Objective: The central objective of this thesis is to better understand factors affecting dropping out from psychological treatment using the specific case of eating disorders. Methods: Following critical reviews of the drop-out literature, it was suggested that dropping out should be thought of and studied as the product of interactions taking place within the treatment relationship. The majority of previous research has unsuccessfully attempted to predict dropping out based on pre-treatment patient characteristics in isolation from therapist or therapy characteristics. Attachment theory framed a series of studies using both qualitative and quantitative methods to explore engagement in the early treatment relationship. Two constructs were used: attachment as a pre-existing trait affecting attitudes toward treatment relationships, and attachment as a state resulting from feelings and perceptions occurring within the early relationship. Results: Attachment concepts may improve characterisation of dropping out: Attachment as trait: Case-note analyses of 2 independent patient series replicated a dose-effect relationship between some childhood traumatic experiences and dropping out (N=224). In multivariate analyses, parental break-up in childhood was predictive. However, the relationship between adult attachment style and dropping out remains unclear. Attachment style dimensions from the Vulnerable Attachment Style Questionnaire (VASQ) did not distinguish drop-outs from other treatment status groups in a prospective study. Attachment as state: 26 in-depth qualitative interviews revealed that therapists' attuned responsiveness in the early sessions was important to establishing a 'secure base', which patients needed to engage. The Therapy Relationship Questionnaire (TRQ) was designed to measure both patient and therapist views of the developing relationship over time (N = 110). Conclusions: Dropping out undoubtedly results from myriad interacting patient, therapist, and therapy factors. However, the therapy relationship underlies these, so measuring it dynamically may be the best way of understanding dropping out. Such an approach, informed by attachment theory, might lead to clinically useful interventions for improving engagement.

Rationale: Clinical reports have indicated that a significant number of lower limb amputees experience psychological adjustment problems. Research had demonstrated a relatively high prevalence of depression in this population but there has been inadequate attention to other aspects of adjustment. This study aimed to identify variables associated with increased psychological distress. Particular attention was given to cognitive models of emotion which postulate a key role for self-consciousness and appearance-related beliefs. Methods: A cross-sectional correlational design was employed. Participants were 67 lower limb amputees. Measures gathered information about different types of self-consciousness, appearance-related beliefs, psychological adjustment, and a range of amputation-related factors including activity restriction, prosthesis satisfaction, phantom and residual limb pain and other medical issues. Results: The prevalence of anxiety was 29.9% and the prevalence of depression was 13.4%. Activity restriction, prosthesis satisfaction and appearance-related beliefs were associated with both distress and psychosocial adjustment difficulties. Public self-consciousness was associated with distress and psychosocial adjustment difficulties but this was not the case for private self-consciousness. Psychological distress was more common amongst those who reported amputation-related pain or additional health problems. Distress was not influenced by age, time since amputation, cause of amputation or level of amputation. Implications: Clinicians need to monitor amputees for distress over a long time period. It is particularly important to assess for anxiety. Interventions that target appearance-related beliefs may be of benefit to this population. Limitations of the current study are addressed and areas for further research are highlighted.

A study was conducted to examine the relationship between post-traumatic stress disorder (PTSD), violence and the selective processing of threat cues. It was predicted there would be a high level of PTSD among a male forensic population and that PTSD symptoms arising from violent trauma would be related to aggression. It was suggested that one mechanism that may provide a link between PTSD (based on violent trauma) and violence, is the selective processing of violent stimuli. An information-processing approach was used as the theoretical basis for the study and a Violent Stroop test was developed. Consistent with previous studies, a high level of trauma and PTSD was found among violent offenders. As predicted, levels of PTSD (based on violent victimisation) were significantly related to violent behaviour, whereas PTSD from non violent events was not related to violent behaviour. Both PTSD symptoms from violent trauma and violent behaviour were significantly associated with Stroop interference for violent words. A number of possible co-variants were also examined. The results were discussed and a critical review of the study was given. Clinical implications and possibilities for future research were provided.

