In recent years, the experiences of sportspeople living with a chronic illness/disorder have seen an emergence within the narrative literature (Smith, 1999; Carless & Sparkes, 2008; Stone, 2009). However, epilepsy has been noticeably absent. As epilepsy and exercise research is mostly quantitative and medico-scientific in nature (Arida, Guimares de Alameida, Cavalheiro, & Scorza, 2013; Dubow & Kelly, 2003; Nakken, 1999; Wong & Wirrell, 2006), there is no qualitative research to show the experiences of sportspeople exercising with epilepsy. Although exercise has shown to be beneficial for most people with epilepsy (Arida, Scorza, & Cavalheiro, 2010; Eriksen, Ellertsen, & Hestad, 2002; Nakken, 1999), research reveals that people with epilepsy often refrain from exercise (Ablah et al., 2009; Nakken, 1999; Sirven, 2009). Furthermore, exercise-induced seizures (EIS) provide a frustration as well as an incentive to refrain from physical activity (Nakken, 1999; Sturm, Berkovic & Reutens, 2002). Therefore, the aim of this research was to provide a glimpse into the narrative experience(s) of a sportsperson/people with epilepsy (SWE) over the course of one year. Using four semi-structured interviews with four participants, differences in experience over time as well as across athletic identity, sport type, and seizure type and frequency were represented. A holistic-content approach and structural analysis were used to analyse the narratives (Carless & Sparkes, 2008; Frank, 1995; Lieblich, Tuval-Mashiach, & Zilber, 1998). Results have shown the importance of time in the narrative construction of the SWE. Presenting a new narrative type, vicious cycle, these narratives also portrayed similar findings as was shown in Lieblich et al. (1998) (e.g., the steady, progressive, and trial and error narrative). The participants expressed a sense of freedom, body control, and mental clarity linked to exercise. These positive benefits encouraged the participants to continue even if hampered by uncontrolled seizures. Furthermore, outside variables (e.g., time, seizure frequency and type, social support, stigma, and athletic identity) have shown to have an affect on the thoughts/ actions of SWE in regards to exercise. Through this research, SWE will have a voice within research. Through this research, the SWE’s story will be told. In turn, it is desired that this new insight leads practitioners to develop and implement more effective ways for SWE to cope with the transition of diagnosis.

Objectives. There is a developing body of evidence that guided self-help can be effective in alleviating distress experienced from symptoms of depression and anxiety. However evidence is not consistently positive and clarification is required about how it achieves its effects. Furthermore, previous research into guided self-help has not investigated patients with milder depression or anxiety. Exploration of the therapy process in guided self-help has crucial importance in developing further understanding about its qualities and how it is experienced. This study aimed to explore the ways in which people experience guided self-help for depression or anxiety within primary care. Design. Qualitative research has been recommended to complement the quantitative work that has been published to date on guided self-help. The data used for analysis was gathered from semi-structured interviews. Method. Interpretative phenomenological analysis was used. Semi-structured interviews were carried out with seven participants who had accessed and completed guided self-help for either mild depression or anxiety. The verbatim transcripts of those interviews served as the data for analysis. Results. Four themes emerged which are described under the broad headings: participants’ intention to feel better, development of understanding and awareness, change: from dependency to independence, and relating to others. Conclusions. Participants experienced a positive outcome of using guided self-help, which included increased knowledge about their thoughts and feelings, and increased self-efficacy in managing their own mental health. These findings shed light on how the patients’ positive outcomes are related to the change process. Findings also suggest that self-determined motivation may impact upon accessibility to guided self-help in addition to patients’ attitudes and expectations.

