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.

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: 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.

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.

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.

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.

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.

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.

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.