Individuals with Major Mental Illness (such as schizophrenia and bipolar disorder) experience increased rates of physical health comorbidity compared to the general population. They also experience inequalities in access to certain aspects of healthcare. This ultimately leads to premature mortality. Studies detailing patterns of physical health comorbidity are limited by their definitions of comorbidity, single disease approach to comorbidity and by the study of heterogeneous groups. To date the investigation of possible sources of healthcare inequalities experienced by individuals with Major Mental Illness (MMI) is relatively limited. Moreover studies detailing the extent of premature mortality experienced by individuals with MMI vary both in terms of the measure of premature mortality reported and age of the cohort investigated, limiting their generalisability to the wider population. Therefore local and national data can be used to describe patterns of physical health comorbidity, investigate possible reasons for health inequalities and describe mortality rates. These findings will extend existing work in this area.

Introduction: Research indicates that children with an intellectual disability [ID] are at an increased risk of developing attachment difficulties and subsequent affect regulation difficulties. Attachment theory may further understanding of the risk factors for individuals with an ID experiencing mental health problems, challenging behaviour and emotional difficulties. However, there is a paucity of research into attachment and adults with ID and there is a lack of valid and reliable measures for assessing attachment security for this group. The Manchester Attachment Scale-Third Party Observational Measure [MAST] was developed to assess degree of secure attachment behaviour for adults with ID and the current study examined the psychometric properties of the MAST. Method: Professional carers [N=40] supporting individuals with an ID completed the MAST and other measures related to the construct of attachment theory (subscales of the Edward Zigler-Yale Personality Questionnaire[EZPQ] and Emotional Rating Scale [ERS] as well as the Learning Disability Casemix Scale [LDCS) regarding individuals with an ID they were supporting [N=57]. Individuals with an ID [N=14] completed the Self-report Assessment of Attachment Security [SRAAS]. Results: The MAST was found to have good internal consistency and test-retest reliability. The convergent validity of the MAST was indicated by positive correlation with the EZPQ subscales (negative reaction tendency, obedience, positive reaction tendency and outerdirectedness) and scores on the SRAAS. The MAST was found to be correlated with both levels of ID and presence of challenging behaviour as measured by LDCS scores. Conclusion: These current results provide preliminary support for the reliability and validity of the MAST as a measure of secure attachment behaviour for adults with ID. The results provide support for previous research that indicates a relationship between attachment security and level of ID and challenging behaviour. The results of the study and the implications of attachment theory for adults with ID are discussed.

In the last twenty years, governments around the world have signed policies and enacted legislation concerning the right of every child to be provided with education. The United Nations Convention on the Rights of Persons with Disabilities (2006), which states that every child with SEN should receive education in a mainstream setting, whenever possible stimulated, at least partly, the enactment of such policies. To some extent, the Mexican government has responded to the UN initiative by reporting a gradual increase in the number of children with SEN being placed in mainstream schools over the last ten years. However, despite the efforts of some parents and teaching assistants, there is an increasing concern that many children with ASD are not educated in mainstream schools or they have been included but without the support of a qualified teaching assistant or teacher, which has a negative effect on the quality of education. This situation has emphasized the need to improve strategies in order to overcome the barriers to effective inclusion for these children. Thus, the main aim of this study was to explore the extent to which children identified as having Autistic Spectrum Disorder are included within in mainstream schools in Mexico with the support from DOMUS a non-profit parent led organisation. This is done by examining the facilitators and barriers that affect the success of inclusion of children with ASD in Mexico. Multiple case studies of children with autistic spectrum disorders were conducted. The data on the perceptions about inclusion was gathered from interviews with head teachers, teachers, teaching assistants, and parents of children with ASD. In addition, observations of the children with ASD both in class and in the playground were carried out along with focus groups conducted with secondary age classmates, sociometric data, and a review of DOMUS’ records. Participants offered many perspectives on the facilitators and barriers that should be overcome in order to include a child with autism in mainstream schools in Mexico. Seven key themes and related subthemes that can act as facilitators or barriers emerged from the analysis. These included family factors, children with ASD’s social and academic abilities, school ethos, role of teaching assistant and DOMUS, and the influence of stakeholders’ experience in overcoming anxieties about inclusion, teachers’ competence, and stakeholders’ attitudes towards children with ASD. The findings are discussed in relation to the literature review. It was concluded that the Mexican government’s inclusive education policies should be taken further, although the teachers involved should initially receive further training in order to help them feel more confident. An ASD friendly school ethos, positive attitudes from stakeholders, and financial resources can also support inclusion. Stakeholders need to overcome their anxieties, and they can achieve this by embracing the opportunity to experience inclusion. This study provides a starting-point in by identifying the facilitators that should be strengthened and the barriers that should be reduced in order to enhance the inclusion of children with ASD in Mexico.

