited from independent inpatient psychiatric hospitals were assessed. A regression analysis examined the relationship between client and therapist attachment styles and client rated working alliance. The nested structure of the data and therapist rated working alliance was controlled for in the analysis. The present study did not find a significant relationship between the difference between therapist and client attachment styles and client rated working alliance. The present study hypothesised that clients’ with psychoses and therapists who were dissimilar in terms of attachment styles would predict better client perceptions of working alliance. Therefore, the current study did not confirm this hypothesis. It is considered that perhaps clients had not had enough time to build up the therapeutic relationship with therapists to allow the difference in attachment styles to lead to a better working alliance, meaning that more time may be needed in the initial stage of therapy. Further research is recommended to tease apart the attachment style interaction, including considering other variables and measuring working alliance over time in longitudinal studies.

Schema therapy was developed as a treatment for chronic and entrenched psychological difficulties, and has progressed to be used as an offence focused intervention that addresses dynamic risk factors. This thesis investigated the lived experiences of people with diagnoses of personality disorder who had offended and who had used the technique of imagery in schema therapy. This was explored because although the literature around schema therapy demonstrates some support for the effectiveness of schema therapy holistically, the individual components of this therapy have not been explored. Interpretative Phenomenological Analysis is felt to be an appropriate methodology to address this gap in the literature as it explored imagery from the perspective of those who had experienced it and also acknowledged the researcher‟s influence in co-constructing the understanding of the experience. This methodology allowed for a starting point of knowledge by beginning to develop an understanding of this area which could potentially inform future research. Semistructured interviews were conducted with six people diagnosed with Personality Disorder, who had offended and who had used imagery in schema therapy. Their experiences were explored using Interpretative Phenomenological Analysis. Throughout analysis a metaphor of life as a journey on which one carries carry emotional baggage resonated and themes were named accordingly. An overarching theme of the life journey (as temporal) enveloped three super-ordinate themes of opening the suitcase (revisiting trauma), unpacking and ordering the contents (therapeutic processes), and closing the suitcase (therapeutic outcomes). The super-ordinate theme of opening the suitcase incorporated a subordinate theme of reconnecting with the childhood self which overlapped with the super-ordinate theme of unpacking and ordering the contents. The super-ordinate theme of unpacking and ordering the contents included three subordinate themes, 1) emotional control (i.e. attempts to control emotions isolate people from others, but losing control of emotions during imagery leads to interpersonal connectedness with the therapist), 2) moving on versus being stuck in the past and 3) the therapeutic relationship as characterized by trust, and meeting needs. The second of these subordinate themes was felt to overlap with the super-ordinate theme of closing the suitcase. The super-ordinate theme of closing the suitcase was felt to contain two subordinate themes of healing the fractured self and applying what has been learned. All three super-ordinate themes were penetrated by another theme; distancing from the trauma (protection from emotional pain). This theme was felt to be embedded within descriptions of revisiting the trauma, re-connecting with the childhood self, emotional control, the therapeutic relationship, healing the fractured self and applying what has been learned. Two other minor themes were also identified relating to use of professional language and avoidance. It was concluded that for the six participants in this study, imagery was described as a process that enabled them to close the suitcase and put it away without fear that its contents would be unintentionally disgorged. These results represent the first qualitative exploration of people's lived experiences of imagery in schema therapy. The results add to the literature around both schema therapy and imagery separately. Although these results are not generalisable, they may be transferable to other groups that have topographically similar experiences and therefore they offer a new way to understand imagery in schema therapy.

Theories of implicit cognition suggest that behaviour is partly influenced by automatic processes of perception and memory (implicit cognition). An important implication of these theories is that patient self−report may not capture influential processes in psychological disorders (as some of these processes may not be available to self-report). For example, a patient may report that they are no longer anxious (based on their current awareness or willingness to disclose) but may retain implicit/hidden processing biases (e.g., in sensitivity to threat) that leave them vulnerable to relapse in the future. Evidence suggests that, for various psychological disorders, relapse following temporarily successful treatment is not uncommon; the literature around implicit cognition may help to improve understanding of relapse processes. Investigation of implicit cognition has further clinical implications: for enhancing our comprehension of how existing treatment may be effective (e.g., through implicit and/or explicit processes) and of how to develop treatment that influences implicit (in addition to explicit) cognition. Researchers have now developed a number of methods for accessing/measuring implicit processes and these have been shown to predict behaviour in various psychological disorders. An important question arising from the literature around implicit cognition and its potential role in psychopathology is: do existing treatment interventions affect implicit processes? More broadly, how malleable are implicit processes? Can implicit processes be changed in a way that supports desired functioning? Research to date is limited and contradictory in its findings. The present research contributed to knowledge by examining the effects of two treatment−analogue interventions on implicit relational processes. The two interventions (exposure and acceptance/defusion) examined in the present research were based on existing clinical treatments. Spider fear was examined as a test construct in this research. The present research applied an implicit assessment procedure, intervention, and interpretive framework deriving from Acceptance and Commitment Therapy (and the underlying Relational Frame Theory). In this way, the present research attempted to draw together theoretically coherent aspects of basic and applied psychology to better understand the constructs of interest. Towards the aim of testing the impact of brief exposure and acceptance interventions on implicit verbal relations in spider-fear (in addition to spider-fear-related self-report and behavioural indices), three specific objectives were identified: 1. To examine effects of exposure and acceptance interventions on implicit (and explicit) measures of spider fear 2. To test the predictive relationship between implicit (and explicit) spider fear and spider-approach behaviour 3. Combining the above, to examine intervention effects on behaviour (directly and/or via fear measures). 48 participants (from a non-clinical sample) were randomly allocated to receive one of the two interventions. Participants completed pre− and post−intervention measures of implicit (and explicit) spider fear and a post−intervention behavioural approach test. Implicit fear incrementally predicted behaviour over explicit fear, replicating previous findings. However, neither intervention appeared to affect implicit fear. Interventions did have differential effects on explicit fear and overt behaviour; notably, defusion facilitated greater approach behaviour than exposure. Discussion centres on clinical and theoretical implications of the research, considering limitations and directions for future research.

