This research explored psychotherapists’ emergent implicit experiences during assessments. It was concerned with unconscious processes occurring during the assessment session and how therapists made sense of and used these experiences clinically, either implicitly or explicitly. The aims of the research were threefold: (1) to understand what and how therapists’ experience the emerging implicit during assessment, (2) to explore how therapists understand their experiences of the emerging implicit, how they use these experiences in the therapeutic work (or don’t) and (3) to explore how therapists put words and meaning to them. Face-to-face semi-structured interviews were carried out with five senior psychotherapists. The interviews offered in-depth exploration of the psychotherapists’ subjective experiences of the implicit emerging in their conscious awareness during assessment sessions. Verbatim transcripts of the interviews were then analysed using Interpretative Phenomenological Analysis (IPA). Three main themes emerged: (1) A dramatic and powerful experience that stands out, (2) What’s going on? and (3) Difficulty in naming the experience. This research found that therapists experienced the emerging implicit as dramatically standing out from other experiences at assessment. The emerging implicit was experienced as a rapid process that came without warning and could not be anticipated or created at will. The therapists’ thinking and responses to the emerging implicit were complex and full of dilemmas. The therapists understood this as an intersubjective and dynamic experience. This research highlights the difficulty in studying common implicit experiences, and in trying to discuss these often profound experiences with verbal language, which is fraught with definitional and meaning issues. The hope was that this research would encourage dialogue concerning the importance of the implicit dimension in assessment sessions.

This thesis investigates the psychological impact of identifying character strengths in individuals with psychosis. Specifically, it investigates the feasibility of using a positive psychology intervention involving completion of a questionnaire to identify character strengths (the Values in Action Survey of Character Strengths, VIA-IS; Peterson & Seligman, 2004) with individuals seen in an Early Intervention for Psychosis service. Part One is a literature review examining the efficacy of psychological interventions in enhancing self-esteem amongst individuals with psychosis. It identifies a small group of randomised controlled trials that have demonstrated the efficacy of cognitive behavioural interventions and cognitive remediation training and considers explanations of the mechanisms of these effects, as well as methodological issues in the evidence base. Part Two is an empirical paper using a pre-post intervention design to examine the feasibility of an intervention involving identification of character strengths using the VIA-IS amongst individuals with early psychosis. Post intervention improvements in positive affect and cognitive performance were observed, with qualitative feedback suggesting that the intervention led to mood enhancement and self-reflection. One week follow up analyses were underpowered, as the majority of the sample declined follow-up, and did not find significant results. Part Three is a critical appraisal, discussing the background context to the choice of research area and the process of study planning and data collection, in order to inform future research and clinical practice relating to the use of strengths-based interventions amongst individuals with psychosis.

A meta-synthesis was conducted to examine the impact of maternal mental health difficulties on the mother-daughter relationship. Nine studies were synthesised which resulted in the development of seven themes. The findings indicated the ways in which maternal mental health difficulties can disrupt the attachment relationship between mother and child. Contextual factors relating to shame, discrimination and marginalisation were also identified, but did not appear to hold the same prominence in the women’s stories. As part of the discussion, the author considered how societal expectations about the roles of mothers and daughters might have affected the participants’ experience of relating to their mother. The research project explored the voices of women who have received a diagnosis of borderline personality disorder (BPD). The voice centred relational method (VRM) was used to listen to the many different and co-existing voices the women used to describe their experiences of distress and the ways in which they made sense of it. The ten voices identified highlighted complex relational dynamics linking to power, blame and shame at an individual and systemic level. Suggestions were made for resistance at both a practice and political level, to challenge the abuse of power and the oppressive practices that continue to silence women by invalidating the multiple ways in which they understand their life experiences. Finally, the critical appraisal considered the role of power and reflexivity within the research project. The author reflected on the ways in which conducting this project and engaging in these issues had shaped her current clinical practice.

Background: Cognitive Stimulation Therapy (CST) is a cognitiveDbased approach for dementia that has been shown to be cost effective and beneficial for cognition and quality of life. However future evidence is needed in relation to the length of the programme required and the effects of CST over an extended period. Aim: To develop and evaluate a 24Dweek programme of MCST, following the Medical Research Council (MRC) framework for the development and evaluation of complex interventions. Methods: A Cochrane Review was conducted in order to consolidate the evidence of cognitive stimulation for dementia and the results were used in the development of the programme, including a Delphi process with a consensus conference and focus groups with service users. A multicentre randomised controlled trial followed, including 18 centres and recruiting 272 people with mild to moderate dementia who received CST initially and were randomised afterwards to receive 24 weeks of either MCST or treatment as usual. Results: The intention to treat analysis showed that the MCST programme significantly improved quality of life of people with dementia at three and six months follow up, and activities of daily living at three month follow up. A sub analysis of people on acetyl cholinesterase inhibitors, showed that the effects of the longDterm intervention were additive to the medication effect. Conclusion: This study provides good evidence for the longDterm quality of life benefits of the CST maintenance programme for people with dementia.