This thesis explores the question, what are the important change processes in the treatment of personality disorder in a male forensic inpatient setting? A number of empirically supported therapies for personality disorder stress the importance of the therapist-client relationship in the change process. Therapist-patient relationships are therefore an important focus in this thesis. However, given the lack of research into change processes in this population, the focus is not limited to the therapist-patient relationship, but also considers other relationships and other aspects of the treatment milieu. A model of change processes for this patient group is developed through a series of studies. The first study, in chapter 3, is a qualitative investigation of patients’ perceptions of the process of change and the factors involved. Twelve patients completed a semi-structured interview and the results were analysed using thematic analysis. The study concludes that the cognitive dissonance between how patients expect to be treated and how they are actually treated is an important factor in motivating them to engage in treatment. It also concludes that the therapist-patient relationship and the wider interpersonal environment are both important to therapeutic change with this population. Chapters 4 and 5 describe the process of developing an appropriate dependent outcome measure for the thesis. Social functioning was selected as the dependent outcome variable. Chapter 4 is a systematic review of social functioning measures used with people with a diagnosis of personality disorder and concludes that there is a need to develop a new self-report measure specifically for people with a diagnosis of personality disorder in inpatient settings. Chapter 5 describes the development and validation of this new measure, the Hospital Social Functioning Questionnaire (HSFQ). Fifty-four patients completed a range of measures including the HSFQ. The HSFQ shows good internal consistency, test-retest reliability and concurrent validity with other measures. It appears to measure different aspects of social functioning from the Global Assessment of Functioning (GAF), the most widely used social functioning measure, and the two measures appear to complement each other. Chapter 6 is a quantitative study using the HSFQ and a self-report measure of patients’ perceptions of therapeutic change processes to test the initial model of change developed in chapter 3. Fifty patients completed a checklist about how they had changed during treatment and the factors that had contributed to that change, as well as measures of social functioning. Self-reported levels of change were highly correlated with measures of patient functioning, though significant levels of change did not occur until the latter stages of treatment. The behaviour of therapists was particularly important throughout treatment, though participants in the final stage of therapy reported that the behaviour of other staff was as important as that of therapists, suggesting that, by this stage of treatment they are able to extend their range of supportive and therapeutic relationships. The results support a limited reparenting attachment-based model of therapeutic change. Chapter 7 is a pattern matching study that tests and refines the model of change. Ten patients completed a semi-structured interview about their interactions with their therapist. Their responses were analysed using a modified version of pattern matching to test hypotheses generated by the limited reparenting attachment-based model of change. The results support the limited reparenting model and suggest that patients’ attachment relationships with their therapists are an important change process for this population, particularly in the earlier stages of treatment. Chapter 8 presents a three-stage model of change based on the results of this thesis. On first admission, patients enter the orienting/ cognitive dissonance phase, in which they start to engage in treatment after perceiving a consistent improvement in how they are currently regarded and treated compared to how they have been regarded and treated previously, particularly in prison. Next, they enter the reparenting phase, during which their relationship with their therapist is the most important factor affecting change. Many features of the therapist-patient relationship during this phase parallel attachment processes between children and caregivers. Finally, patients enter the exploration/ generalisation phase in which they are able to explore from the secure base of their relationship with their therapist and develop supportive and therapeutic relationships with other staff members. This model provides a useful framework for working therapeutically with this patient group.

Introduction: The link between experiences of childhood trauma and youth offending behaviour is well documented. However, the relationship between trauma and offending is complex and few studies have examined the mechanisms that might account for this link. Youth Offending Team (YOT) staff work closely with many young people who have experienced traumas, which may allow them to gain a unique insight into these links. They also have the ability to significantly influence a young person’s future; therefore, an understanding of their perceptions of this cohort is critical. Consequently, this study aimed to obtain a detailed understanding of YOT staff’s knowledge and perceptions of the trauma-offending pathway. Methodology: Ten YOT workers from three YOTs in South Wales engaged in semi-structured interviews. Data was collected and thematically analysed, drawing on Constructivist Grounded Theory principles. Results: Three key themes were identified; ‘Staff perceptions of the mechanisms linking trauma and offending’, ‘Exits from offending’ and ‘The role of YOS and other services’ in supporting these young people. Discussion: This study helped bridge the gap between child welfare and juvenile justice research. It is argued that understanding the mechanisms that exacerbate or mitigate the link between trauma and offending can improve outcomes for young people and wider society. This study provides a detailed understanding of staff perceptions of the links between trauma and offending behaviour, which can help guide our understanding and inform future practice and research in the trauma-offending field.

