This thesis explores the narrative identities and self-constructs of individuals with histories of sexual and violent offences. It comprises of three sections: a systematic literature review of individuals’ accounts of sexually abusing children, an empirical research study exploring the narratives of individuals with violent offending histories after engagement in schema therapy, and a critical appraisal reflecting on the relational aspects of doing qualitative research in forensic contexts. The literature review is a meta-synthesis integrating eleven studies. The findings indicate individuals who have sexually abused children develop narratives of negating harm or of mutuality, facilitating ongoing abuse and leading to self-constructs dis-identifying themselves from dominant discourses of “sex offender” identities. The review presents a framework for considering offence processes within diverse forms of sexually harmful behaviours, identifying shared perspectives among heterogeneous groups. It also highlights how social constructions of this population can distance professionals, and individuals themselves, from personal narratives thus inhibiting meaningful considerations of risk and rehabilitation. The research study explores the narratives of nine individuals from medium and high secure settings with histories of violent or sexual offending, who have engaged in schema therapy. Narrative analysis of transcripts identified self-constructs presented in interviews. Developing coherent and holistic narratives through schema therapy facilitates integration of offender identities within a more holistic self-construct integrating a multiplicity of selves. Individuals can then relate differently to themselves and others, suggesting reductions in risk of reoffending. Relationally secure contexts were crucial for therapeutic gains, and the study emphasises the fundamental importance of relational security for effective forensic rehabilitation. The focus of the critical appraisal is congruent with the central role of relational aspects throughout the literature review and research study. Reflections are presented on interactions with participants, relating to written and spoken data, supervision, therapeutic relationships, and impacts of these on the thesis.

The formation of approach- and avoidance- type goals and the cognitive appraisals we construe of our goals are thought to impact upon emotional state. This study investigated whether shared and distinct approach- and avoidance- goal cognitive appraisals, specifically, conditional goal setting (CGS), expectancy, difficulty, progress and effort, predict depression and anxiety. A young adult clinical sample was recruited from a university student primary care service. Participants generated two approach- and two avoidance- type goals before rating them on the specified goal cognitive appraisals. As expected, results identified shared and distinct goal cognitive appraisals in predicting depressive and anxious symptoms. Less perceived approach goal progress and heightened approach goal effort predicted both depression and anxiety. Whereas, heightened approach goal difficulty and CGS, and reduced avoidance goal progress uniquely predicted depression. Unexpectedly, avoidance goal cognitive appraisals did not predict anxiety. Results provide key considerations for future clinical practice.

Obesity is a complex condition that impacts on multiple aspects of functioning and can result in serious health conditions and reduced life expectancy and psychological distress. Obesity disproportionately affects women and current incidence rates are indicative of a ‘global epidemic’. The aim of this study was to explore experiences of interpersonal and intrapsychic emotional functioning, and the functions of food and eating in women who were severely or morbidly obese. The final participant sample were seven adult women all in the morbidly obese range (BMI ≥40kg/m²), all of whom were under assessment at a psychological therapies service. The women were interviewed using a semi-structured interview schedule and transcripts were analysed using Interpretative Phenomenological Analysis (IPA). The following four master themes were derived from their transcripts: 1)‘Uncertainty in Close Relationships’, 2)‘Behind the Mask: The Pursuit of Self-Worth’, 3)‘Emotional Expression: The Conflict of Sharing or Withholding’, 4)‘The On-Going Battle with Weight and Emotions’. The study findings highlighted the complex and multidirectional relationship between interpersonal experiences and functioning, self-worth and emotional functioning and the development and maintenance of problematic eating patterns and weight difficulties. Early interpersonal experiences had influenced the development of the self and expectations of relationships. Problematic relationships with food and eating had developed in response to the distress of intra- and interpersonal functioning. The consequential weight difficulties were experienced as frustrating and distressing and difficult to overcome, further impacting on emotional distress and self-worth. The findings have implications for treatment approaches, emphasising the importance of non-stigmatising multicomponent services that empower and offer therapeutic interventions focusing on problematic relational patterns and self-worth and the development of adaptive coping mechanisms. This study has the capacity to inform future research on relational and intra-psychic emotional factors in the development and maintenance of obesity and consideration of the mediating mechanisms of emotional eating.

This thesis focuses on a model of affect regulation; Gilbert’s (2005) three systems model, to explore emotional reactions to mental imagery. Compassion focussed imagery (CFIm) is the focus of the literature review as this is a specific type of mental imagery which is grounded in a coherent model of affect regulation. The empirical paper then aims to explore individuals’ emotional reactions to the mental imagery of a positive social memory. The three systems model, along with findings from the literature review are drawn upon to inform the hypotheses for the empirical paper. A concluding chapter, which includes a lay summary and a future research proposal then follows.

