This thesis begins with a literature review examining whether family interventions for people diagnosed with Bipolar Disorder (BD) lead to better outcomes for their relatives, who often exhibit greater service utilisation and greater distress than the general population. Following a systematic search of the quantitative literature, ten papers were identified, analysed for relevant data, and assessed for their methodological rigour. Results indicated that family interventions may improve relatives’ feelings of carer burden and psychological distress, but that these conclusions must be treated with caution given methodological issues in the evidence base. Suggestions are made as to which type of family intervention clinicians should consider offering, and which priorities future researchers in this area may wish to address. Decisions not to use medication among people diagnosed with BD are often viewed as indicative of a ‘lack of insight’ into the nature of bipolar moods and medication. However, research has not examined the individual’s experiences once they decide to manage bipolar moods without medication. The empirical paper presented here seeks to elucidate the processes by which people manage bipolar moods without medication by using grounded theory methods. Ten participants were interviewed and a model developed from their data. This model suggests participants engaged in a complex decision-making process as to how to manage their moods, frequently with reference to beliefs they held about themselves and their mood, suggesting that the ‘lack of insight’ model may be inadequate for understanding the processes involved in managing bipolar moods without medication. On the basis of the model developed from the data, suggestions are made regarding clinical interventions and future research. There then follows a critical appraisal of the work conducted in the empirical paper, focussing on challenges in the area of recruitment, in the hope that reflections provided will aid future researchers in this area.

This thesis explores the psychological experiences relating to two types of potentially traumatic cardiac treatments: heart transplantation and implantable cardioverter defibrillators (ICD). It was hoped that such an endeavour would yield novel insights into these treatments that might facilitate the development of pertinent theory and psychotherapeutic approaches designed to alleviate the psychological distress that often results from them. The literature review comprises a metasynthesis of 19 papers derived from 13 different studies on the posttransplant psychological experiences of cardiac patients. This yielded four themes: 1. ‘The ambiguous presence of the donor’; 2. ‘Reborn but still not in control’; 3. ‘Striving for autonomy and normality’; and 4. ‘The search for acceptance and new meaning’. The chief novel finding from the synthesis was that successful psychological recovery from the myriad traumas associated with heart transplantation might best be characterised as a form of posttraumatic growth. The empirical paper comprises a qualitative exploration of the psychological experiences of six ICD-patients who have received ‘electrical storms’ from their devices i.e., episodes of multiple ostensibly therapeutic ‘shocks’. The use of interpretative phenomenological analysis enabled the exploration of divergences and convergences across the accounts, culminating in the identification of five themes: 1. ‘Fear of imminent death’; 2. ‘Living with a sense of dread’; 3. ‘Problematic attempts to regain control’; 4. ‘Beliefs about what constitutes acceptable support’; and 5. ‘The ongoing struggle to accept the device and its implications’. The analysis revealed that shocks may be triply traumatic, not least because they can make recipients fear that their lives are in imminent danger. Long-term post-storm adjustment may be influenced by the recipients’ locus of control orientation and by the degree to which they inhibit their emotions. The clinical, theoretical and research implications of both papers’ findings were explored.

Within the psychiatric paradigm, suicide is usually viewed as an irrational act arising from mental disorder. Philosophical perspectives have at times challenged this assumption, arguing that there may be circumstances in which suicide can be viewed as rational. However, such circumstances are generally only considered to include physical disease, terminal states and chronic pain. Psychogenic pain rarely qualifies as acceptable grounds for rational suicide. People with schizophrenia who voice suicidal ideation are usually deemed irrational in their desires by both psychiatric and philosophical paradigms, wherein their desire to die is seen to arise as a direct consequence of mental disorder. Suicide prevention in such cases is therefore considered to be morally justified in preventing what are considered substantially nonvoluntary acts. This construction of suicide and schizophrenia however fails to take account of two key variables: Firstly, the risk of suicide for people with schizophrenia is highest when positive symptoms are in remission and/or where insight is greatest. Secondly, quality of life studies show that subjective satisfaction is substantially related to social functioning and not the severity of positive symptoms. Such data questions the assumption that suicidal ideation for people with schizophrenia is always a direct result of psychotic phenomena. In this work, I challenge the view that people with schizophrenia are always globally irrational and nonautonomous, and argue that such persons may reasonably evaluate the course and consequences of living with serious mental illness. For the person with schizophrenia, who is subjected to repeated relapses and rehospitalisation, consequent psychic, social and interpersonal losses may lead to a state of hopelessness. I propose that such existential hopelessness is not necessarily pathogenic, but may be a rational response to unendurable suffering. Therefore, I conclude, that such prolonged psychological suffering may legitimately influence a person's desire to die and that there may be circumstances where the suicides of people with schizophrenia can be correctly viewed as rational

