Although cognitive behavioural therapy (CBT) is recommended by the National Institute for Clinical Excellence (2004) as the treatment of choice for bulimia nervosa, it has only been found to be effective for 50-60% of individuals. In addition, the evidence base for the efficacy of CBT in the treatment of anorexia nervosa is weak. It is commonly recognised that there is a high comorbidity between personality disorders (and their associated traits) and eating disorders. The purpose of this study was therefore to examine the cognitions underpinning personality disorders in individuals with eating disorders, and to investigate whether those cognitions reduce the impact of CBT for eating disorders. Participants were 59 individuals with a diagnosed eating disorder presenting for CBT at a specialist eating disorder service. Each participant completed measures of personality disorder cognitions, eating disorder attitudes/dysfunctional assumptions and other psychological symptoms at session one of CBT. Participants were then asked to repeat the measures of eating disorder attitudes/dysfunctional assumptions at session six of CBT. Drop-out rates were recorded. Findings provided evidence of the rapid onset of action of CBT for eating disorders. There was a significant reduction in eating disorder attitudes over the first six sessions. Six personality disorder cognitions were significantly associated with eating disorder attitudes/dysfunctional assumptions and other psychological symptoms. These were avoidant, obsessive-compulsive, dependent, borderline, histrionic and paranoid personality disorder cognitions. Higher levels of dependent and narcissistic personality disorder cognitions were associated with dropping out of treatment before session seven of CBT, and higher levels of histrionic, avoidant and borderline personality disorder cognitions were associated with an improvement in eating disorder attitudes in the first six sessions of CBT. The limitations of the study and recommendations for future research are discussed. In addition, the clinical implications of the findings are considered.

Literature Review: A meta-ethnography synthesised nine papers to explore the question ‘How do family members of an individual with an autism spectrum disorder (ASD) make sense of their experience?’ Papers included the experiences of parents, grandparents and siblings of an individual with ASD. Reciprocal translations synthesised eight themes; autism is not our relative, family life revolves around autism, the stress and strain of being a family with autism, tolerating that autism can bring aggression, families’ accepting and seeking to understand autism, families’ celebrate their relative’s achievements and cherish happy moments, feeling judged and isolated by others, and fighting an inaccessible system. These themes provide insight into families’ experiences and were considered in relation to a model of parental stress (Deater-Deckard, 1998). Recommendations for more qualitative research in the UK were made. Research Report: Background: Social Stories™ are an intervention which provides contextual information to individuals with ASD (Gray & Garand, 1993). The evidence base for use with adults is limited and little is known about the experience of using this intervention. Aim: This paper asked “What are the experiences of an adult diagnosed with a Learning Disability and ASD, and their carer who have used a Social Story™?” Design: A participant and carer used a Social Story™ and participated in a semi-structured interview. Thematic Analysis (Braun & Clarke, 2006) was initially undertaken and Interpretative Phenomenological Analysis (IPA, Smith et al., 2009) was subsequently undertaken to allow a more interpretative analysis of the data. Results: Thematic Analysis highlighted the explicit cognitive behavioural, information processing explanations of the story’s benefit. In contrast, the IPA illuminated a relational aspect of using the story, reflected in the over-arching theme; ‘need to contain separation anxiety’. Conclusion: These two psychological processes may be occurring in parallel when using a Social Story™ and this area requires further research. Critical Appraisal: This paper offers reflections on the process of undertaking the thesis.