This study reports the application and outcomes of Conversation Analysis (CA)-motivated interaction-focused therapy for a case series of eight couples managing the impact of aphasia on their conversations. It builds on previously reported interaction-focused therapy case studies (e.g. Lock, Wilkinson, & Bryan, 2001, Wilkinson, Bryan, Lock & Sage, 2010; Wilkinson, Lock, Bryan & Sage, 2011). Therapy was individualised for each couple, based on CA findings, but taking account of language, cognitive and self-reported disability assessments, and the couples' own observations during informal interviews. The participating couples were beyond the spontaneous recovery period for aphasia and presented with different types (e.g. Wernicke's, Broca's, Anomic) and severities of aphasia. Each couple video-recorded at least 80 minutes of baseline conversation at home, over eight recordings of ten minutes or more. Another eighty minutes were recorded immediately post-therapy, and again three months later. Results were evaluated by comparing pre- and post-therapy data, with the maintenance data used to evaluate whether changes were sustained three months after therapy ended. The findings indicated that four couples implemented behavioural changes following interaction-focused therapy. There was no systematic evidence of change in the other four couples' data. Reasons for successful and unsuccessful outcomes are hypothesised, including resistance to changing adaptations that mask aphasic difficulties, despite the loss of communicative effectiveness these adaptations may cause. Preliminary analysis of linguistic and cognitive assessment data has not revealed any patterns that can be related to response to therapy, but more work is warranted to further explore this data. New findings include two interaction-focused therapy targets: 1) eye gaze by people with aphasia to stall/mobilise help with repair from their partners, and 2) facilitating the person with aphasia to gain the floor more regularly by beginning a turn in the partner's turn space. Other new findings are the use of CA to assess aphasic comprehension impairments, the effectiveness of environments of possible occurrence (Schegloff, 1993) as a measure for evaluating success in interaction-focused therapy studies, and benign pedagogics. The study identified some areas for future research, including the development of an interview to elicit attitudes and beliefs about managing aphasia, as these seemed to influence response to therapy. Clinical applications have been suggested in terms of when this form of therapy may be relevant and for whom it might be expected to prove beneficial.

This thesis explored attachment in individuals with intellectual disability (ID). It investigated the role that attachment may have in presenting difficulties, including trauma symptoms, which has a growing body of literature, particularly in people without ID. Paper 1 describes a systematic review of the available literature relating to the psychological well-being of young people with ID in the UK who are 'looked after children' (LAC) or who live away from their birth families. Evidence suggests that both LAC and people with ID, may be vulnerable to developing mental health difficulties. However, there is a paucity of research investigating the psychological well-being of young people with ID who are LAC or who live away from birth families. 17 studies were reviewed, which ranged between 21% and 71% in quality as measured by the QATSDD (Sirriyeh, Lawton, Gardner, & Armitage, 2012). . Only one study was found that directly focused on the psychological well-being of LAC with an ID. The available studies offered some insights into the prevalence, characteristics of young people with ID who are LAC or who live away from their birth families and some of the psychological difficulties they encounter. However, given the methodological limitations of the included studies, no firm conclusions could be drawn. Paper 2 describes an empirical study that investigated the relationship between attachment security and trauma symptoms in adults with ID. 27 staff and service users participated in the research. Service user participants completed a self-report questionnaire regarding trauma symptoms with the researcher and staff participants provided demographic information and completed questionnaires that measured attachment security, trauma symptoms, depressive mood and traumatic events in relation to the service user. No relationship was found between attachment security and trauma symptoms. However, it provided tentative evidence with respect to the type of traumatic events experienced by people with ID and of the prevalence of mental health difficulties in people with ID. There were however several methodological limitations, including a small sample size. Implications for future research and clinical practice are outlined. Paper 3 provides a critical and personally reflective account of undertaking the systematic review and empirical study as outlined above. Strengths and limitations of the research are interwoven throughout. Recommendations for future research and implications for practice are also considered.

