The effectiveness of psychological therapies has received increasing attention in recent years with a confidant optimism building in the strong research evidence for its efficacy. However, criticism comes from the study of attrition from therapy in routine clinical practice, which studies show can reach from 30 to 60%. Searches for the causes of attrition have uncovered a multitude of correlations but only socio-economic variables emerge as significant predictors of attrition. This present study proposes and tests a theoretical model with clear implications for practice and research. In reviewing three broad literatures on health service use the concept of the Decision Action Pathway Interactive Network (DAPIN) began to emerge. Health decisions are seen as taking place within an emerging decision/action pathway that is subject to a dynamic interaction network. Decisions are made by individuals based on rational calculations, with network interactions providing the mechanism by which the social factors influence the decision/action pathway. Empirical testing of DAPIN consisted of the construction of a patient self-report cost attached to therapy attendance (CATA) measure that could be used to determine whether people of low SES do in fact have higher network costs attached to attending therapy and whether this is related to higher attrition. A small sample of patients attending their first appointment completed CATA and those who unilaterally terminated in the first four sessions compared with those who continued therapy. Weak support was obtained for the DAPIN model. The Demand sub-scale of CAT A proved to be a powerful predictor of unilateral termination from therapy (attrition) at the early stage of therapy attendance and provides a useful short tool for routine clinical practice. The small and idiosyncratic sample used meant that the DAPIN model could not be adequately tested. However, the evidence accumulated suggests that the model is worthy of more extensive testing.

There is a lack of a conceptual framework as to how cognitive demand and attributional variables interact and influence staff beliefs in response to challenging behaviour. This study tests the applicability of Gilberts (1989) attributions framework for understanding how staff cognitive demand influences staff attributions of challenging behaviour in a residential setting within Weiner's (1986) model of attributional dimensions. The use of this model may also serve to support the applicability of Gilberts' (1989) model in Geriatric settings in the context of previous research findings. The basic notion that is outlined in the introduction highlights that when we attempt to perform several operations at once, then this often results in the failure of the least automatic (most effortful) operation. A rationale for cognitive demand attributions is based on the research that has suggested that people go through a two-stage process when making attributions (Gilbert, 1989, 1991). Firstly, people assume that a person's behaviour is something to do with their disposition (internal factors) before an attempt is made to explain their attributions externally, accordingly taking into account external situational factors. It may be argued that if a person is already pre-occupied, distracted and experiencing high levels of cognitive demand when making an attribution about another person's behaviour, they may not get to the second stage, as making such adjustments needs more concentration and effort than the first step which occurs spontaneously and quickly (Gilbert & Osbourne, 1989). Therefore, the implication is that staff experiencing high levels of cognitive demand would be more likely to make negative and blaming internal dispositional attributions of challenging behaviour. They are more likely to report higher levels of controllability for the behaviour and report that they feel less optimistic that the behaviour would change and that it affects wider areas of their life. The study employed a cross-over experimental design. Participants were asked to watch 2 video clips of challenging behaviour, one under conditions of cognitive demand (cognitive demand) and one under conditions of no extra demand (non-demand condition). A total of 46 staff working in nursing and residential homes for the elderly completed a self-reported attributions questionnaire developed for the purpose of the study, demographics questionnaire and stress measures. Results In general, the hypothesised model in the current study was found to be partially supported as results suggest that cognitive demand does have a role in determining staffs attributions of internality. There is evidence that more internal attributions are made under cognitive demand conditions for aggressive behaviour. No support however was found for "other" behavioural classifications. More weighting was given in the interpretations for aggression as the content of the videos was considered to be more matched in terms of behavioural typologies displayed in the video clips. Partial support was found for the role of cognitive demand on attributions of controllability. A significant relationship was found between cognitive condition and attributional dimension of controllability for "other" behavioural classifications. The results indicate that participants attribute higher levels of controllability whilst under cognitive demand conditions than whilst under non-demand conditions. However, no such support for a relationship between cognitive condition and attributional dimensions of controllability for ratings of aggression was found. The model was not found to be generalised to the other attributional dimensions identified within Weiner's model - no support was found for the role of cognitive demand on the other main attributional dimensions (Stability, Generability. and Globality) for either "aggression" or "other" behavioural classifications. No effect of stress was found. Conclusion The study set out to test the applicability of Gilbert's (1989) attributional framework for understanding how staff cognitive demand influences staff attributions of challenging behaviour in a residential care setting and with reference to Weiner's (1986) attributional dimensions. The hypothesised model in the current study was found to be supported, as results suggest that cognitive demand does have a primary role in determining staff attributions of internality and controllability. The model was not found to be generalised to the other attributional dimensions identified within Weiner's model apart from partial support for the influence on control. In conclusion cognitive demand was found to impair care staffs' ability to use contextual/situational information when forming causal attributions regarding an individual with dementia displaying challenging behaviour.