The literature review aimed to systematically review the effects of compassion-based interventions on wellbeing and distress in adults. Three electronic databases, reference lists and forward citations were searched. Fifteen papers met the inclusion criteria. Study quality was appraised and found to be weak overall. Interventions were predominantly group meditation programmes with non-clinical samples or Compassion Focused Therapy (CFT) informed augmentations to treatments of clinical samples. Findings showed that compassion-based interventions could be effective in reducing depression, anxiety and other psychological symptoms over time but between group differences were inconsistent or could not be assessed. Outcomes were similar when the compassion-based intervention was compared to active controls or alternative interventions. Further research is needed into mechanisms of action and with more robust clinical trials. The aims of the research were to identify therapist competencies necessary to deliver CFT. The Delphi method was used to explore expert opinion in three rounds of data collection. Twelve CFT ‘experts’ were interviewed for round one. Data were analysed using Template Analysis to generate a draft Competency Framework and a survey. Fourteen participants in round two and seven in round three completed the survey. The CFT Competency Framework (CFT-CF) was produced, identifying twenty-five main competencies within six key areas of competence. The areas were: Competencies in Creating Safeness; Meta-skills; Non phase-specific skills; Phase-specific skills; Knowledge and Understanding; and Use of Supervision. Overall there was consensus regarding the necessity of 14 competencies and 21 exceeded the 80 per cent agreement level (N=7). Potential clinical and research applications of the CFT-CF are discussed. Reflections and a critical appraisal of the research project are presented.

In Trinidad, negative attitudes towards mental health and unwillingness to access mental health care because of cultural restrictions and stigma deter some women with somatization disorder and experiences of domestic violence from seeking help (Hadeed & El Bassel, 2006; Kassiram & Maharajh, 2010; Maharajh, 2010). Several theoretical explanations for these interrelated issues are discussed in this thesis; grounded in considerations of the influence of culture and ethnicity. Somatization disorder appears to be more prevalent among Asian populations, and has a higher comorbidity with domestic violence within this ethnicity (Bhui, 2002; DSM-IV-TR, 2002; Fernando, 2002; Hardin, 2002) with some even stating that somatization disorder may be a culture bound ailment (Kassiram & Maharajh, 2010; Schrag & Trimble, 2005; Samelius, Wijma, Wingren & Wijma, 2008). In many Asian cultures emotional distress is still stigmatized compared to medical problems, resulting in delayed help-seeking (Hardin, 2002). To date, no research has been conducted regarding the possible links between somatization disorder, domestic violence experiences and help-seeking in Trinidad. This thesis utilized a mixed methods approach to explore the occurrence of somatization disorder and domestic violence among Indo- and Afro-Trinidadian women and their help-seeking choices. Drawing on data gathered from a combination of questionnaires (250; 150 with women and 100 with religious leaders and medical doctors) and interviews (12 participants; employing an Interpretative Phenomenological Approach) the key findings were that Indo-Trinidadian women were three times more likely to have symptoms associated with somatization disorder if they had domestic violence experiences compared to Afro-Trinidadian women. Both Indo-and Afro-Trinidadian women appear to internalize their distress as a means of coping. The women also reported mixed opinions about assistance received from both religious leaders and medical doctors when they sought help for their somatic symptoms and domestic violence experiences. Finally, despite medical doctors being more knowledgeable and reporting that they possessed better resources for assessing and intervening for both somatization disorder and domestic violence compared to religious leaders, they were less inclined to explore these intersecting issues with women patients. These findings are congruent with international research: culture emerged as the crucial component for the manifestation, reporting, and assistance sought for both somatization disorder and domestic violence experiences specifically in Trinidad, West Indies.

