Main Research Project: An investigation of perceptions of OCD, caregiver burden, distress and accommodation. Caring for someone with Obsessive Compulsive Disorder has a demonstrated impact on psychological distress and quality of life. Relatives often struggle to know how best to help and it has been suggested that most engage in some form of accommodation of symptoms. Given the impact of OCD on carers, and the potentially detrimental effects of symptom accommodation and interpersonal difficulties on treatment outcome, it seems appropriate to include family members in treatments, but it is not yet fully understood which factors contribute to these interpersonal difficulties. The self-regulation model suggests that carers’ perceptions of an individual’s difficulties will have implications for both emotional and behavioural responses. For this purpose, individuals with OCD and their caregivers completed questionnaires to assess their appraisals of OCD, psychological distress, perceived criticism, caregiver burden and family accommodation. Caregiver perceptions of severe consequences of OCD were associated with increased perceived burden, whereas perceptions of chronicity and consequences were both independently associated with higher levels of caregiver psychological distress. Caregiver appraisals of OCD were not associated with levels of accommodation, but the appraisals of personal control held by the individual with OCD were, with lower perceived control associated with more accommodation. These findings suggest that aspects of the self-regulation model can be used to understand that appraisals of the chronicity, consequences and control one has over OCD can influence the distress of caregivers and also the extent to which they engage in potentially unhelpful accommodating behaviours. It is hoped that this model can help therapists to fine-tune the already efficacious treatments available. Service Improvement Project Improving Multidisciplinary Clinical Discussion on an Inpatient Mental Health Ward Purpose – Multidisciplinary team (MDT) clinical supervision is being used in many mental health services but at present has not received adequate attention by researchers in order to generate evidence based approaches. This paper aims to explore the utility and staff perspectives of an MDT model of clinical supervision in the form of a “Clinical Discussion Group” (CDG) on an acute inpatient mental health ward within the context of the current literature on the components of effective supervision in order to make recommendations for practice. Design/Methodology/Approach – Twelve members of staff working on the ward were interviewed to gather their perspective on attendance, helpful aspects, outcomes, unhelpful aspects, and changes. Interview transcripts were analysed using thematic analysis. Findings - eleven themes were identified, three within “The Group and how it operates” (Attendance, Discussion Topics and Facilitation), five within “Impact and Usefulness” (Valued by Staff, Understanding a Case, Emotional Benefit, Learning and Working together as a Team) and three within “Changes to the Group” (Organisation, Discussion Topic and Group Outcomes). Originality/Value – This paper explores the benefits and challenges of a CDG from the perspective of the staff who attend. It presents some recommendations for good practice which should be of use to managers and supervisors who wish to use team supervision to improve patient outcomes and also makes suggestions for future research in this field. Critical Review of the Literature Involving the wider system in skills-based treatments for Borderline Personality Disorder: A systematic review The transactional model of Borderline Personality Disorder (BPD) describes how both individual factors and systemic factors influence each other reciprocally to contribute towards the development and maintenance BPD. As such, treatments involving family members or carers have the potential to result in better outcomes. This paper reviews evidence for the effectiveness of involving family systems in skills based treatment approaches for BPD. A systematic search yielded 17 studies of 3 different skills based interventions that included members of the patients’ system: Dialectical Behaviour Therapy- Adolescents (DBT-A); Systems Training for Emotional Predictability and Problem Solving (STEPPS); and Family Connections. Each of the 3 types of intervention were effective in significantly reducing symptoms of BPD. However the heterogeneity of the research available limits the conclusions that can be drawn regarding the additive benefit of involving the wider system. More rigourous research designs focusing on the comparison of skills based interventions with and without systemic components will enable the identification of the mechanisms through which systemic involvement can improve outcomes for people with BPD.

Background: Previous studies have suggested that PTSD is related to burden and psychological distress in the wives of combat veterans with PTSD. However, these links have not been studied in non veterans with PTSD. This study recruited NHS patients who were undergoing treatment for PTSD, along with their 'significant others', including partners, other family members and close friends. The links between levels of PTSD and the effects of PTSD on the psychological functioning and perceived burden in significant others were examined. Method: Two groups of participants were assessed. The first comprised 25 patients and the second comprised 25 nominated significant others. Patients completed a measure of trauma (IES-R) and significant others completed measures of anxiety and depression (HADS), burden (BI) and social support (MSPSS). Results: Spearman correlations revealed that the IES-R was not significantly associated with the BI and no statistically significant correlations were found between the IES-R and the anxiety and depression subscales of the HADS, or between the BI and the anxiety and depression subscales of the HADS. Furthermore, the MSPSS and BI were not significantly correlated. Conclusion: In contrast to previous research, there were no statistically significant relationships between levels of PTSD and levels of significant other burden. However, many patients were unable to nominate significant others. Analyses were underpowered; therefore it is not possible to conclude unequivocally that relationships between PTSD and burden do not exist, although it is not possible to draw firm conclusions based on the present data. The present study extends existing knowledge by including patients from an NHS setting and their significant others.