<p> The purpose of this study was to record and analyze how an end-of-life (EOL) doula and EOL doula care-recipient&rsquo;s [doulee&rsquo;s] family members perceive and describe their personal doula lived experiences during their participation in an EOL doula program. Additionally, it sought to gain clarity on how an EOL doula can augment current palliative and hospice care services to improve and more accurately meet the needs and wants identified by the EOL doulees as reported by the EOL doulee&rsquo;s family members and the EOL doulas that accompanied them. To accomplish this, 15 co-researchers, 11 EOL doulas and 4 doulee family members, from JFCS, Inc. were interviewed wherein they shared their personal doula lived experiences. </p><p> The interviews were analyzed through existential-phenomenological thematic analysis and generated 10 major themes: (a) Just being there, being present, and spending time; (b) No one should die alone; (c) It is important to be a good listener; (d) An EOL doula can work together with hospice because his or her role is different; (e) An EOL doula can provide spiritual support; (f) An EOL doula needs to have certain personality traits; (g) An EOL doula remains open to engage in activities wanted or needed by the EOL doulee; (h) An EOL doula needs to be aware of his or her comfort level with the different phases of dying; (i) An EOL doula can also provide support to the EOL doulee&rsquo;s family and loved ones; and (j) The EOL doula program has comprehensive and ongoing trainings and supervision for all EOL doulas.</p>

<p> Literature extolling the psychological benefits of self-forgiveness is robust, yet there are no evidence-based models for facilitating self-forgiveness in individual psychotherapy. Further, there is no consensus in the literature on the definition of self-forgiveness. This quantitative, survey-based study examined licensed clinicians&rsquo; (<i>N</i>=57) perceptions of the efficacy of self-forgiveness treatment interventions, their preferred definitions of self-forgiveness, and how frequently treatment methodologies were utilized. Correlational analyses examined the relationship between clinicians&rsquo; definitions, perceptions of efficacy, and frequencies of use of self-forgiveness methods and the clinicians&rsquo; demographic factors (theoretical orientation, type of licensure, age, years of clinical experience, and type of training). Hong and Jacinto&rsquo;s (2012) definition was the most frequently chosen (36.8%), followed by Hulnick and Hulnick&rsquo;s (2011) definition (35.1%). Most clinicians (57.9%) were not familiar with any of the various treatment methods. Among clinicians familiar enough to rate the methods, Hulnick and Hulnick&rsquo;s (2011) method received the highest efficacy rating (<i>M</i> = 4.11, <i>SD</i> = 1.17), followed by Enright et al. (1996) method (<i>M</i> = 3.67, SD = 0.71). The most frequently used were Jacinto and Edwards&rsquo; (2011) method (<i> M</i> = 2.09, <i>SD</i> = 1.35) and Hulnick and Hulnick&rsquo;s (2011) method (<i>M</i> = 2.04, <i>SD</i> = 1.58). Correlations were significant for theoretical orientation and source of training; theoretical orientation provided the largest explanation for variance. Implications for future research, clinical training, and development of evidence-based treatment modalities are discussed. Linkage between self-forgiveness and remediating shame, recidivism, spiritual psychology, and Jungian psychology are reviewed. Keywords: self-forgiveness, psychotherapy, counseling psychology, spiritual psychology, quantitative study</p>