Background: Borderline personality disorder (BPD) is a complex disorder, characterised by instability of affect, interpersonal relationships, self image and behaviour. Recurrent self-harming and suicidal behaviour are common amongst individuals with the diagnosis, and the literature has historically placed an emphasis on parents‟ role in the development of the disorder. Despite this, with the emphasis on community support for individuals with a diagnosis of BPD, parents are frequently relied on to provide a significant level of care to their child and to manage their self-harming and suicidal behaviour. Aim: The aim of the study was to explore parents‟ experiences of self-harm and attempted suicide as displayed by their daughters, who have a diagnosis of BPD. Method: A qualitative approach was adopted and seven parents (five mothers, two fathers) were interviewed. Interpretative Phenomenological Analysis was used to conduct an in-depth analysis of the verbatim interview transcripts. Results: Three super-ordinate themes were identified, including lack of control, blame and burden, and loss and isolation. These themes, along with their associated sub-themes, were identified through analysis and interpretation of the parents‟ narratives and are discussed in detail. Conclusions and Recommendations: The analysis indicated that parents‟ felt powerless in response to their daughters‟ behaviour, and that this sense of powerlessness was compounded by healthcare professionals‟ obligations to maintain patient confidentiality. Exclusion from their daughters‟ treatment and care led parents‟ to feel they lacked the necessary skills and knowledge to support their child, and many spoke about feeling angry, frustrated or exhausted. Parents‟ accounts suggested that over time they felt that health professionals increasingly involved them, with many accessing available services. Relationships with friends and family appear to have been affected, as have parents‟ life plans. To cope with the difficulties faced, parents‟ described using multiple coping methods. Despite the majority of parents‟ voicing that their daughters‟ were self-harming and attempting suicide less often, if at all, ongoing worry and self blame was evident. Although the findings are specific to the sample, they provide an insight into parents‟ experiences and emphasise the importance of collaborative working and parents receiving up-to-date information and practical advice, as promoted by modern policy documents. Additionally it appears that parents would benefit from health professionals being proactive in involving them and signposting available services and organisations. It is hoped that the findings will act as a driver for future research, for instance, little is known about the experiences of parents from other cultural backgrounds. Furthermore, exploration of parent and child experiences, and health professionals‟ attitudes towards parents, is needed.

The positive psychology movement has grown out of recognition of an imbalance in medically oriented clinical psychology that focuses on studies of disorder and psychological damage. The movement aspires to encourage research in neglected areas of positive human experience. Also, the beginning of the positive clinical psychology faction has been announced. It aims to extend the scope of positive psychology research and practice onto individuals with psychological difficulties. Understanding and facilitating happiness is the core objective of positive psychology. In the present research, a correlational study examined the suppositions of the four-dimension model of happiness and psychological distress amongst people experiencing psychosis. The study‟s objective was to check how emotional distress resulting from psychosis affects the individuals‟ satisfaction with life. Forty-seven individuals with diagnoses of paranoid schizophrenia completed self report measures of psychoticism, paranoid ideation, depression and anxiety (Brief Symptom Inventory), positive affect (Bradburn‟s Affect Balance Scale), and life satisfaction (Satisfaction With Life Scale). Correlational patterns of the four-dimension model of subjective wellbeing and psychological distress were replicated with people with experiences of psychosis. However, although the levels of depression and anxiety were clearly elevated in comparison with general population norms, the levels of positive affect remained similar to those in general public, and the average life satisfaction appeared only slightly decreased. Extended statistical analysis was conducted and the series of mediation analyses were carried out to examine whether the levels of depression, anxiety, and positive affect mediated the relationship between psychosis related distress and the individuals‟ satisfaction with life. The data were consistent with the dominant, indirect-only mediating role of depression. Possible explanations for the findings are proposed, and clinical and ethical implications from the applied positive psychology perspective are suggested. Study limitations are discussed and recommendations for future research are made.