The supposed synonymity of obsessions and intrusive thoughts is critically examined. It is suggested that there may be distinct differences in the appraisal of classic intrusive thoughts which feature aggressive or sexualised content and the appraisal of contamination fears. This is significant for both the current definition of obsessions and to the cognitive model proposed by Salkovskis (1985, 1989). Following a review of the research into the relationship between intrusive thoughts and obsessions, Salkovskis's cognitive-behavioural model of obsessive-compulsive disorder (OCD) (Salkovskis, 1985, 1989) is examined and two key papers, which are often cited to support the view that intrusive thoughts in the normal population are synonymous with obsessive thoughts as experienced by OCD patients, are critically appraised. Evidence from a number of phenomenological studies is also considered as an alternative source of information about the nature of obsessions in the clinical population. The development of a new measure, the Obsessive Thoughts Appraisal Scale is reported. This measure was used with both clinical and non-clinical samples (n = 109). It was found to have adequate psychometric properties. The results of the hypothesis testing indicate that judgements of ego-syntonic are not restricted to some small number of patients suffering from overvalued ideation, but rather ego-syntonic appraisals of some obsessions appears to be widespread but closely related to the individual's degree of obsessionality. Furthermore, obsessions concerning contamination were found to be significantly less ego-dystonic than those that concerned aggressive or sexually intrusive thoughts. Suggestions are made for both clinical practice and future research.

The research literature on factors associated with relationship satisfaction and relationship failure suggests that the expression of emotion has a vital role in the maintenance or failure of marriages and cohabiting partner relationships. Relationship failure is a significant clinical concern because of the association with increased suicide risk for separating partners and negative consequences for children of parents whose relationship is characterised by high levels of conflict. Longitudinal follow up studies have been used to clearly describe a destructive style of conflict resolution, based on a lack of communication of emotion between couples who then subsequently divorce or separate. However no research has been carried out to determine how the alexithymic personality trait, which is characterised by an inability to express emotion impacts upon cohabiting partner relationships such as marriages. This study used a clinical sample of men presenting with mental health problems to two adjoining community mental health teams. The study investigated whether the ability of men to express emotion, measured by the Toronto Alexithymia Scale was correlated with their satisfaction levels in cohabiting relationships (measured by the Relationship Assessment Scale). In addition, the hypothesis that alexithymic men may be more vulnerable, through their difficulties in expressing emotion to enter destructive partners of conflict resolution that lead to relationship failure was also investigated by correlating alexithymia scores with the number of failed precious cohabiting relationship the men had experienced. Results were not statistically significant, as it was only possible to collect a small, homogenous sample of men that was not sufficient for fairly evaluating the hypotheses of this study. The replication of this preliminary study within a primary care service, where participants may be more numerous, along with the additional incentive of payment for participation is recommended, due to the difficulties encountered in recruiting men to participate in a study about relationship satisfaction.

Since Wing's (1981) seminal paper, Asperger's syndrome: a clinical account, research into more able or 'high-functioning' individuals with autistic spectrum disorders has tended to focus on children. For adults, limited research has suggested a general trend toward recovery from earlier autistic 'symptoms'. However, continued social isolation and poor levels of social integration have been reported to remain common. This study explored how six able autistic adults (five male; age range 22 to 37 years) understood their experiences of social disability. All participants had prior psychiatric diagnoses of an autistic spectrum disorder (one 'Infantile Autism', five 'Asperger's syndrome'). Candidates requiring residential care and those with a dual-diagnosis of learning disability (mental handicap / mental retardation) or psychiatric illness were excluded. A directed sampling procedure was used and qualitative data were gathered in individual interviews. Grounded theory methodology was used for data selection and transcript analysis. A core construct termed 'Social fit' was identified in the analysis. This represented participants' constructions of disability as a relationship between self and 'others'. Within this construct, an explanatory process model was developed comprising three main categories of experience. These represented, respectively, participants' gradual awareness of personal difference, their revaluation of personal identity and their subsequent understanding of social inclusion. The analysis was discussed in relation to literature on autism and disability theory.

There is evidence that men are experiencing body image dissatisfaction in growing numbers. The term muscle dysmorphia has been used to describe one expression of extreme body image distress and is thought to be particularly prevalent in male body-builders. This study aimed to explore male body-builders understanding and experiences of their body image. A grounded theory methodology was used, situated within a contextual constructionist epistemology. Five male body-builders were interviewed and the transcripts analysed. Control emerged as the core concept, expressing participants' feelings of control loss and attempts to mediate this. Four higher order categories emerged as areas where issues of control were most obvious self-image gym culture social pressures and health beliefs and behaviours. A model of the relationships between the categories and control was developed. Feelings of uncertainty about self in relation to body image were evident. Mediation occurred through attempts to control the social environment leading to further immersion within the gym culture. Nutritional beliefs and diet behaviours were another way in which the participants' attempted to exert control over their body image. Implications for clinical practice were discussed, with particular emphasis on men presenting to services expressing distress about their body image in relation to body fat and physique. Recommendations for future research were made and limitations of the study were discussed.

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