Patients' expectations pre-treatment for cancer can impact on subsequent treatment experiences. The existing literature is conflicted about whether expectations should be positive or realistic, with some studies reporting expectations as predictors of experiences and some studies highlighting the expectations-experiences gap as more important. Research has been narrow in focus and there exists no broad measure of expectations. Clinical Nurse Specialists (CNSs) manage expectations, therefore their perspectives are important but are currently under-researched. This thesis aimed to explore patients' expectations of cancer treatment more broadly, develop and validate new measures, and better understand CNSs' perceptions. The thesis consists of six empirical studies. Study 1 qualitatively explored patients' (n=16) expectations of cancer treatment. It highlighted a broader range of expectations than in the literature and suggested a role for the expectations-experiences gap. Study 2 designed two measures, validating them in a cross-sectional sample of cancer patients (n= 200). This produced a 39-item measure of expectations and a matched 36-item measure of experiences. Study 3 used the above sample to explore the expectations-experiences relationship and found that the expectations-experiences gap may be particularly important in a wide range of experiences. Study 4 measured expectations and experiences longitudinally but recruitment difficulties resulted in a case study of one cancer patient, which showed support for the findings from Study 3. Study 5 qualitatively explored CNSs' (n=8) beliefs about patient expectations and found that CNSs believe balancing hope and honesty is the best approach to their management. Study 6 qualitatively explored CNSs' (n=8) experiences of providing care and found that it was challenging but rewarding. This thesis contributes a broader understanding of patient expectations, facilitates their measurement and suggests that setting more realistic pre-treatment expectations is preferable. It shows that CNSs believe in balancing hope and honesty and that their roles are challenging but rewarding.

The main purpose of this study was to inform the development of screening tools for identifying dyslexia in the Persian language. Measures based on those used in English tests were investigated to assess their relevance for Persian-based assessments. Five studies were conducted. In the first, 140 Persian speaking pupils from five different grades were tested to determine the appropriateness of the measures for use across these grades. In the second study, 64 students were examined with more complex test items to reduce ceiling effects in the data. Overall, the results of these studies suggested a high level of accuracy in text reading in early stages of Persian literacy development. Three further studies then contrasted Persian and English, and dyslexic and non-dyslexic, children. Study 3, in which 40 Persian and 50 English pupils in the third and forth year of schooling were tested, revealed consistency in phonological processing predictors of literacy levels across cohorts. Study 4 compared 36 dyslexic and 58 non-dyslexic grade 1 and 2 Persian children and identified deficits among dyslexic children in literacy and phonological processing. Similar conclusions were derived in study 5, which contrasted differences in performance of year 3 English dyslexics (N=23) and non-dyslexics (N=25) with those found with grade 2 Persian dyslexics (N=16) and non-dyslexics (N=30). These results could be argued to be confirmatory of theories of dyslexia that propose a universal (cross-language) phonological deficit as the primary cause of dyslexia amongst children. However, the studies reported in this thesis also indicated that the Persian learners reached higher levels of accuracy earlier than their English counterparts, a finding more consistent with script-dependent viewpoints. The data are discussed in terms of these underlying causes and the implications for practice (assessment and intervention) are considered for this relatively under-studied language.

This Research Dossier contains each of the 3 research papers submitted over the course of my doctoral practitioner training programme (PsychD) in Psychotherapeutic and Counselling Psychology. This research dossier is comprised of: in Year 1, a literature review, entitled ‘Mindfulness: a panacea for counselling psychologists? A Review of the Literature’; in Year 2, a research project entitled ‘How do UK female psychologists experience working at relational depth in the context of their mindfulness practices? An interpretative phenomenological analysis.’; and, in Year 3, a further research project entitled ‘The Relationship Between Mindfulness, Political Dialogue and Technologies of the Self: A Foucauldian Discourse Analysis’. The methodologies for both research projects followed qualitative designs. My research orientation has been founded on relativist ontological and constructionist epistemological principles.