Introduction: People with learning disabilities who display challenging behaviour are significantly more likely to experience a number of negative life events. The empirical evidence base highlights that in order to understand and successfully intervene in challenging behaviour it is essential that staff reactions are understood. It is considered that staff responses tend to be counter-habilitative and are likely to shape and maintain challenging behaviour. A number of factors may contribute to staff responses including: lack of knowledge, organisational factors, staff attributions and emotional responses. This thesis aims to explore the impact of a one day workshop and four oneto- one support sessions on participant's level of knowledge, attributions and emotional responses. Method: An experimental, repeated measures design was employed in this study. Fifty-four staff members who worked in inpatient services for people with learning disabilities who displayed challenging behaviour were recruited as participants. Participants in the experimental condition attended a one-day workshop and four oneto- one support sessions with the principle researcher. All participants completed outcome measures on four occasions: pre and post training; post one-to-one support sessions and at 12-week follow-up. Outcome measures assessed behavioural knowledge, attributions and emotional responses. Results: All data were analysed using quantitative, parametric analyses which examine the interaction between groups across conditions. There were no statistically significant interactions in measures which examine behavioural knowledge and overall adoption of a behavioural perspective. There were statistically significant interactions in some measures which examine attributions between groups across conditions but not in others. There were no statistically significant interactions in measures which examine emotional reactions between groups across conditions. Discussion: The findings of this study would suggest that the combination of training and one-to-one support sessions increased the likelihood that the participant would shift their attributions from an internal emotional model towards a behavioural model. Further, these changes appeared to be maintained. It is suggested that interventions such as those implemented in this study could make a positive contribution to the support of people with learning disabilities who display challenging behaviours. This thesis also highlighted that the majority of the current evidence-base regarding staff attributions, including this research, has significant limitations since the measures used to assess attributions have poor ecological and construct validity. These limitations impact on the generalisability of most attributional research within this field. It is considered crucial that future research develops outcome measures which overcome these limitations.

Objectives: Posttraumatic Stress Disorder (PTSD) has been shown to be prevalent in individuals with Substance Use Disorders (SUD). The current study aimed to investigate the factors associated with comorbid PTSD-SUD and to identify any differences between groups of individuals with PTSD-SUD and those with SUD only. Methodology: Thirty participants were recruited from community services for injecting drug users. All participants completed: The Maudsley Addiction Profile (MAP) to give measures of physical and psychological health problems, risk of blood bome vims (BBV) infection, and interpersonal conflict; The Leeds Dependence Questionnaire (LDQ) to measure severity of drug dependence; and the Posttraumatic Stress Diagnostic Scale (PDS) to determine the severity of trauma symptomatology. Comparisons were made between participants who met full diagnostic criteria for PTSD (A=19) and those who did not (N=11). Results: Severity of drug dependence was positively correlated with trauma symptomatology and with the number of traumatic events experienced. The comorbid PTSD-SUD group had higher rates of psychological health problems and BBV risk than those with SUD only. There was no difference in rates of interpersonal conflict and a trend towards an association with physical health problems. Conclusions: Presence of PTSD is associated with higher rates of dependence, psychological distress, and risk of acquiring a blood borne virus amongst injecting drug users. Comorbid PTSD-SUD has been shown to negatively impact on treatment outcomes in individuals with substance use disorders. These findings therefore support the need for integrated treatment models for PTSD-SUD in order to effectively meet UK service delivery objectives.