This thesis is an investigation of structural brain abnormalities, as well as multisensory and unisensory processing deficits in autistic traits and Autism Spectrum Disorder (ASD). To achieve this, structural and functional magnetic resonance imaging (fMRI) and psychophysical techniques were employed. ASD is a neurodevelopmental condition which is characterised by the social communication and interaction deficits, as well as repetitive patterns of behaviour, interests and activities. These traits are thought to be present in a typical population. The Autism Spectrum Quotient questionnaire (AQ) was developed to assess the prevalence of autistic traits in the general population. Von dem Hagen et al. (2011) revealed a link between AQ with white matter (WM) and grey matter (GM) volume (using voxel-based-morphometry). However, their findings revealed no difference in GM in areas associated with social cognition. Cortical thickness (CT) measurements are known to be a more direct measure of cortical morphology than GM volume. Therefore, Chapter 2 investigated the relationship between AQ scores and CT in the same sample of participants. This study showed that AQ scores correlated with CT in the left temporo-occipital junction, left posterior cingulate, right precentral gyrus and bilateral precentral sulcus, in a typical population. These areas were previously associated with structural and functional differences in ASD. Thus the findings suggest, to some extent, autistic traits are reflected in brain structure - in the general population. The ability to integrate auditory and visual information is crucial to everyday life, and results are mixed regarding how ASD influences audiovisual integration. To investigate this question, Chapter 3 examined the Temporal Integration Window (TIW), which indicates how precisely sight and sound need to be temporally aligned so that a unitary audiovisual event can be perceived. 26 adult males with ASD and 26 age and IQ-matched typically developed males were presented with flash-beep (BF), point-light drummer, and face-voice (FV) displays with varying degrees of asynchrony and asked to make Synchrony Judgements (SJ) and Temporal Order Judgements (TOJ). Analysis of the data included fitting Gaussian functions as well as using an Independent Channels Model (ICM) to fit the data (Garcia-Perez & Alcala-Quintana, 2012). Gaussian curve fitting for SJs showed that the ASD group had a wider TIW, but for TOJ no group effect was found. The ICM supported these results and model parameters indicated that the wider TIW for SJs in the ASD group was not due to sensory processing at the unisensory level, but rather due to decreased temporal resolution at a decisional level of combining sensory information. Furthermore, when performing TOJ, the ICM revealed a smaller Point of Subjective Simultaneity (PSS; closer to physical synchrony) in the ASD group than in the TD group. Finding that audiovisual temporal processing is different in ASD encouraged us to investigate the neural correlates of multisensory as well as unisensory processing using functional magnetic resonance imaging fMRI. Therefore, Chapter 4 investigated audiovisual, auditory and visual processing in ASD of simple BF displays and complex, social FV displays. During a block design experiment, we measured the BOLD signal when 13 adults with ASD and 13 typically developed (TD) age-sex- and IQ- matched adults were presented with audiovisual, audio and visual information of BF and FV displays. Our analyses revealed that processing of audiovisual as well as unisensory auditory and visual stimulus conditions in both the BF and FV displays was associated with reduced activation in ASD. Audiovisual, auditory and visual conditions of FV stimuli revealed reduced activation in ASD in regions of the frontal cortex, while BF stimuli revealed reduced activation the lingual gyri. The inferior parietal gyrus revealed an interaction between stimulus sensory condition of BF stimuli and group. Conjunction analyses revealed smaller regions of the superior temporal cortex (STC) in ASD to be audiovisual sensitive. Against our predictions, the STC did not reveal any activation differences, per se, between the two groups. However, a superior frontal area was shown to be sensitive to audiovisual face-voice stimuli in the TD group, but not in the ASD group. Overall this study indicated differences in brain activity for audiovisual, auditory and visual processing of social and non-social stimuli in individuals with ASD compared to TD individuals. These results contrast previous behavioural findings, suggesting different audiovisual integration, yet intact auditory and visual processing in ASD. Our behavioural findings revealed audiovisual temporal processing deficits in ASD during SJ tasks, therefore we investigated the neural correlates of SJ in ASD and TD controls. Similar to Chapter 4, we used fMRI in Chapter 5 to investigate audiovisual temporal processing in ASD in the same participants as recruited in Chapter 4. BOLD signals were measured while the ASD and TD participants were asked to make SJ on audiovisual displays of different levels of asynchrony: the participants’ PSS, audio leading visual information (audio first), visual leading audio information (visual first). Whereas no effect of group was found with BF displays, increased putamen activation was observed in ASD participants compared to TD participants when making SJs on FV displays. Investigating SJ on audiovisual displays in the bilateral superior temporal gyrus (STG), an area involved in audiovisual integration (see Chapter 4), we found no group differences or interaction between group and levels of audiovisual asynchrony. The investigation of different levels of asynchrony revealed a complex pattern of results indicating a network of areas more involved in processing PSS than audio first and visual first, as well as areas responding differently to audio first compared to video first. These activation differences between audio first and video first in different brain areas are constant with the view that audio leading and visual leading stimuli are processed differently.