This thesis presents doctoral research conducted during training as a counselling psychologist. The research comprises three self-contained projects; a literature review, a quantitative research study and a qualitative investigation. The literature review focuses on research into Buddhist-derived compassion meditation and implications for working with children. The second project explores the relationship between Alcoholics Anonymous, self-compassion and shame, while the third piece of work draws on interpretative phenomenological analysis to explore how Generation X males experience internet pornography.

The Research Dossier consists of a literature review and two empirical studies. The literature review critically evaluates depression in Black African and Caribbean people living in the UK. The first study utilises a qualitative methodology and explores Nigerian peoples’ understanding of the term depression. The second study adopts a quantitative approach which investigates perceived ethnic discrimination, shame related beliefs and emotional well-being of Black Africans compared to White British adults.

This thesis presents a literature review and two qualitative research papers that explore the under-researched and under-reported topic of iatrogenesis (unintended harm). There seems no clear theory within Counselling Psychology which encompasses the notion of iatrogenesis. Therefore, this research draws upon relevant theories from other domains. The research in this thesis is underpinned by Merton’s (1936, 1968, 1972, 2016) sociological theory of unintended consequences, which supports a detailed exploration of what happens when two people meet in the social context of the consultation room. Each of the three studies which form this research will explore a different aspect of iatrogenesis. This is intended to support an exploration of unintended harm from various epistemological and methodological positions, and different analytical perspectives. For a conceptual consistency across the research, harm is defined as, “a negative effect [that] must be relatively lasting, which excludes from consideration transient effects ... [such as in-session anxiety or between session sadness, and] must be directly attributable to, or a function of, the character or quality of the therapeutic experience or intervention” (Strupp, Hadley, & Gomes-Schwartz, 1977, pp. 91-92). The theoretical grounding of the Literature Review is Merton’s (1936) theory of the Unanticipated consequences of purposive social action, which I have used to explore the dilemmas involved when the unintended consequences of actions expected to engender helpful change, can result in an unexpected or unexpected outcome. The research begins with a review of the literature that reports the prevalence of iatrogenesis as 10% of the public attending therapy. Therapists in the role of client report the greatest level of harmful experiences, at up to 40%. In the review, the process of iatrogenesis is explored from the perspectives of quantitative, qualitative and mixed methods research. Each method reveals the strengths and weaknesses of the research approach when exploring the complex topic of iatrogenesis. The Literature Review concludes by suggesting there is a gap in the literature and indicates the relevance of qualitative studies as a means towards filling it. The second study will present an Interpretative Phenomenological Analysis (IPA: Smith, Flowers, & Larkin, 2009), of the experiences of psychotherapists in the role of client. Merton’s (1972) distinction between ‘insiders-outsiders’ is applied, which in this study translates as ‘insider’ (client) and ‘outsider’ (therapist) roles, or positions. These positions help explicate potential mechanisms of change that are deemed to engender harmful experiences in psychotherapy sessions. A phenomenological approach was applied by interviewing counselling psychologists about their ‘insider’ experiences in their personal psychotherapy sessions. As their philosophical training is rooted in phenomenological, reflexive and humanistic training, counselling psychologists were assumed to be able to speak from the dual focus of being an informed client, as well as being an informed practitioner. Therefore, counselling psychologists were considered the most suitable group who would be best placed to help me explore the research question. Semi-structured interviews were conducted with four participants, all qualified psychotherapists. The data was analysed using IPA’s methodology. The findings yielded three master themes: Competing world views: clashing epistemologies; How and by whom is therapy constructed?; and Making sense of an experience. The third study builds upon the Literature Review and broadens the findings of the IPA, by applying a qualitative method of Thematic Analysis (Braun & Clarke, 2006). The Thematic Analysis utilises Merton’s (2016) distinction of the ‘manifest’ and ‘latent’ functions of purposive social actions. The notion of ‘manifest’ and ‘latent’ functions serves to explicate the experience of iatrogenesis from the perspective of psychotherapists delivering psychotherapy, who perceived their delivery of psychotherapy to have engendered unintended harm. The notion of functions serves also to explicate potential latent processes that can be obscured, and also the more subtle influences within and beyond the therapeutic space that impact upon what happens within the consultation room. The Thematic Analysis is framed by the increasing number of clients who are complaining to professional registration bodies regarding perceived harmful experiences during their psychotherapy. One response has been to introduce new codes of ethics. Applying Thematic Analysis, I conducted interviews with 20 practitioners from various modalities about their experiences of providing psychotherapy sessions. They reported their day-to-day experiences of ‘do no harm’. The Thematic Analysis indicated three themes; ‘Preparation for practice’; ‘Boundaries’; and ‘Issues of safety’. An overarching fourth theme was Professionalism. Transcending all the comments was the notion of tensions, which questioned: ‘Is therapy an art or a science’? Implications are drawn for training, supervision, practice and the future. Across the three studies, I practice and research from a stance which is critical realist, which is to say we each edit the reality we perceive to accord it with our beliefs. My research position is that of a reflective scientist-practitioner, and I identity strongly with counselling psychology’s philosophy and ethical value-base. The research stance is critical-realist.