Whilst there is a growing body of literature on working with issues of difference in psychotherapy, there is very little literature and almost no empirical research on the implications of ‘sameness’ in the therapeutic dyad. This research continues the conversation on how contextual issues may impact therapy, but does so from the ‘inside’, with the aim of developing intra-cultural competence. Intra-cultural competence is defined as the ability to work ethically and reflexively in a therapeutic dyad in which the therapist and client share culture, values, lifestyle, worldview or identity in significant ways, by holding a paradoxical stance of affirmation, acceptance and curiosity with respect to those aspects of shared experience. The focus of this research was on developing Christian counselling, where the client and therapist explicitly share faith, and this is the story of that exploration in the context of my work as a lecturer in Christian counselling at London School of Theology (LST). Using the insider action research paradigm, some of the relational dynamics and ethical implications of clients and therapists sharing faith in Christian counselling were explored, initially by interviewing the teaching team at LST about their experiences of clinical work with Christian clients. Based on the analysis of the focus group interview, the team then decided to further explore the concepts of power and liminality in Christian counselling. A number of activities were carried out as a result, including a workshop on power dynamics in Christian counselling, followed by the incorporation of this material into the undergraduate and postgraduate courses. The insider action research approach offers some interesting parallels to intra-cultural work with its similar challenges of reflexivity, belonging and distance. Both the researcher and the therapist in intra-cultural therapy find him or herself in a position of ‘in’ and ‘out’ with respect to their own group to which they belong, and it is argued that the emotional toll of this needs careful consideration at times. As well as the power dynamics associated with difference, it is argued that there is the kinship power of belonging and sameness that deserves equal attention in the therapeutic process. On the one hand, this may facilitate an initial openness and trust in the therapeutic relationship, but may also be associated with unexamined assumptions, expectations and collusion. Though, at first, less obvious to the eye, being part of the same tribe as our clients raises challenges but also interesting and creative opportunities. This research has begun to articulate and discuss some of these, and considers the implications for other dyads in which there is meaningful sameness, such as Islamic counselling.

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Recent evidence from behavioural and cognitive-neuroscience experiments has already yielded exciting discoveries into how we might code, process and perform judgments of facial social stimuli (indeed research into the latter provides a good vehicle for examining vision and object recognition in general). Nevertheless, the evidence regarding the role of top down control in face processing and the significance of the role of attentional capacity limits is contradictory or indeed absent in certain facial social trait judgments such as trustworthiness. In this thesis, I seek to present a portrayal of these roles, directed by load theory. Load theory suggests that perception has limited capacity but proceeds automatically on all stimuli until capacity is exhausted. Whether this process applies to arguably exceptional stimulus classes such as faces is contentious. Moreover, how this is related to social facial judgments such as trustworthiness, as compared to other evaluations such as threat and dominance judgments is unknown, as up until now, research on face-attention interactions has focused on directing visuospatial attention to emotional visual information rather than to facial trait judgments such as trustworthiness. In spite of this, the theory's predictions are clear; increasing the perceptual load of a task should consume capacity, thereby reducing processing of stimuli external to that task. Here I show that these predictions hold only for certain types of facial image evaluations but not for others. In a series of experiments that applied load theory, employing a combined visual search and face judgment task (where the level of attentional load in the search task was manipulated by varying the search set size of similar non-target letters), I find that under high perceptual load, observers become moderately less able to classify certain facial targets e.g. trustworthy ones as compared to dominant ones, even when these stimuli are fully expected and serve as targets. I also show the robustness of perceptual load effects by countering possible confounds and alternative explanations. Potential order effects are countered by reversing the order of the experiment, indicating that a possible attenuated short term memory imprint for the facial stimuli does not change the pattern of results previously experimentally demonstrated. Additionally, I find that high working memory load does not reduce social judgment evaluations under load, suggesting that perceptual biases during competitive interactions in visual processing are causative of the earlier demonstrated load effects. Following on from the modest but resilient results for trustworthiness modulation experimentally demonstrated here, the issue of bias for trustworthiness judgments is addressed in a signal detection paradigm (allowing bias to be discounted as a likely explanation of load effects). In the wake of the relatively robust results for trustworthiness perceptual load modulation, a new avenue for trustworthy judgments under attention is explored, investigating the possible role of dopamine in such evaluations in a clinical cohort of Parkinson's disease (PD) patients (as contrasted to age matched controls). PD has been linked with facial expression judgment impairment, although, this impairment could be subordinate to other cognitive processes enmeshed in facial evaluation, such as selective attention. Our results once again point to a pervasive role for perceptual load modulation of facial judgments, rather than a specific attentional deficit of PD. Finally, I explore the neurobiological correlates associated with facial social evaluations under perceptual load. In a neuroimaging study, I show neural responses to trustworthy facial images interact with attentional demands, demonstrating reduced activity under high perceptual load. I found high load only affects the facial components of trustworthiness (as compared to neutral faces) in cortical areas involved in social and facial processing (but not the facial signal components of untrustworthiness as compared to their neutral counterparts). The effects of load being specific to the trustworthy aspects of faces coheres with earlier presented behavioural results. As a final point, the demonstrated findings of negative-linear effects in the amygdala are consistent with prior research underlining the role of the amygdala in facial trustworthy judgments. This research presented here, although subtle in some experiments, provides convergent evidence that top-down cognitive and neural mechanisms are involved in influencing the degree to which facial visual judgments are processed. The results demonstrate the role of attentional modulation in facial social judgments and illuminate a possible role of perceptual load and attention in the facial automaticity debate. Both the type of facial judgment and category of facial valence are factors which determine the efficacy of perceptual load effects in facial evaluations.