Background: Many individuals have thoughts of self-harm, but only a proportion act upon them and engage in self-harm behaviour. Currently, our ability to differentiate which individuals who think about self-harm will translate those thoughts into actions, is limited, and is a critically important area for future research to inform suicide prevention efforts. This thesis presents three empirical studies underpinned by the recently proposed model of suicidal behaviour, the Integrated Motivational-Volitional model (IMV; O’Connor, 2011), which specifically makes predictions about factors which differentiate between suicidal thoughts and behaviours. Two putative variables within this model may be sensitivity to emotional and physical pain; indeed threshold and tolerance for physical pain have been found to be elevated in individuals who have engaged in self-harm, relative to healthy controls. Furthermore, previous research has suggested that elevated physical pain tolerance may be potentiated by an individual’s state of distress. Emotional pain sensitivity, however, has been demonstrated to be reduced in those who have engaged in self-harm. Whether changes in sensitivity to emotional and physical pain are a cause or a consequence of self-harm, is unknown, and could be an important target for treatment and intervention development. Methods: A systematic review of the literature around physical pain and self-harm (n = 25 studies) was conducted in order to assess the quality and extent of the existing knowledge in this area. Three empirical studies were then conducted investigating the relationship between emotional and physical pain in self-harm ideation and enactment. Two of these (n = 102; n = 88) were laboratory studies, employing a combination of self-report and behavioural measures of emotional and physical pain sensitivity, and one took the form of a large online self-report study (n = 351). Results: The studies within this thesis found no evidence to suggest that behavioural threshold or tolerance for physical pain is elevated in self-harm ideation or enactment. Furthermore, pain tolerance does not appear to differ as a function of stress. Self-reported sensitivity to emotional pain was highest in those who had engaged in self-harm, followed by those who had ideated about self-harm and was lowest in healthy controls. There were no significant associations between self-reported and behavioural measures of emotional and physical pain sensitivity. Negative mood decreased following administration of a painful stimulus for all groups (controls, self-harm ideation and self-harm enactment). As predicted, motivational phase variables within the IMV did not differ significantly between the ideation and enactment groups, however, volitional phase variables did exhibit a significant difference. Conclusions: The findings from this thesis provide some support for the IMV model of suicidal behaviour (O’Connor, 2011), demonstrating that the volitional phase variables impulsivity and exposure to social modelling of self-harm, differentiate between those with thoughts (only) of self-harm and those who have gone on to engage in the behaviour. This is an important finding with implications for intervention and treatment development. The similar pattern of elevated emotional pain sensitivity across self-harm ideation and enactment suggests that this could be a pre-motivational phase variable within the IMV. The lack of expected between-group differences in behavioural measures of emotional and physical pain call into question the findings of previous studies. Furthermore, as neither of the laboratory studies presented within this thesis found significant differences in pain threshold or tolerance between self-harm ideation, self-harm enactment and control groups, there is a clear need for more research in this area.