<p>Mindfulness interventions and practice have seen a recent explosion of interest among researchers and practitioners. The present study examines the research literature on the role of mindfulness in the practice of psychotherapists, specifically in the areas of stress management for clinicians, management of countertransference, development of the therapeutic alliance and attunement, development of empathy and therapeutic presence, and client outcomes. Both qualitative and quantitative research articles published over the past 10 years have been included and meta-analytic techniques utilized where possible. Examination of these data shows that mindfulness is associated with better ability to manage stress among clinicians, better therapeutic alliance, increased empathy, and better client outcomes. These data raise important theoretical and practical considerations, including questions about what makes mindfulness effective, issues regarding the use of techniques derived from the Buddhist tradition outside of their cultural and ethical contexts, and others. Implications and ideas for further research are discussed. </p>

Separation anxiety (SA) is often thought to occur exclusively during childhood; however, recent research has identified a putative diagnosis of Adult Separation Anxiety Disorder (ASAD), which mirrors separation anxiety often exhibited during juvenile years. Several studies have suggested that exposure to certain parental features during childhood may lead to the development of ASAD, including parental depression, parental anxiety, and parental overprotection. This study aimed to address these hypotheses by examining retrospective report of exposure to specific parental features among a population of adults diagnosed with ASAD and to elucidate important clinical correlates related to ASAD, such as impairment in daily functioning. The present study used a survey design which was nationally representative and based on the National Comorbidity Survey-Replication and which consisted of a population of 436 participants with a lifetime diagnosis of ASAD and 2,438 participants with no history of a DSM-IV diagnosis. Participants were asked to respond retrospectively about their exposure to the above-mentioned parental features during childhood. Chi square tests revealed that participants with a diagnosis of Adult Separation Anxiety Disorder endorsed exposure to significantly more parental anxiety and parental depression. Additionally, chi square tests indicated that these individuals reported more features related to preoccupied attachment. Using survey participants with a diagnosis of ASAD or subclinical levels of ASAD, the effects of treatment on daily functioning, as well as the level of functional impairment associated with ASAD was measured. Individuals with a history of treatment for ASAD reported significantly more functional impairment in the area of work than those without treatment. An independent-samples t-test revealed that respondents with a diagnosis of ASAD endorsed significantly more parental overprotection than did respondents with no diagnosis. Last, the continuity hypothesis, which states that juvenile symptoms of separation anxiety continue into adulthood, was explored. A chi square goodness-of-fit test was used to determine whether these data fit the continuity hypothesis model. Results did not support the continuity hypothesis, as the number of participants who endorsed childhood separation anxiety was significantly lower than the expected count. Future research should aim to identify efficacious treatments for ASAD, as few studies to date have demonstrated effective means of treating patients with this disorder.

<p>In Post-Traumatic Stress Disorder (PTSD), social and emotional dysfunction has been interpreted as a secondary consequence of the broad impact of amygdala and fear circuitry dysregulation. However, research in social neuroscience has uncovered a number of neural systems involved in attachment and emotional regulation that may be impacted by trauma. One example is the Default Mode Network (DMN), which is implicated in human beings&rsquo; sense of self and ability to connect with others. </p><p> This qualitative study explored the impact of physical and emotional traumata on the structures and functions of the DMN. The goal was to determine if dysregulation of the DMN could account for aspects of the psychological and social dysfunction found in PTSD. This study explored the following two questions: 1. What does the research literature tell us about the role of the DMN? 2. How does trauma impact DMN functioning? </p><p> The DMN has been associated primarily with autobiographical recall, self-referential processing, social cognition, prospection, and moral sensitivity. The DMN appears to support internal reflective capacity, further maintaining and connecting self-functions and social cognition. Trauma results in internetwork rigidity, as well as overall reductions in DMN activity, volume, and connectivity. These objective changes result in a Traumatized Resting State (TRS), characterized by increased Salience Network connectivity and reductions in Central Executive functioning. Studies suggest that a TRS develops in reaction to acute trauma, even before the development of PTSD, and may continue despite the stabilization of other networks. Overall, DMN incoherence significantly disrupts core psychosocial processes. </p>