Effective writing rehabilitation for people with acquired dysgraphia following a stroke could lead to more opportunities to communicate, reduce isolation and improve quality of life. Previous research has suggested that both impairment-focused spelling therapies and assistive technologies can support writing rehabilitation, although the strength of the evidence is limited. The central aim of this PhD study was to investigate whether a combined approach to writing therapy, including impairment-based therapies and assistive technologies, could improve the email writing of participants with varying severity of acquired dysgraphia. An email writing assessment was developed for outcome measurement and data from 42 control participants were collated to determine the neuro-typical range of email writing performance on this task. A within-participants, multiple case design was used to evaluate the effects of two different approaches to therapy with participants with dysgraphia. In the first study, two impairment-based therapies (uni-modal and multi-modal) were compared with eight participants with dysgraphia and the effects of these on spelling accuracy of treated and untreated words were measured. The functional outcomes (email writing, written picture description, writing frequency and perception of disability) of these therapies were also investigated in a second study. The third study evaluated the effects of training eight participants with dysgraphia (six of whom had participated in the first two studies) to use an assistive writing technology for functional writing. There was a wide range of performance in neuro-typical participants on email writing, with both age and education emerging as determinants of performance. Within the clinical studies, there were no significant differences between uni-modal and multi-modal therapies with respect to spelling accuracy, but these lexical therapies led to significant improvements to accuracy of treated and untreated words, written picture description and word length within emails. Training and use of assistive writing software resulted in significant improvements in spelling accuracy and word length within emails. All participants with dysgraphia showed some responsiveness to intervention. Both impairment-based and compensatory approaches to writing rehabilitation were found to have benefit, although the effects varied across participants and outcome measures. This study has highlighted the need for further research into assessments and therapies for writing in aphasia, specifically focusing on candidacy for specific approaches to writing rehabilitation.

This research project explored how mothers experiencing depression after childbirth perceived their mental illness. Illness perceptions were assessed across the dimensions outlined within the Self-Regulatory Model (SRM, Leventhal, Nerenz & Steele, 1984) via the use of the Revised Illness Perceptions Questionnaire (IPQ-R, Moss-Morris, Weinman, Petrie, Horne, Cameron & Buick, 2002). The psychometric properties of the IPQ-R within this clinical sample and relationships between illness perceptions, depression severity and maternal bonding were assessed. A literature review of the use of the IPQ and IPQ-R within mental health identified that these measures with modifications (in particular to the causal and identity subscales) were largely reliable and valid measures of assessing illness perceptions in mental health. The illness dimensions outlined within the SRM were largely endorsed within the clinical populations sampled, offering support of the applicability of the SRM within mental health. Mental illnesses were consistently viewed as chronic with serious negative consequences. Perceptions regarding mental illness consequences, chronicity and controllability were associated with coping strategies and help-seeking. Treatment adherence and attitudes towards taking medication were associated with illness controllability beliefs. The IPQ-R modified for depression after childbirth was shown to be a reliable measure for assessing illness perceptions within this clinical sample and was shown to be reliable over a four-week time period.Mothers experiencing depression after childbirth perceived their depression as having a moderate number of symptoms, a high number of negative consequences and responded to their depression with a number of emotions. Mothers perceived having a coherent understanding of their difficulties, believing that depression was amenable to treatment and personal control and that depression was cyclical in nature. Commonly reported symptoms experienced attributed to depression included depressed mood, difficulties concentrating, loss of interest/pleasure in activities, fatigue/loss of energy and sleep difficulties. Frequently endorsed causes of depression included stress or worry, hormonal changes, own emotional state, family problems, mental attitude and own behaviour. Interestingly, no significant difference was found between illness perceptions of mothers who previously experienced psychological problems and mothers who had not.Mothers who perceived having many symptoms and a high emotional response to depression were more likely to report higher depression severity. Whereas mothers who believed they had control over their depression were more likely to report lower depression severity. Illness identity and consequence beliefs were associated with maternal bonding difficulties. The project's findings were presented with reference to previous literature with implications for theory and clinical practice explored. Difficulties and limitations of the research and its related theory were discussed in addition to reflections upon the research project. Possible improvements to the research procedure and areas for future research were also identified.

Chapter 1 reviews the literature. It gives a historical overview of hypnosis. It reviews the literature on dental anxiety, including its prevalence and aetiology. It reviews behavioural and cognitive behavioural treatments of dental fear. Inhalation sedation its mechanism of action, effectiveness and draw-backs are discussed. The literature on hypnosis is selectively reviewed, its use in anxiety and dentistry and lastly, the combination of sedation techniques, particularly IHS, is discussed. It is concluded that evidence for the use of hypnosis for the alleviation of dental anxiety needs to be critically addressed. Chapter 2 presents the published protocol of a Cochrane systematic review followed by qualitative results of this review. 11 studies of generally poor quality were included in the review which concludes that there are significant problems with the evidence due to methodological issues, the different outcome measures used and the generally high or unclear risks of bias. There is some evidence that hypnosis may help patients who have a normal range of dental anxiety but who are undergoing a stressful dental procedure. Studies of phobic patients were characterised by high levels of drop-out behaviour and hypnosis could not be shown to be superior to other forms of behavioural treatment. Chapter 3 describes two studies which aimed to develop a Mood Induction Procedure to induce temporary dental anxiety in volunteers. This was used in two later studies. A non-clinical sample was used as a ‘proof of concept’ study was desirable. Study 1tested excerpts of a film, producing only a medium rise in anxiety (ES r = .49). The second study used a shorter, more concentrated film. This produced a large increase in anxiety (ES r=.86). Heart rate was investigated as a possible physiological measure of anxiety, but was not found useful. Chapter 4 describes two randomised controlled studies aiming to investigate whether hypnosis combined with IHS would reduce the anxiety produced by the film more than a control procedure in which IHS was combined with the reading of a story. These studies suggested there may be some effects attributable to hypnosis, but conclusive benefit was not demonstrated. Chapter 5 presents discussion and the overall conclusions of the thesis. Conclusions include the need for further well designed large scale trials involving hypnosis.