Previous research suggests that individuals have revealed moderate to serious personal issues to bar tenders, hairdressers, divorce lawyers and industrial supervisors and that training for these groups may provide a ‘cost-effective’ method of allowing people to access ‘primary care’. Such training already exists for the police, the military and in education settings and has been shown to be effective at imparting knowledge, building skills, and moulding the attitudes of these groups. Current training offered to personal trainers (PTs) relates specifically to clients referred with diagnosed mental health problems, rather than those sharing personal issues for the first time. This study investigates PTs’ experiences of clients sharing personal issues during a PT session. Eleven PTs aged 21 to 34 years (M = 26.3) participated in 26-58 minute semi-structured interviews. Interviews appeared to have reached saturation, and were analysed using Inductive Thematic Analysis. Four main themes were identified, with PTs expressing that “I didn’t think that supporting clients with personal or emotional problems was part of being a PT”. Because PTs felt that “it’s difficult to balance boundaries with building a good rapport”, this meant that they found themselves in situations where “I’m having to deal with clients opening up about a whole range of things on a regular basis” and were consequently left “managing the fallout”. PTs regularly experience clients sharing of personal issues during PT sessions and many wish to receive further education, training and guidance regarding this issue.

People with Obsessive Compulsive Disorder (OCD) have deficits in decision making under ambiguity, also known as probabilistic reward-based learning (RBL). In these tasks participants are not aware about the target probabilities of each option and need to use trial-by-trial feedback to learn these probabilities during the task in order to improve their performance. An open question from the previous literature is why OCD participants present this specific deficit. The review of the limitations of previous RBL studies with OCD patients and the use of a new task paradigm allowed us to explore new directions in this research field. Firstly, previous studies had the following limitations: sometimes they did not control for the use of medication, for the presence of common comorbidities associated with OCD, or for differences between distinct OCD subtypes. In addition, previous tasks usually manipulated several factors at the same time, such as feedback direction (positive vs. negative feedback) and feedback magnitude (e.g. less vs. more positive feedback), for instance. Therefore, it is not possible to know which factor affected the RBL performance in OCD patients. Furthermore, previous studies did not consider the effect of symptom-related feedback on RBL. Secondly, task performance was only measured with accuracy, even though RBL involves the use of previous trials to make predictions for the current decision. Finally, while it is reported that participants do use distinct previous trials to perform these tasks, sequential effects were not previously investigated in OCD patients, neither for random-sequences nor for patterns sequences. Based on this, the presented PhD thesis addressed some of these gaps in the literature. The investigation was restricted to subclinical checkers which is the most common OCD subtype. A binary decision making task was designed that allowed us to separately manipulate feedback direction and feedback magnitude. In addition, the study compared probabilistic RBL performances between checkers and non-checkers for random and pattern sequences. New analyses techniques were employed to investigate the use of previous trial information for the current decision making, e.g. win-shift, lose-shift, and cross-correlations. Studies 2 and 3 examined the effect of feedback direction (positive vs. negative feedback) on decision making in subclinical checkers. Results showed that subclinical checkers were more biased towards exploitation when using negative feedback. Studies 4 and 5 examined the effect of the feedback magnitude for both the positive and the negative feedback direction. Results showed that subclinical checkers were able to change their bias towards exploitation within the positive direction experiments depending on the feedback magnitude of the experiment. They were more biased towards exploitation in the positive task presenting a higher error magnitude. In addition, checkers were always biased towards exploitation within the negative direction experiments, irrespectively of the feedback magnitude. Study 6 examined the effect of the manipulation of feedback magnitude when a symptom related feedback was added as an increment of the negative feedback. Results showed that subclinical checkers were not affected by the presence of the symptom-related feedback and, in terms of feedback magnitude, they continued to present a bias towards exploitation. The findings show that checkers were able to adapt towards exploitation in the positive experiments when higher feedback magnitudes are given. This strategic shift might be related to the higher error magnitude associated with the absence of reward, when the incorrect option was chosen. In contrast, checkers were not able to adapt their exploitation behaviour within the negative experiments when enhancing the feedback magnitude. In this way, this indicates that subclinical checkers present a deficit that bias their responses towards exploitation, when the magnitude associated with the error in the task surpasses a certain value of negative magnitude. This bias could reflect deficits regarding negative prediction errors in OCD or a hyperactivation of brain areas related with exploitation. Both explanations could be linked with a hyperactive dopaminergic system in OCD, so these results could encourage new research about the role of dopamine and prediction errors deficits associated with OCD. Additionally, heightened emotions and reward magnitudes might reduce treatment success because of the enhanced exploitation behaviour, so one crucial aspect of future therapies might be to carefully study the employment of stimuli with such higher error magnitudes.