<p> Persons suffering from addiction have been found to have higher shame and lower self-compassion than non-addicted persons yet lower shame and greater self-compassion are associated with improved treatment outcomes (O'Connor, Berry, Inaba, Weiss, &amp; Morrison, 1994; Wiechelt &amp; Sales, 2001; Brooks, Kay-Lambkin, Bowman &amp; Childs, 2012). This study examined the relationship between various aspects of the Alcoholics Anonymous (AA) program and levels of shame and self-compassion. The sample consisted of 148 active AA members; 32% had been members for over ten years whereas 16% had under a year of sobriety. The results found significant negative correlations between level of engagement in AA as measured by the AA Involvement Scale, length of time attending AA meetings, time clean and sober and shame as measured by the Internalized Shame Scale. The study also found significant positive correlations between level of engagement in AA, length of time attending AA meetings, time clean and sober and self-compassion as measured by the Self Compassion Scale. Out of a range of AA activities that included prayer and meditation, working with a sponsor and meeting attendance, the activities most predictive of lower shame and higher self-compassion were active social activities such as meeting with AA members outside of meetings, meeting with sponsees, and being a speaker at meetings. The study also found that participants who completed the fifth step (sharing their amends with their sponsor) had significantly lower levels of shame and higher levels of self-compassion compared to those who hadn't done a fifth step. Likewise, participants who completed the ninth step (making their amends) had significantly lower levels of shame and higher levels of self-compassion than those who had not completed this step. In a step-wise regression that regressed level of engagement in AA, time attending AA meeting, time clean and sober, and completion of the fifth and ninth steps onto shame and self-compassion, only time clean and sober was significant in predicting lower shame and higher self-compassion; this accounted for 21% and 20% of the variance in outcome, respectively. These findings suggest that AA members who actively engage in the program experience continued benefits with more sobriety, lower shame and higher self-compassion. Recommendations for further research are discussed.</p>

<p> The purpose of this study is to explore clinicians&rsquo; perspectives on assessing older adults with early life trauma. While research has shown that traumatic experiences are common in childhood and early adulthood, there has been a dearth of research on the perspectives of clinicians working with older adults with early life trauma. In this current study, the researcher interviewed 8 licensed clinicians with an average of 11 years of clinical experience working under varying professional licenses. Utilizing grounded theory methodology, semi-structured interviews were conducted to answer the primary research question: What are the experiences, insights, and reflections of clinicians on assessing older adults with early life trauma? A grounded theory of <i>barriers and corresponding strategies for assessing older adults with early life trauma</i> was developed from data derived from the interview transcripts of 8 participants. Two categories and 7 subcategories were identified and saturated with 24 major codes and 3 minor codes. The category <i> impact of childhood trauma in late life</i> was determined to be the context of the grounded theory. The context elaborates the prevalence and common types of early life trauma of older adults, its relationship with the aging process, and its impact on mental health. The results indicate there are 6 barriers to assessing early life trauma that can be categorized into two groups: (a) older adult&rsquo;s factors and (b) clinician&rsquo;s factors. In order to tackle these barriers, 9 corresponding strategies proposed by the participants were categorized into three groups: (a) relationship building, (b) information gathering, and (c) knowledge acquiring. The results of this study provide evidence that posttraumatic stress symptoms may emerge or re-emerge in older adults with mental health issues. This is the first study from clinicians&rsquo; perspectives to point out the barriers and corresponding strategies for assessment of early life trauma in older adults. The emergent theory is not a traditional theoretical model, but rather provides practical guidelines for clinicians to be more prepared for the challenges of assessing the early life trauma of older adults.</p>

The portfolio has three parts: a systematic literature review, an empirical study and a set of appendices. Part one: Comprises a systematic literature review in which studies relating to the use of self-initiated pain coping strategies in adults with cancer are reviewed. Fifteen studies were included in the review, including qualitative, quantitative and mixed methods designs. The studies reviewed had to have explored pain coping strategies and have included patient characteristics such as demographic, psychological or clinical variables that would allow for the investigation of possible relationships between the two. Part two: Comprises an empirical paper which explores the experiences of older people who self-manage their cancer pain at home. Patients attended semi-structured interviews with the main researcher. These interviews were analysed using Interpretative Phenomenological Analysis (IPA). The data was analysed, emergent themes are presented and implications are discussed in regard to existing literature. Methodological limitations are discussed and potential areas for future research are identified. Part three: Comprises the appendices which support the work of the first two parts, and includes a reflective statement on the research process, an epistemological statement, and a worked example of IPA analysis.