Parallel Distributed Processing (PDP) modelling has simulated developmental learning across a range of domains such as reading (e.g. Seidenberg & McClelland,1989) or Semantics (e.g. Rogers et al. 2004). However aside from two notable exceptions (Plaut, 1996; Welbourne & Lambon Ralph, 2005b) modelling research has not addressed the simulation of relearning during spontaneous recovery or rehabilitation after brain damage, and no research has considered the effect of the learning environment. This thesis used an established PDP model of semantic memory (Rogers et al., 2004) to simulate the influence of the learning environment. A novel quantitative measure (called representational economy) was developed to monitor efficiency during learning. Developmental learning is considered to be multimodal (e.g. Gogate et al., 2000) whereas rehabilitation is normally carried out through therapy sessions employing unimodal learning tasks (Best & Nickels, 2000). This thesis hoped to discover whether multimodal rehabilitation may be more efficient (as suggested by Howard et al., 1985). Three sets of simulations were conducted: The first set contrasted multimodal and unimodal learning in development and recovery, and tested internal representations for robustness to damage finding multimodal learning to be more efficient in all cases. The second set looked at whether this multimodal advantage could be approximated by reordering unimodal tasks at the item level. Findings indicated that the multimodal advantage is dependent upon simultaneous item presentation across multiple modalities. The third set of simulations contrasted multimodal and unimodal environments during rehabilitation while manipulating background spontaneous recovery, therapy set size and damage severity finding a multimodal advantage for all conditions of rehabilitation. The thesis findings suggest PDP models may be well-suited to predicting the effects of rehabilitation, and that clinical exploration of multimodal learning environments may yield substantial benefits in patient-related work.

In 2003, Winter, Watson, Gillman-Smith, Gilbert and Acton criticised the DSM-IV’s psychiatric conceptualisation of BPD, proposing a set of alternative descriptions based on Kelly’s (1955) Personal Construct Psychology (PCP) and diagnostic constructs. According to Winter et al. (2003), PCP offers not only a less “pre-emptive” stance towards BPD but is more clinically useful given its intrinsic implications for treatment. This correlational research study aimed to determine whether BPD symptomatology is associated with these proposed characteristics of construing. In addition, it was hypothesised that those with a belief that BPD was a part of their identity and untreatable would display higher levels of hopelessness. Ten participants with an existing diagnosis of BPD completed the following measures: a) Personal Construct Inventory (PCI; Chambers & O’Day, 1984); b) Millon Clinical Multiaxial Inventory, Third Edition, (MCMI-III, Millon, 1994); and c) Beck Hopelessness Scale (BHS; Beck & Steer, 1988). Participants were also asked to complete a repertory grid and a Likert Scale indicating the extent of their belief that: a) BPD is an intrinsic part of them; and b) BPD is a treatable condition. Two of the participants are presented as case examples. The most significant finding related to the hypothesis that greater BPD symptomatology would be associated with a higher degree of change in self-construction over time (‘slot-rattling’). Contrary to our prediction, similarity of construing of the elements ‘Me Now’ and ‘Me in the Past’ was correlated with greater BPD symptomatology. This may indicate a belief among participants that they are unable to change or may represent Kellian hostility. Construing one’s mother and father similarly to one’s therapist was associated with greater BPD symptomatology, as was construing one’s father and partner similarly, suggesting, as hypothesised, that those diagnosed with BPD tend to construe current relationships in the same terms as early relationships. Pre-emptive construing and poorly elaborated self-construction were also found to be associated with increased BPD symptoms as predicted. Content analyses performed on elicited constructs revealed that emotion regulation is the most salient area for participants. While the majority of participants considered that BPD was a part of their identity, most were uncertain as to whether BPD is treatable although these findings were not significantly correlated with levels of hopelessness. Participants’ feedback about their experiences of being diagnosed with BPD raises important ethical questions. Further hypotheses are generated based on the study findings and suggestions are made for a revision of the way in which psychological distress is conceptualized, with a particular emphasis on the utility of the PCP approach towards BPD. Clinical implications, limitations of the study and possibilities for further research are discussed.