Background: Posttraumatic Stress Disorder (PTSD) is a common disorder that causes a significant health, social and economic burden for the individuals who suffer from it and consequently, for society as a whole. However, little is known about the consequences of PTSD, and in particular there is a lack of empirical data in relation to its economic impact on individuals and health systems, or on the treatments that might be provided. Aims: The aim of this research is to assess the health, social, and economic impacts of PTSD by focusing on the individuals exposed to the London bombings by: a) reviewing the current evidence and measures of the health, social and economic impact of PTSD; b) assessing the impact of the London bombings in terms of service use and the impact on health, social, and economic activity of those affected; c) conducting an economic evaluation of the ‘screen and treat’ programme implemented as a mental health response after the London bombings; and d) assessing the broader implications and feasibility of screening for PTSD in primary care. Method: Semi-structured interviews with 230 participants, screen and treat programme users and potential users conducted as a part of the evaluation of the NHS mental health response to the London bombings, analysis of the dataset on the outcomes collected as a part of the programme, and semistructured interviews on the benefits of and barriers to implementing screening for PTSD in the primary care sector. Analysis: A range of quantitative and qualitative methods are conducted including: estimation of the costs associated with exposure to the London bombings, analysis of cost and outcome variation between individuals exposed to the bombings, economic evaluation of the screen and treat programme distinguishing three comparator groups, and directed qualitative content analysis of fourteen interviews on the benefits of and barriers to screening for PTSD in primary care. Results: The higher prevalence of London bombing-related problems for individuals who were not treated, even as long as two and a half years after the 9 bombings, confirms the benefits of long-term screening after exposure to traumatic events. Participants who used the screen and treat programme reported significantly higher average direct and total costs. The treated group reported up to three times higher total costs in comparison to individuals who were screened and assessed only, with work-related costs making the highest contribution to the total cost, followed by the programme itself, and then other health care costs. Similar service use patterns were found between the treated, and the screened and assessed only groups. The main cost drivers identified in the analysis for the full sample of individuals exposed to the London bombings were being of female gender, being in a non-white British ethnicity group, experiencing injury, old age, and feeling one might be killed and/or injured. The treated group consisted of individuals who were more severely affected by the London bombings when compared to the group who were screened and assessed only. Conclusions: The effects of trauma exposure and PTSD have a wideranging and long-term health-related and economic impact on exposed individuals. The findings suggest that the screen and treat programme was successful in identifying participants with greater mental health needs and providing them with treatment. Providing the best evidence-based treatment early in the form of the ‘screen and treat’ approach does not seem to be costeffective. However, without having a proper waiting list comparison group the questions on effectiveness and cost-effectiveness of the ST programme are difficult to answer with certainty. This study has pointed out vulnerable groups such as minority ethnic groups and women who are likely to experience worse outcomes and generate higher direct and indirect costs. There is a need for timely, rigorously-implemented economic evaluations of mental health interventions for PTSD. There is a role for non-RCT study designs in economic evaluations of PTSD interventions. There is also a need for economic evaluation of screening for PTSD intervention in primary care.

Background: Dyspraxia, a form of developmental coordination disorder (DCD), is one of the most common disorders of childhood (Wann 2007). However, while there is increasing evidence that in many cases childhood motor difficulties persist into adulthood (Kirby et al 2013) little is known about the impact of the condition during adolescence. Moreover, existing research reflects the interests and concerns of professionals and parents rather than the perspectives of teenagers themselves. Methodology: The study was guided by the philosophical principles of interpretative phenomenological analysis (IPA). A Research Reference Group of older teenagers and young adults with dyspraxia was involved in the study design and analysis of findings. Sixteen interviews were carried out with teenagers aged 13-15 years over a two year period. Participants’ accounts were subjected to a systematic process of ideographic, inductive and interpretative analysis. Findings: Five themes that represent the lived experience of dyspraxia during adolescence emerged. These were: “Doing everything the hard way”; “I didn’t want to be seen as someone different”; “I’m an intelligent person but I can’t even write. It’s making me fill up”; right help, right time; and making sense of the diagnosis. In accordance with the philosophical principles of IPA the findings prioritise the voice of the participants, and my influence as the researcher and insights offered by the Reference Group on the interpretation of findings are acknowledged. Evidence built through the process of interpretative analysis is drawn together into a conceptual framework. This is presented as a novel means of demonstrating the complex interaction of personal and environmental factors that influence the lived experience of DCD/dyspraxia during adolescence and their impact on teenagers’ sense of identity, agency, ambition and emotional resilience. The thesis concludes by summarising the new understandings about DCD/dyspraxia that the study brought forth, identifying how these might help parents, professionals, support organisations including the Dyspraxia Foundation and researchers to improve outcomes for teenagers living with DCD/dyspraxia in the future.