This thesis emerges from a 10 month ethnographic participant observation project of an charity-run Youth and Social Clubs conducted between September 2014 - July 2015 that examines the sensory experiences of autistic individuals in relation to their favourite, routinised activities or “habitual favourites”, alongside taking part in club activities such as board games, console gaming, casual discussion and club trips to public spaces. The research included 6 focus groups with 6 Youth Club participants, all white with 4 males and 2 females aged between 16-25, alongside 4 focus groups with 6 Social Club participants, all male and white from age 25-65+. The study uses a sociology of the senses approach to explore the habitual ways in which those with autism interact with their “favourites”. The thesis argues that the concepts of quasi-object and parasite reveal the complex interdependencies of stability and disruption in sensory experience. This complexity is also reflected in the author’s own experiences, and autoethnographic reflections consider how habitual and sensory experiences impact autistic academic identity, writing and research practices. Sensory experience is fruitfully understood through the influences of emplaced milieus of sensory and habitual interaction which are mutually constituted through distributed relations of human and non-human relations. Autistic experiences constitute a way to explore our taken-for-granted notions of social interaction and develop accounts that expand what we consider to be the condition of the human. Sociological attention to autism in the habitual favourites framework provides empirically rich and nuanced concepts to develop insights into autistic experience.

The central aim of this thesis is to explore resources for turn construction and interactional adaptations in the conversation of adults with aphasia (a language difficulty acquired most commonly after stroke) in the linguistically diverse Malaysian population. Malaysia has a long history of societal multilingualism, necessitating individual bi/multilingualism; the thesis investigates for the first time the impact of aphasia on conversational interactions in this population. As a result, the thesis applies Conversation Analysis (CA), with an emphasis on localised investigation of participants’ turns within particular sequences. The data are from two sources: video recorded natural conversations in the homes of three participants with aphasia and their regular conversation partners, and conversations outside the home with a friend, where languages other than the home language were reportedly used. The data driven procedures of CA reveal turn construction resources of topic-comment structure, co-construction and repetition are deployed by PWAs in conversation with regular and less familiar conversation partners and these resources cross the linguistic boundaries of the languages in their repertoire. These resources also occur in the non-aphasic conversation partners’ turns and exhibit similarities to those documented in studies of the conversations of monolingual English speakers with aphasia. Given that two or more sets of linguistic resources are available for each partnership, code-switching is found to be a compensatory resource for dealing with word finding difficulties as well as a resource for claiming or ascribing identity. A comparison of conversations with a friend indicates that a partnership’s familiarity influences interactional outcomes. However, the relationship between familiarity and interactional success is a complex one which appears to vary for each partnership. The findings of this thesis have theoretical and clinical implications for planning support services for aphasia in societies where bi/multilingualism is the norm. The significance of this contribution becomes evident when global trends in linguistic diversity are taken into consideration.

Linguistic research into aphasia, like other areas of language research, has mainly been approached from the perspective of rule-based, generative theory (Chomsky, 1957 onwards). In turn, this has impacted on clinical practice, underpinning both aphasia assessment and therapy. However, this theory is now being widely questioned (e.g. Tomasello, 2003), and other approaches are emerging, such as the constructivist, usage-based perspective, influenced by cognitive and construction grammars (e.g. Langacker, 1987; Goldberg, 1995). This approach has yielded important results in, for example, child language (e.g. Ambridge, Noble, & Lieven, 2014), but it remains largely unapplied to language in aphasia. This thesis begins to address this by conducting an exploratory examination of spoken language in aphasia from a constructivist, usage-based perspective. Two central features of usage-based theory, the nature of constructions and the role of frequency, form the basis of the studies reported in the thesis. Reliable methods of transcription and speech segmentation appropriate for an analysis that employs this approach are developed and then applied to the examination of spoken narratives of the Cinderella story by twelve people with a range of aphasia types and severities. Beginning at the single word level, the effects of general versus ‘context-specific’ frequencies on participants’ nouns are examined, demonstrating that most participants’ noun production appears to be more influenced by context-specific frequency, that is, the frequency of nouns in the context of the Cinderella story. This is followed by an analysis of errors in marking these nouns for grammatical number. A main finding here was that error production seems to be affected by general frequency: the noun form used erroneously was always more frequent than that expected. Finally, beyond the single word level, an in-depth analysis is provided of the participants’ verbs and the strings these were produced in. This focuses on the number and productivity of constructions apparently available to the participants and shows that these speakers can be placed along a continuum largely corresponding to their expressive language capabilities. The productions of the more impaired speakers were mainly limited to a small number of high-frequency words and lexically-specific or item-based constructions. In contrast, those with greater expressive language capabilities used a larger number and variety of constructions, including more lengthy schematic patterns. They seemed much more able to use their constructions productively in creating novel utterances. In addition, an analysis of the errors in participants’ verb strings was conducted. This revealed some differences in the types of errors produced across the participant group, with the more impaired speakers making more omission and inflection errors, whilst the participants with greater expressive language capabilities produced more blending errors. The analysis demonstrates how these seemingly different error types could all be explained within a constructivist, usage-based approach, by problems with retrieval. In showing how the results of these studies can be accounted for by constructivist, usage-based theory, the thesis demonstrates how this view could help to elucidate language in aphasia and, equally, how aphasia offers new ground for testing this approach.