This doctoral thesis explores paradigms currently used in mental health services. The thesis comprises a literature review, a research paper and a critical appraisal. A final section is dedicated to the ethical procedures undertaken prior to undertaking the research. The literature review is a systematic review which synthesises 14 qualitative papers studying the experiences of accessing mental health services for individuals who have received a diagnosis of borderline personality disorder. The overarching theme ‘bpd is a double-edged sword’ is labelled along with four sub-themes: ‘undeserving of care’, ‘disempowerment’, ‘safety and containment’ and ‘approaching recovery’. Findings suggest the need for further inclusion of service users in the development of service provision and an approach that is formulation-based and grounded in attachment theory. The research paper explores psychiatrists’ understanding and use of psychological formulation. A constructivist grounded theory framework led to an initial conceptualisation and model. Four conceptual categories were named as ‘conceptualising formulation’, ‘singing off the same hymn sheet’, ‘barriers to formulation’ and ‘making a Frankenstein’s monster’. In particular the findings suggest that psychiatrists view and use psychological formulation in a different way from that outlined by clinical psychologists and that there are multiple barriers to its use. Finally, the critical review presents challenges encountered during the research project and personal reflections on the process. Overall the thesis highlights the need for mental health services to embrace multiple paradigms and remain open to alternative discourses around mental illness in order to provide a holistic and integrated service provision. A formulation-based approach may provide such an arena, while allowing space for individualised care. Clinical psychologists are well placed to promote such an approach via service development and consultation with multidisciplinary staff.

Understanding the processes involved in therapy are crucial to maximising its benefits. This doctoral thesis explores two aspects of therapy which are crucial to the beginning and ending phases of therapy i.e. the formation of the therapeutic relationship and the experience of ending therapy. It is hoped that this contribution to the research base will provide clinicians with practical recommendations based on empirical evidence and prompt future research to investigate these topics further. The first section of this thesis describes a metasynthesis of qualitative studies exploring the formation of the therapeutic relationship from the client’s perspective. Findings highlight clients’ initial assessment of therapist characteristics to see whether they fit with their perceived needs. Displays of openness and respect from the therapist were found to facilitate the formation of the relationship and allow for a deep connection between client and therapist to be established. The second section of this thesis presents a grounded theory study focusing on therapists’ experiences of ending therapy with clients. The theory explains the processes that play a significant role in the ending experience (therapist context, therapeutic approach, level of connectedness, level of investment and therapist’s perceived responsibility) and how they impact on different types of therapy endings. Elements of the therapy were found to continue beyond the final session as therapists described learning from each ending experience which served to influence their future work with clients. The third section of this thesis comprises personal reflections on the process of engaging in the thesis project. Specifically, this critical appraisal explores the difficulties experienced by the author in positioning herself within a consistent ontological and epistemological stance. The reflections offered in this section follow the developmental journey made by the author as a result of engaging in this project.

In recent years, previous research has indicated that symptoms such as delusional beliefs may have a defensive function against underlying negative schemata (Candido & Romney, 1991; Lyon et al. 1994). However, hitherto research has failed to examine information processing in psychosis across the processing spectrum. The aim of the present research was to investigate cognitive functioning in psychosis on several tasks operating at different levels of conscious and non-conscious processing in order to ascertain at what level the defence operates. The research also investigated the impact of personally salient stimuli on information processing in addition to the standardised emotional stimuli employed in previous studies. Results indicated that people with psychosis demonstrate a processing pattern similar to that of depression on tasks employing non conscious processes. Both people with psychosis and depression were found to demonstrate a self-blaming attributional style on covert tasks (ExpA), whilst showing implicit memory biases for both positive and negative stimuli (Exp.2). Differentiation between the two groups was found on a conscious level, with people with psychosis demonstrating an explicit memory bias for positive stimuli whilst revealing a self-serving attributional style and people with depression revealing an explicit memory bias for negative stimuli and a self-blaming attributional style. In contrast to people with depression who demonstrated an attentional bias for negative stimuli, people with psychosis were found to demonstrate a trend in attentional bias for positive stimuli (Exp. I). People with psychosis were also found to be particularly hasty in their decision-making (Exp.S). No difference between the groups, however, was found on the emotional Stroop task (Exp.3). Thus, the results support previous research and suggest that the symptoms of psychosis may have a protective function against underlying negative schemata.