Frith (1992) proposed that disruptions to 'theory of mind' (Premack and Woodruff, 1978) or 'mentalising' could explain the signs and symptoms of schizophrenia. For Frith, persecutory delusions represent a disorder in monitoring the thoughts and intentions of others. Following Frith's (1992) model, disruptions to theory of mind have been included in the main cognitive models of persecutory delusions. This review will first outline Frith's neuropsychological model of schizophrenia. It will then summarise the role theory of mind disruptions are given by the main cognitive models of persecutory delusions (Bentall, Corcoran, Howard, Blackwell and Kinderman, 2001 Freeman, Garety, Kuipers, Fowler and Bebbington, 2002) and the cognitive model of positive symptoms (Garety, Kuipers, Fowler, Freeman and Bebbington, 2001). The empirical evidence for such a disruption is then reviewed from studies with a patient population and studies with a non-patient population who vary of the dimension of schizotypy. It is concluded that empirical studies to date have mostly employed traditional theory of mind tests that are designed to assess simple theory of mind deficits such as those seen in autism or the behavioural signs of schizophrenia (Frith, 1992). It is suggested that traditional tests are not able to detect the subtle disruptions to theory of mind related to persecutory delusions. The concepts of 'hyper-ToM' (Abu-Akel and Bailey, 2000) and 'over-mentalising' are discussed and it is suggested that future research should focus on the development of tests which are able to detect 'hyper-ToM' or 'over-mentalising' in patients with persecutory delusions or non-clinical populations who are high on delusional ideation and paranoia.

The literature review examines the research on general practitioner (GP) referral rates and referral decisions. It explores the variation in GP referral rates to medical specialists, addressing the shift from quantitative to qualitative methodologies in studies that have examined GP referral decisions. The final section focuses on GP referrals to mental health professionals and looks at the effects of on-site mental health professionals on GP referrals. The empirical paper is a qualitative study examining GP decisions to refer, or not refer, patients suffering from minor mental illness to on-site clinical psychologists and counsellors. 14 GPs were asked to compare and contrast matched patient pairs, consisting of a patient who had been referred paired with another similar patient the general practitioner was treating. Three main themes of Patient Choice, Patient Benefit and GP Capacity to Help were identified, each including factors for and against referral. The critical appraisal reflects on what prompted this research, examines the research process, its strengths and weaknesses, and considers what might have been done differently. The clinical implications of the study are then discussed, alongside possible avenues for future research. Finally, it ends with a personal reflection on how this project has influenced my views concerning qualitative research and my clinical practice.

Assessment of family processes is essential to clinical practice. However there are currently no systematic methods for observing and interpreting parent-child interactions suitable for routine use in clinical settings. Therapeutic approaches using a Family Domains framework have been described (Hill et al., 2011) and a coding scheme for the assessment of domains processes has been developed. The aim of this research was to establish the viability of applying this coding scheme in a clinical setting.

Approximately a quarter of people with a long-term condition experience a comorbid mental illness. This can result in poor clinical outcomes, quality of life and prognosis. Cost-effective psychological interventions which can improve outcomes are required. Although empirical support for Acceptance and Commitment Therapy (ACT) has been growing in the last ten years, reviews in the context of group-based ACT are lacking. Paper 1 presents a systematic review of randomised-controlled trials of group-based ACT for adults with long-term conditions. PsycINFO, MEDLINE and Web of Science databases were electronically searched and twelve studies met the inclusion criteria. Study quality was assessed and study outcomes are summarised across a range of domains including depression, anxiety, quality of life and disability. Overall, findings suggest that group-based ACT appears to be more effective than waiting list controls and as effective as other psychological interventions. Paper 2 presents a randomised pilot study of group-based ACT for stroke survivors. To the authors’ knowledge, this is the first randomised study of group-based ACT with stroke survivors. Fifty-three participants (60% male; mean age: 63 years) were randomly assigned to group-based ACT or to a treatment as usual (TAU) group. The ACT intervention consisted of four weekly 2-hour group sessions. Measures were completed at pre-treatment, post-treatment and two month follow-up. Results found that compared to participants in the TAU control, group-based ACT significantly reduced depression and increased self-rated health status and hopefulness in stroke survivors, with medium effect sizes. Significantly more participants reached clinically significant change of depression in the ACT intervention in comparison to the control group. Paper 3 is not intended for publication and consists of a critical appraisal of the research process. Strengths and limitations of the research are discussed, as well as implications for future research, theory and clinical practice. Personal-professional reflections are offered.