Transcranial direct current stimulation (tDCS) as a means for enhancing learning and memory has received a lot of attention in recent times. However, its applicability in a wider context has been limited due to lack of replicability across the literature. This may likely stem from inter-individual differences such as age, gender, nutrition, stress, brain morphology and sleep. Sleep in particular may be a source of inter-individual differences in tDCS-effect because of its link to brain plasticity mechanism such as long-term potentiation (LTP). The extent to which sleep may account for inter-individual differences in tDCS outcomes has not been assessed in the literature. Therefore, the central aim of this thesis is to investigate 1) the effect of sleep quality 2) circadian mis- /alignment 3) prior sleep compared to wake on tDCS-enhanced learning. Findings from this thesis suggests that sleep quality does not affect variability in tDCS-effect on cognitive performance, while circadian mis/-alignment and prior wakefulness before task may modulate tDCS-efficacy. In conclusion, data suggests that tDCS-effect is greater in a brain which is in a non-optimal state in terms of circadian misalignment and prolonged wake, and in this context, sleep may be responsible for variabilities in tDCS studies. These findings have implications for researchers and clinicians using tDCS. Further studies are required to fully characterise the findings from this thesis.

Physical load carriage is an essential duty for military personnel. Physical load carriage induces psychological and physiological effects, but the influence of load carriage on brain activity and subsequent cognitive performance is largely unknown. This due to difficulties in disentangling the subtle behavioural effects under load carriage in complex occupational settings. To investigate how load carriage influences cognition directly, continuous measures of brain activity must be obtained in realistic settings. Mobile EEG is ideally suited to this task. Across four studies, mobile EEG recordings were used to assess to what extent load carriage influences attention. Four objectives were defined. 1. To evaluate mobile EEG as a viable tool in real-life settings (studies 1-4). 2. Investigate the influence of walking on attentional processes (study 1, selective attention; study 2, change detection). 3. Establish the impact of load carriage on brain activity during walking (study 3). 4. Assess the interaction of load carriage on attentional processes during walking (study 4). Interpretations of resulting data were conceptualised in the proposed dynamic resource allocation model of cognitive performance. Successful application of Mobile EEG was evident and found signal quality comparable to EEG recorded in a laboratory. Moreover, walking influenced attentional processes in an indirect way, moderated by the environment and concurrent perceptual load. While a steady state neural index of walking was recorded in a natural setting, this was invulnerable to load carriage effects. Further, and most pressing for this thesis, load carriage had little influence on neural indices of attention. Despite this, there is some indication from the data that fatigue plays a prominent role in the interaction of load carriage and cognitive function, and further exploring the neural underpinnings of motivation may prove fruitful in future studies of load carriage and cognitive function.