Combining qualitative and quantitative evidence may enhance understanding of how complex healthcare interventions work. How best to integrate quantitative reviews of interventions with reviews of qualitative research on patients’ views on issues relating to components of such interventions is challenging. In this thesis I used adherence to therapy as a worked example to answer: 1) How can qualitative evidence of patients’ views help understand heterogeneity of effect in complex healthcare interventions? (2) What approaches to combine different data, collected from different research disciplines, can best be applied to the mixed review evidence? I used evidence from qualitative reviews on patients’ suggestions on how to promote adherence with outputs from quantitative evidence on the effectiveness of trialled interventions promoting adherence. I compared in a table, patients’ suggestions with the content of interventions. I summarised narratively, and used analytical approaches: qualitative comparative analysis (QCA) and regression. The approaches differed in data requirements. Regression was most restricted, even when adapted for smaller datasets. QCA and regression differed in presentation: regression sought across trials the most parsimonious factors in relation to outcome; whilst QCA sought to identify multiple pathways and combinations of factors. QCA may offer understanding of most relevance in its presentation but does not provide a measure of the precision of its findings, and its weaknesses are not fully understood. The approaches generated new findings. Some concurred. The suggestions most commonly found linked to effective interventions corresponded with two distinct ways to promote adherence, one being interactive (focusing on personal risk factors) and the other more didactic (emphasising clear information). This thesis compares methods to integrate qualitative evidence on patients’ views with evidence on the effectiveness of complex interventions. It advances discussion on the value of qualitative evidence in intervention development and provides new evidence on how to promote adherence to therapy.

This review concerns the factors influencing a clinician's preference for therapeutic orientation, i.e. the theoretical frameworks used by practitioners of psychological therapy to guide formulation of a client's difficulties, and intervention. Despite the predominance within training institutions of a "school" approach to the teaching of psychological therapies, and the current Zeitgeist within clinical psychology of selecting the treatment for a particular clinical problem which is scientifically validated, little is known about how individuals arrive at a preferred way of working. Literature on the following factors related to preference for orientation is reviewed: 1) the personality of the therapist, 2) their philosophical standpoint, 3) professional experiences and 4) life experiences. The review concludes with a summary of methodological issues, suggestions for future research, and a discussion of the implications of this area of research in terms of training, model integration and acceptance of evidence-based treatments.

The UK End of Life Care Strategy proposed that all people should identify preferences for end of life care. Aims To explore whether family carers of a person with dementia (PWD) can accurately predict their preferences for end of life care and what factors influence this. Methods: This mixed methods study began with nominal groups to explore if PWD and carers could generate and prioritise preferences for end of life care and how much carers influenced the PWD’s choices. The second phase involved 60 dyad interviews using a modified Life Support Preferences Questionnaire to assess whether carers of PWD could predict the PWD’s preferences for treatment in three health states. The influence of carer burden and distress, and relationship quality, on a carer’s ability to predict the PWD’s treatment preferences were measured. This was examined further by qualitative interviews to provide personal contexts to decision making. Results: In nominal groups, PWD found it difficult to conceive of their future selves and think about preferences for end of life care. Carers’ views were influenced by their experiences of caring and negative media coverage of dementia and, when together, carers tended to override the PWD’s views. In interviews, carers could predict the PWD’s preferences in the here-and-now but were less accurate in future hypothetical health states. PWD and carers showed marked uncertainty about end of life treatment choices. Relationship quality, carer distress and burden had no influence on accuracy of prediction. Qualitative interviews revealed that while dyads claimed to have a shared decision making approach, joint healthcare decision making had largely been untested. Conclusions: Families affected by dementia require practical and emotional support at the outset to enable them adapt to changes in usual patterns of decision making, prepare for changes ahead and ensure, where possible, that the PWD’s preferences are upheld.

This review examines the research evidence for cognitive deficits in first episode psychosis (FEP), their neurological basis and their relation to social functioning. Twenty-six papers were identified by searching computer databases (e.g. PsycINFO, the Cochrane Library, etc.), hand searching relevant journals, and searching reference sections of key papers. The papers identified were then categorised into 3 subject areas: neurological, cognitive deficits, and social ftinctioning. FEP patients showed an excess of neurological soft signs and differences in brain morphology compared to healthy controls. While there appears to be clear evidence to support a generalised cognitive deficit in FEP, there may also be a sub-group of patients who have specific impairments in some aspects of cognitive function. There appears to be little or no evidence of an association between cognitive deficits and social functioning in FEP, though this area requires further research in the future.