This thesis constitutes a qualitative exploration of individuals’ experiences of cognitive behaviour therapy (CBT) in both physical and mental healthcare settings. The literature review comprises a meta-synthesis of nine papers exploring experiences of CBT, which resulted in the identification of six themes: shared experience allowing reconnection; CBT skills enabling changing relationship with illness; therapist factors central to engagement; therapy as challenging; the importance of being able to talk to someone outside of the family; and therapy as life-changing. The main implication of these findings is the need for greater consideration of the complex nature of social support in the context of chronic illness and the specific challenges and benefits of engagement in CBT in this population. The empirical paper provides a qualitative exploration of the experiences of adults who have dropped out of CBT in a community mental healthcare setting. Thematic analysis resulted in the identification of five themes: the role of therapist factors; limitations of the CBT model; CBT as pathologising; the socio-political context of CBT; and responsibility for engagement and change. This is the first qualitative exploration of CBT drop-out across diagnostic groups and, as such, this study contributes an important insight into the challenges associated with engagement in CBT and the influence of socio-political context. Finally, the strengths, limitations and challenges of the research process are discussed in the critical appraisal, with particular reference to the broader theme of occupying the position of both clinician and researcher.

This study looks at the place and importance of the patient's introduction and use of cultural artefacts as an unconscious aid, or guide or communication, in the analytic dyad, with specific reference to the erotic transference. My thesis is that these communications offer a map to a pre-symbolic landscape which needs to be discovered in the analytic work. This is particularly useful for patients who have suffered very early loss and deprivation and are searching for an original experience which enables them to gain access to the symbolic and their individual place in it. The artefacts in a central affect ridden case study, were introduced to the analytic setting by the patient, Flora, at specific moments as a mode of communication to the analyst. The hypothesis that slowly emerges for the analyst is that these introductions are representing and describing a defensive and creative response to a perceived change. Flora spontaneously reaches for an alternative world or atmosphere which both describes the change as well as escaping from it. The use of artefacts are also related to the emergence of an erotic attachment to the analyst and aid the analyst to try and understand the difficult underbelly of this attachment, which feels like another form of escape. However, both the use of artefacts and the erotic transference, which initially seem defensive, display prospective and healing possibilities in the relational field.

Multiple Sclerosis (MS) is an autoimmune disease involving demyelination and neurodegeneration of the central nervous system (Compston & Coles, 2002). In the UK it is the most common form of non-traumatic neurological disability in young adults (Compston & Coles, 2008). Common symptoms of MS include sensory disturbance in limbs, visual loss, fatigue, mood disturbance and motor disturbance (Bobholz & Gremely, 2011). MS is often categorised depending on symptoms. The most common type is relapsing remitting, experienced by approximately 80% of people at onset (NICE, 2014). It is characterised by relapses, where new or existing symptoms become more severe, and remissions, a partial or total recovery of symptoms. Other types of MS include secondary progressive (gradual progression of symptoms and only partial recovery during remissions) and primary progressive (no periods of remission and gradual progression of symptoms). There is currently no cure for MS, current treatments include medications aimed at modifying disease activity and symptom management. Approximately 50% of people with MS experience cognitive symptoms (NICE, 2014). Cognitive difficulties in people with MS have been shown to effect social functioning and quality of life (Rao et al., 1991). Clinicians often rely on MS patients’ subjective reports of their difficulties in cognitive functioning. However, studies have shown that the relationship between MS patients’ self-reported cognitive difficulties and their objective cognitive functioning, as measured by neuropsychological tests, is inconsistent. Several studies have demonstrated a discrepancy between self-reported cognitive functioning and objective performance on neuropsychological tests (Carone, Benedict, Munschauer, Fishman, & Weinstock-Guttman, 2005; Julian, Merluzzi, & Mohr, 2007; Lovera et al., 2006; Middleton, Denney, Parmenter, & Lynch, 2006). Both fatigue (Kinsinger, Lattie, & Mohr, 2010) and depression (Kinsinger et al., 2010; Maor, Olmer, & Mozes, 2001) have been shown to influence MS patients’ self-reported cognitive functioning, more than their objective functioning. MS patients with higher levels of depression and fatigue report more subjective cognitive difficulties. Chapter 1 of this thesis systematically reviews the literature examining the relationship between subjective and objective cognitive functioning, and examines whether depression and fatigue influence MS patients ability to accurately perceive their cognitive functioning. The systematic review demonstrated inconsistent findings when examining the relationship between subjective and objective cognitive functioning. Both fatigue and depression were found to be associated with subjective cognitive functioning, explaining some of the variance. However, other variables are likely to influence this relationship and these influential variables are investigated in Chapter 2. Self-efficacy has previously been shown to play an important role in the MS population. It can be described as a level of self-confidence about an individual’s ability to manage specific situations or conditions, relating to perceptions of competency, rather than actual performance (Ng et al., 2013). A recent study by Schmitt, Goverover, DeLuca, and Chiaravalloti (2014) demonstrated that self-efficacy influences MS patients subjective cognitive functioning, after controlling for both depression and functional impairment. Chapter 2 builds upon the findings of the review paper and additionally examines the role of self-efficacy as a predictor of subjective cognitive functioning and quality of life. The empirical paper has demonstrated that self-efficacy is a significant predictor of subjective cognitive functioning and quality of life even after controlling for age, MS duration, depression, anxiety, fatigue and objective cognitive functioning. People with MS reporting higher levels of self-efficacy reported fewer cognitive difficulties and greater quality of life. As self-efficacy was shown to be a significant predictor of subjective cognitive functioning and quality of life, even after controlling for other influential variables, it seems prudent for future research to target self-efficacy for intervention. Interventions aimed at improving self-efficacy in people with MS could potentially improve their accuracy at appraising their cognitive functioning and improve their quality of life.