Firefighters have a high likelihood of being exposed to a variety of traumatic events. The psychological cost of this exposure may be an increased risk of long-term problems such as PTSD symptoms, depression and anxiety. Saudi firefighters in Makkah province are often exposed to elevated levels of potentially traumatising events through the course of their work which can affect them physically and psychologically. However, providing sufficient mental health professionals is difficult due to the absence of psychological trauma care in Saudi Arabia and Saudi culture associated with the psychological support. The aim of this thesis is to understanding the psychological impact of being a firefighter and seeing whether narrative exposure therapy (NET) is an effective treatment for traumatised Saudi firefighters. Three studies were conducted In order to achieve these aims. The first administered questionnaires to 200 Saudi firefighters; the second was a qualitative study comprising of semi-structure life story interviews with 9 traumatised Saudi firefighters, whilst the final randomized control trial (RCT) examined the effectiveness of NET with 34 Saudi firefighters with PTSD. A high prevalence rate of PTSD (57%), anxiety (44.4%), and depression (53.3%) symptoms with limited mental health support were reported. Single firefighters reported PTSD symptoms and the use of passive coping strategies more than the married firefighters. The results also revealed that marriage was associated with low levels of PTSD, while high levels of PTSD correlated with anxiety, depression, and with passive coping strategies. The qualitative study illustrated themes and subthemes reflected family life, education, experience of being firefighters, traumatic, coping strategies. Two narrative analysis cases presented with the life plot trend with the positive impact of the individual’s life story interview which inform the using of narrative technique in the intervention study. The RCT study demonstrated a significant reduction in PTSD, anxiety, and depression symptoms after 6 weeks, but this was not sustained at 3 and 6 months. The research provides evidence for the applicability and effectiveness of a narrative intervention for traumatised Saudi firefighters. It tried to facilitate the wider dissemination of psychological intervention to promote recovery from traumatic stress for the first responders. Four sessions might not give firefighters sufficient time to process all the relevant information, and they therefore reported an increase in PTSD symptoms in the follow-up time. It would be preferable for firefighters to receive two or three NET sessions after a 3 and/or 6-month follow-up. The findings help advance current knowledge in the management of PTSD among firefighters, in-depth understanding the psychological, coping, and cultural backgrounds, in developing countries, contribute to the validation of PTSD theories, and inform future research. The implications of developing a multi-factorial and holistic approach to the treatment of first responders’ traumas are presented and a case is made for the use of narrative methods in the treatment of complex trauma.

Purpose and Background This mixed methods study explored the importance of therapist body-confidence and gender upon the Eating Disordered client and recovery. Examination of previous literature highlighted a lack of research exploring negative treatment experiences from the perspective of individuals who have an Eating Disorder. With reference to socio-cultural theoretical models, initial findings in the literature indicate that aspects of therapist appearance may be an important factor in treatment experience. The potential sensitivity of exploring therapist appearance is considered as one reason that this topic remains largely unexplored in the literature. Method 143 males and females with self-reported current or historical experience of an Eating Disorder completed an anonymous, online survey which was designed by the authors for the purpose of the study. Questions exploring body-confidence and recovery were analysed using Thematic Analysis incorporating Saliency Analysis. Questions pertaining to therapist gender and body-confidence were analysed using statistical tests. Rationale is provided for the epistemological stance, methodological approach and design of the current study. Results Thematic Analysis revealed three overarching themes about body-confidence and three overarching themes about recovery. The body-confidence themes suggested that individuals who have an ED progress along a continuum of beliefs about body-confidence, initially believing that it is linked to body-size, before acknowledging that their Eating Disorder is unrelated to body-confidence and finally realising that body-confidence is possible regardless of size. The recovery themes indicated that individuals who have an ED go through a cycle where they feel restricted, begin to reconcile self and culture and achieve resilience on the path to recovery. Statistical analysis revealed that participants rated therapist body-confidence as highly important and showed a strong preference for a gender-same therapist. There was also some indication that participants judged the body-confidence of male and female therapists differently, although the effect size of this finding was small. The results are discussed within the context of previous literature and in keeping with the epistemological position of the current study. Conclusions These findings offer further support for the continued investigation of therapist appearance, in particular body-confidence and gender, and how it might impact upon the therapeutic experience of Eating Disordered clients. Further contribution is the addition of the perspective of individuals who have an Eating Disorder to the literature about recovery from an Eating Disorder. There are important implications for services, how they are organised and how therapists are trained to work with this population. Future research should further explore the ways in which aspects of therapist appearance impact upon therapeutic experience for Eating Disorder clients and whether there are mediating factors. Finally, the principle researcher’s critical reflection about theoretical, scientific and ethical aspects of the research process is provided.