Background: Relational depth is defined as ‘a state of profound contact and engagement between two people, in which each person is fully real with the Other, and able to understand and value the other’s experiences at a high level’ (Mearns and Cooper, 2005, p. xii). The concept emerged in humanistic therapies and became an area of interest in research on the therapeutic relationship. Evidence suggests relational depth may be associated to psychological growth and therapy outcome. The Relational Depth Inventory (Wiggins, 2007) provided a first instrument to measure presence of relational depth in a significant event. To this day there is no validated instrument to measure the frequency of relational depth in therapy. Aims: The principal aim of this project is to develop and validate a scale that can reliably measure the frequency of relational depth in therapy. Other aims include explorations of the demographic moderators of the frequency of relational depth. Methods: Standard procedures included the creation of an item pool, expert rating of items, and Three-Step Test interviews. A psychometric exploration was used to assess internal consistency in a sample of 556 clients and therapists, convergent validity with the RDI and WAI-SR, divergent validity with a measure of self-compassion, a principal component analysis, and associations in demographic variables. Findings and further research: The 20-item Relational Depth Frequency Scale(RDFS) has excellent reliability in this sample and good initial construct validity. We uncovered two dimensions of relational depth: enduring relational depth and intense moments of relational depth. Therapists had higher relational depth frequency (RDF) than clients. Qualified practitioners had higher RDF than trainees. Individuals who self identified as spiritual had higher RDF than those who self-identified as atheists. Therapists had higher RDF the longer the therapy was. Clients showed lower RDF between the sixth and twenty-fourth session. The RDFS can be used for further research particularly in assessing the predictive validity of relational depth on outcome.

Attachment status from 12 months onwards has been linked to later psychopathology and cognitive abilities. Although there are many ways of measuring attachment from infancy onwards, none aim to assess attachment security before the age of 12 months. This is despite evidence to suggest that infants as young as 3 months might be in an 'attachment in the making' phase and are already beginning to develop some of the necessary cognitive and emotion regulatory skills. There is good reason to suppose that patterns of attachment with parents are acquired over the first weeks or months of life in interaction with caregivers, and that thereafter they show some degree of stability. Establishing whether or not infant attachment security is established before 12 months is potentially important, both to our understanding of early developmental processes, and to refining approaches to early intervention. Methods. As part of a wider longitudinal study, a community-based sample of first-time mothers, stratified by risk, took part in the Still-Face and Strange Situation Paradigms with their infants at 7 and 14 months. A total of 224 mother-infant dyads had complete data at each age. Starting with a consideration of emotion regulatory strategies and building on the methodology of the Strange Situation (Ainsworth, Blehar & Waters, 1978), a hierarchical algorithm was devised to assign infants to attachment categories at 7 months. This used established scales of infant behaviours (Murray, Fiori-Cowley, Hooper, & Cooper, 1996) during the still-face and reunion episodes of the Still-Face. Results. Four-way classification from the Still-Face yielded a distribution that was very similar to the distribution of attachment derived independently from the Strange Situation. Validity of the method was supported by significant associations at age 7 months, between attachment security and maternal sensitivity, and disorganised attachment and partner violence, and by a lack of association between attachment status and infant temperament. Stability of attachment classification from 7 to 14 months was similar to that of published findings for stability over the second year of life, and prediction from attachment in the Still-Face to attachment in the Strange Situation was not accounted for by maternal sensitivity at 7 months. Conclusions. This study showed evidence to suggest that it is possible to measure attachment status in the Still-Face paradigm at 7 months, indicating that infants differ systematically in the ways they make use of their mothers to solve distress from earlier than previously thought. Further studies are needed to examine the timeline for the establishment of attachment strategies over the first year of life. It is suggested that the Still-Face might be a useful tool for this and for possible clinical interventions as it is robust and can be used from the age of two months.