People with intellectual disabilities are more likely to experience living circumstances and life events associated with an increased risk of mental health problems, compared to the general population (Hulbert-Williams & Hastings, 2008). These include: lack of meaningful relationships, stigmatization, unemployment, and discrimination (Martorell et al., 2009; Thornicroft, 2006). Prevalence of mental health problems are difficult to determine within this population, with estimates ranging from 10% to 39% (Emerson & Hatton, 2007). Pharmacological and behavioural approaches have often been used in the treatment of mental health problems for people with intellectual disabilities (Vereenooghe & Langdon, 2013). Bender (1993) argued that the lack of psychotherapeutic interventions available was due to a perceived “therapeutic disdain” towards this population. Difficulties identifying mental health problems in people with intellectual disabilities, perceived lack of training amongst practitioners, and lack of research evidence have also been cited as reasons for lack of provision of psychotherapy services (Emerson, Moss & Kiernan, 1999; Royal College of Psychiatrists, 2004; Taylor & Knapp, 2013). These views have been challenged by clinicians, and there is a growing evidence base of the effectiveness of psychological therapies with people with intellectual disabilities (Willner, 2005). The research has come from both single case studies (Kellett, Beail, Bush, Dyson & Wilbram, 2009; Salvadori & Jackson, 2009) and controlled clinical trials (Taylor, Novaco, Gillmer, Robertson & Thorne, 2005). Recent systematic reviews and meta-analyses have also highlighted the effectiveness of Cognitive Behavioural Therapy (CBT) and psychodynamic therapy with this population (James & Stacey, 2014; Nicoll, Beail & Saxon, 2013; Vereenooghe & Langdon, 2013). In one of the most comprehensive reviews to date, Prout and Nowak-Drabik (2003) reviewed the outcome and effectiveness of 92 studies and found that there was a moderate benefit of psychotherapy for people with intellectual disabilities. Recent legislation in the United Kingdom has responded by recommending improved access to psychological therapy for people with intellectual disabilities (Department of Health (DoH), 2007; 2009). The emergence of practice-based evidence has also meant that there is a growing expectation that services that provide psychological therapies show some evidence for the effectiveness of what they do (DoH, 2010). Coupled with this is the Payment by Results (PbR) initiative, where commissioners will pay healthcare providers dependent on the number of patients seen and outcomes achieved (DoH, 2013). One of the difficulties for providers of psychological therapies for people with intellectual disabilities is the availability of valid and reliable therapy outcome measures that can be easily used in service settings and accurately assess the effectiveness of interventions (Skelly, 2011; Weston, Elsworth & Stacey, 2011). Thesis This thesis aims to address the difficulties in measuring outcomes of psychological therapy with people with intellectual disabilities. The first paper will systematically review the quality of outcome measures that have been used in psychological therapies with adults with intellectual disabilities. The second paper will assess the psychometric properties of the Psychological Therapy Outcome Scale – Intellectual Disabilities (PTOS-ID), a newly developed therapy outcome measure designed specifically for use with people with intellectual disabilities. Timeline of Work Elements of research reported in this thesis were completed before the commencement of the Doctorate in Clinical Psychology programme. These were the development of the PTOS-ID, which included selection of the dependent variables through the use of focus groups; the selection of the item pool; and the development of the response format (please see the Introduction of the research paper for further details). The assessment of the psychometric properties of the PTOS-ID (i.e. construct validity, concurrent validity and internal consistency) was completed for the research study reported in this thesis in partial fulfilment of the award of Doctor of Clinical Psychology. Data were collected through service audits both prior to, and during, the period of study for this doctorate.