Postnatal Depression (PND) is a construct that exists across time and culture, affecting both women and men at a ratio of 2:1 respectively. The dominant discourse focuses on women’s experiences of PND and the motherinfant relationship, presented within the framework of an overarching biomedical model that produced a plethora of studies underpinned by the positivist paradigm. In contrast, this research seeks to explore what it actually means for men, as fathers, to experience depression during the postnatal period. The literature to date highlights a threefold gap regarding approach to research into the phenomenon of PND: the epistemological underpinning, the methodological approaches chosen and the gender bias. To address this gap it is necessary for a paradigm shift regarding approach to research to embrace further qualitative methodology. Interpretive Phenomenological Analysis is the methodology identified for this research, as it provides the medium for consideration of the phenomenological and idiographic nature of the experience of PND, to include the role of the researcher and interpretation that reflects the central tenet of reflexivity within the discipline of Counselling Psychology. The overall gestalt presents a transitional adjustment process whereby the life event of the birth of a child initiated a process of deconstruction in preparation for adjusting to a new role within a changed family dynamic. The data revealed three super-ordinate and six sub-ordinate themes highlighting a complexity regarding how men made sense of their experience of depression during the postnatal period, including contemplation of past, present and possible future selves. Negative cognitive appraisal and attribution of meaning relating to childhood experiences, negative perceptions of fatherhood, masculinities, gender roles, the fatherchild relationship and socio-cultural contextual influences blocked the reconstructive process, resulting in increased stress and anxiety that led to depression. This study draws attention to risk factors, such as, childhood trauma, negative inter-generational relationships and differences in gendered expression of cognitive dissonance and anxiety. Conclusions consider implications for Counselling Psychology, highlighting the complex inter-subjective nature of men’s experiences and the value of an inter-disciplinary approach to future research, healthcare practice and intervention strategies to develop appropriate care and support for parents, particularly for men during the perinatal period.

The aim of the research presented is to gain a better understanding of the processes underlying the persistent report of somatic, cognitive and affective symptoms (known as post-concussion syndrome, PCS) after a mild brain injury (mTBI), and to elucidate whether there are any replicable biological factors contributing towards this syndrome. The results demonstrate that although PCS-like symptoms are present to a similar degree in the non-head injured population, individuals with mTBI and persistent PCS have significantly worse working memory, attention and information processing speed performance. Individuals who suffer an MTBI but do not report continued PCS perform these cognitive tasks to the same level as non-head injured controls. Following on from this, the research presented evidence that individuals with greater PCS severity had greater white matter damage, and greater attention related activity during cognitive tasks. Metabolic differences were also observed in the prefrontal cortex of individuals with mTBI, with a reduction in creatine suggesting some residual energy impairment in chronic mTBI. Combining the structural, metabolic and functional MRI data, we suggested that the increased attentional regulation observed during cognitive tasks may be compensating for reduced working memory capacity and a variation in white matter transmission caused by the structural and metabolic changes after injury. This compensation may in turn underlie some PCS symptoms such as fatigue, headache and insomnia. Therefore, the research as a whole suggests that there may be a neurophysiological basis for persistent PCS.