Background: Up to 70% of stroke patients experience cognitive impairment in at least one cognitive domain. Guidelines currently recommend that stroke patients be screened as soon as is reasonably practicable for potential cognitive impairment. For a screening test to be diagnostically valid it needs to demonstrate adequate levels of sensitivity and specificity. Cognitive impairment can be identified globally or as an impairment in a specific cognitive domain. Research into commonly used screening tests for cognitive impairment has failed to identify a test with adequate levels of sensitivity and specificity for cognitive impairment in an acute stroke population. The Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) has demonstrated adequate diagnostic validity in differing diagnostic groups and has shown to be appropriate for use with acute stroke patients. However, the RBANS has not yet been evaluated for sensitivity and specificity for cognitive impairment following stroke. Aims: The aim of this pilot study was to establish whether an extended study of the diagnostic validity of the RBANS as a sensitive and specific screening test of post stroke cognitive impairment was justified. The study objectives were to compare the RBANS scores with full neuropsychological test battery overall conclusions for cognitive impairment and non-impairment, to compare the RBANS with measures of impairment in specific cognitive domains, and to identify RBANS optimum cut-off scores for discrimination of cognitive impairment / non-impairment in an acute stroke population. Methods: This study used a cross sectional design. Stroke patients admitted to a large city hospital were considered as potential participants. Patients were excluded if they had language impairment as identified by the Sheffield Screening Test, were aged over 80 years old, had had a previous stroke or neurological impairment, and had hearing or sight difficulties that precluded them from completing cognitive testing. Recruited participants completed the RBANS and a ‘gold standard’ battery of neuropsychological tests. Comparison of the two tests were made to identify levels of sensitivity and specificity on global and domain specific cognitive impairment. Analysis was completed to identify RBANS optimum cut of scores for identifying global and specific cognitive impairment. Results: 40 participants were recruited. The RBANS demonstrated poor levels of sensitivity (52%) and good levels of specificity (100%) for global cognitive impairment when using the manual recommended cut off scores. Receiver Operating Characteristic curve analysis identified an optimum cut off score for RBANS Total scale of 102.5 that provided excellent sensitivity (100%) and adequate specificity (83%), and index scores that showed adequate levels of sensitivity and specificity to domain specific cognitive impairment with the exception of Attention. Discussion: It was tentatively concluded that the RBANS demonstrated acceptable diagnostic validity, though problems were highlighted with the Attention index and the use of a test of visual memory within the full battery that placed a heavy burden on motor skills. Recommendations were made for potential improvements to the study design and procedure, and it was suggested that further research into the evaluation of the RBANS as a sensitive and specific screening test of post stroke cognitive impairment justified and potentially feasible.

This study aimed to explore clients‟ experiences of receiving eye movement desensitisation and reprocessing (EMDR) as an intervention for trauma-related symptomatology, consistent with post traumatic stress disorder (PTSD). Seven outpatients who had experienced EMDR as an intervention for trauma-related symptomatology were interviewed using a semi-structured interview schedule, from which the verbatim transcripts provided the raw data for an interpretative phenomenological analysis (IPA). The themes that were extracted from the data were considered under five superordinate headings which were: „living with trauma‟, „doubt and apprehension; „making safe and making sense‟, „the process of „processing‟ and „change‟. Both active and passive processes were identified within participants‟ descriptions of the process of EMDR and change. Discussion focuses on the themes in relation to previous literature and further, in respect of the unique understanding of EMDR that a qualitative phenomenological study provides. Implications for future clinical and theoretical research are suggested and the limitations and theoretical underpinnings of the study are made explicit. The conclusions drawn from the study suggest that EMDR should be viewed as a holistic approach with elements such as the development of the therapeutic alliance given equal investment to the search for the active mechanism of the bi-lateral component. Additionally, it is argued that the bi-lateral element potentially involves more than a single mechanism, particularly in relation to the enhancement of positive affect and that this would benefit from further exploration.

The capacity to report subjective quality of life inventory (CapQOL) is a brief screening tool designed to evaluate ability to appraise subjective QOL, complete related QOL measures and assess cognitive impairment. The purpose of this study was to assess the CapQOL’s test-retest reliability, internal consistency and associations with cognitive impairments (memory and executive functioning) and negative symptoms in a sample of people with chronic schizophrenia that reside on care facilities. The CapQOL, cognitive and schizophrenia symptom assessments were administered to 23 participants (mean age = 43, s.d. = 9.7, male = 13). The CapQOL had good test-retest reliability (rs (21) = .868, p < .01) and internal consistency (α=.850). 43% of the chronic schizophrenia sample were identified by the CapQOL as having the ability to complete a subjective QOL measure (a significantly smaller percentage than a prior study with an early psychosis patient sample). The CapQOL demonstrated a poor agreement with the cognitive assessments (κ-<.40) and a non-significant correlation with negative symptom scores (p>0.05). The main limitation of the study was the sample size that may have affected the range of scores on the measures, the resulting associations with the CapQOL and the number of factors that could be assessed. Further validation studies of the CapQOL are indicated.