Research with clinical and nonclinical samples has linked multiple psycho-social risk factors with psychosis. There has since been an emphasis on the importance of investigating specific symptoms experienced within the psychosis spectrum to better understand the psychological processes involved. The studies included in this doctoral thesis used cross sectional methods to explore relationships between specific social adversities and specific symptoms within the psychotic domain and also depression, using a number of different samples (students, client groups and general population). This thesis also explores mediating mechanisms between adversities and specific symptoms, paying particular attention to the role of specific adversities in paranoid ideation. I found that perceived childhood inequality, neglect and adulthood social deprivation and insecure attachment styles predicted paranoid thoughts in student, epidemiological and clinical samples. In my student study I further developed and validated a tool to measure perceived relative deprivation. I then used this tool and found that personal perceptions of injustice and low social rank mediated the relationship between perceived relative deprivation and paranoia. In my epidemiological study I found that experiences of discrimination, lack of trust and stress partially explained the relationship between current social disadvantage and paranoia. In my two clinical studies I found that negative self-esteem explained the association between insecure attachment dimensions and paranoia, and strong perceptions of injustice and an over perception of justice in the world explained the association between childhood emotional neglect and paranoia. Considering hallucinations, I found specific associations between perceived childhood deprivation and hallucinations in my student sample and between sexual abuse and hallucinations in my patient sample, although none of the mediating variables tested in this thesis accounted for these associations, suggesting other mechanisms may be important. The findings of the current studies suggest that it is possible to identify specific associations between adversity and psychotic symptoms in general, and highlight the need to develop a science of public mental health, which at present barely exists as a discipline. In the future, more complex and imaginative designs examining specific environments, specific outcomes, and specific mediating mechanisms will be required if this is to be achieved.

Long Term Conditions (LTCs), such as diabetes, asthma and dementia, typically cannot be cured (NHS Confederation, 2012). The prevalence of LTCs in England is rising, with an estimated 30% of the population diagnosed with at least one LTC (NHS Confederation, 2012). LTCs not only have a huge impact on the life of the person, but also on their family and carers. Carer burden and stress have been extensively researched and systematically reviewed to date (Cousino & Hazen, 2013; Etters, Goodall, & Harrison, 2008; Rigby, Gubitz, & Phillips, 2009), with research indicating that carer wellbeing can have a significant impact on the wellbeing of the person with a LTC, as well as on their ability to manage their condition (Whittemore, Jaser, Chao, Jang, & Grey, 2012). Current recommendations, particularly following a recent systematic review by Cousino and Hazen (2013), suggest a proactive approach, focussing on what prevents or reduces carer stress, should be explored. Two psychological concepts that have increased in clinical interest in recent years are mindfulness and selfcompassion (SC). Mindfulness is the ability to remain non-judgmental, whilst paying attention in a particular way in the present moment (Kabat-Zinn, 1990); whilst SC involves showing kindness to oneself, particularly in the face of personal suffering (Neff, 2003). Whilst there has been a recent review exploring the efficacy of mindfulnessbased interventions for caregivers of people with dementia (Hurley, Patterson, & Cooley, 2014), there are no reviews that explore the literature of both mindfulness and SC in carers of people with LTCs. Chapter one presents a systematic review of the quantitative literature to date, which aims to investigate the role of mindfulness and SC in carers of people with LTCs. There is extensive evidence considering parental distress as a consequence of caring for a child with a LTC (see recent review by Cousino & Hazen, 2013). Mindfulness-based and compassion-based approaches are relatively new, transdiagnostic and evidence-based developments in the field of clinical psychology (Neff & Germer, 2013). They may be useful interventions for family members who are also caregivers. Several quantitative cross-sectional studies have explored the constructs of trait mindfulness and SC and how they relate to wellbeing (Baer, Lykins, & Peters, 2012; Hoge et al., 2013; Hollis-Walker & Colosimo, 2011; Van Dam, Sheppard, Forsyth, & Earleywine, 2011; Woodruff et al., 2013) but to date, no studies, to the author’s knowledge, have explored these two concepts in relation to parents or carers of people with a LTC. As type 1 diabetes (T1D) is one of the most common LTCs in children (Kelo, Eriksson, & Eriksson 2013), and is at the forefront of current research, Chapter two is an empirical study from a positive clinical psychology perspective (for a review see Wood & Tarrier, 2010), which aims to explore trait mindfulness and SC as predictors of wellbeing in parents of young people with T1D. This dissertation was undertaken to fulfil the research component of the Doctorate in Clinical Psychology.