Background: It is well established that diagnoses of autism spectrum disorders are increasing in numbers nationally. There has been a recent and growing awareness amongst clinicians of females on the autism spectrum having unique and different presentations, and that these females may be overlooked for diagnoses until later in life. This focus on females has not been reflected in published research; there is a paucity of research on the unique experiences of females on the autism spectrum. Furthermore, whilst research indicates that some young autistic adults aspire to have, and enter, romantic relationships, previous studies have had a quantitative focus and have not explored the unique experiences of females, hence the need for qualitative research on the lived experiences of romantic relationships of young autistic women. Current research: This qualitative study used semi-structured interviews with six young women (aged 19-29) to gather data on their experiences and aspirations about romantic relationships. Five of these young women had received a formal diagnosis of an autism spectrum disorder and one had self-diagnosed. This study takes a social constructivist epistemological perspective and used interpretative phenomenological analysis to analyse data. Key findings and implications: Key themes for individual participants included relationship violence and abuse, child sexual exploitation and grooming, non-monogamy, unassertiveness in relationships, and rejection. Themes which were found across more than one participant included vulnerability and naivety, asexuality and non-heterosexuality, gender identity and confusion about flirting. The implications of these findings are that young autistic women may be vulnerable to relationship abuse or exploitation. This is the first qualitative study where autistic young women have spoken about their non-typical gender identities and sexualities. A committed romantic partnership is an aspiration for some autistic young women and with an increasing focus on aspirations and preparing for adulthood, educational psychologists will have a role in helping support young women to reach these outcomes.

This thesis is presented in three parts; the literature review, empirical paper and critical appraisal. The literature review considers the effectiveness and acceptability of interventions aimed at carers of people with eating disorders. Included studies described a variety of approaches to educate, and provide skills and emotional support to carers, although were generally of a poor methodological quality. Overall, the interventions led to improved carer outcomes, were considered helpful and there was some limited evidence to suggest beneficial client outcomes. The empirical paper explores whether engaging in various tasks can help hospitalised patients with eating disorders to improve the experience of ‘feeling fat’ during the post-meal period. The tasks comprised of the game ‘Tetris’ (visuospatial), a general knowledge ‘Quiz’ (verbal) and translating ‘Braille’ (somatic), which were designed to reduce intrusive images, thoughts and bodily sensations. When compared to a control condition - ‘Sitting Quietly’, the tasks requiring activity were superior at improving negative affect and additional benefits were seen for all other indicators of the post-meal experience. The critical appraisal discusses the rationale behind the literature review and empirical paper. Some of the methodological decisions are reviewed, such as choosing the tasks and the use of an online programme to deliver the trials. Dilemmas that arose whilst conducting the research are explored, such as recruitment difficulties, with suggestions for how the research could have been approached differently. The appraisal concludes with personal reflections developed over the course of the research process.

This thesis is presented in three parts. The overall focus of the thesis is medical students’ attitudes towards healthcare for people with learning disabilities. Medical students’ attitudes are important because, as tomorrow’s doctors, they will have opportunities to reduce the health inequalities experienced by people with learning disabilities. The first part presents a review of literature on medical students’ attitudes towards people with learning disabilities and their healthcare. Despite being limited by methodological weaknesses, reviewed studies suggested that pedagogical interventions could enhance medical students’ attitudes. It was concluded that further investigation of medical students’ attitudes towards healthcare for this population was warranted. Part two is an empirical paper that documents qualitative and quantitative studies of medical students’ attitudes towards healthcare for people with learning disabilities. In the first study, a thematic analysis of data from individual interviews with medical students was described. A measure of medical students’ beliefs about healthcare for people with learning disabilities was developed and psychometrically evaluated in the second study. Together, these studies indicated that medical students’ attitudes might benefit from more learning disabilities teaching and direct experiences with people with learning disabilities. Part three is a critical appraisal of the literature and the two studies. The research rationale and strengths and weaknesses of the research were explored. Then, practical implications and future research directions were discussed. Finally, a conclusion and personal reflections were provided.