Purpose: Research investigating psychological predictors of health anxiety and related outcomes is lacking. This study investigated whether mental defeat, existential concerns, beliefs about emotions and intolerance of uncertainty predict levels of health anxiety, quality of life, depression and anxiety in cancer patients in remission. Method: A quantitative prospective design was employed. Ninety participants aged 23-80, who had completed cancer treatment with curative intent were recruited from two hospitals, support groups and the Macmillan website. Self-report questionnaires were used to measure mental defeat, existential concerns, beliefs about emotions and intolerance of uncertainty, health anxiety, quality of life, depression and anxiety at two time points, 4 weeks apart. Results: Clinically significant levels of health anxiety were reported in 52.2% of the sample. Elevated health anxiety at Time 1 (T1) was significantly associated with intolerance of uncertainty. Quality of life at T1 was significantly associated with mental defeat and beliefs about emotions. Psychological distress at T1 was significantly associated with mental defeat and intolerance of uncertainty. Stepwise regressions demonstrated that mental defeat was a significant predictor of health anxiety (including avoidance and reassurance seeking), quality of life and distress 4 weeks later. Conclusions: This study provides evidence that clinically elevated health anxiety is high in cancer survivors, and highlights the importance of consideration of the risk factors underlying elevated health anxiety, psychological distress and poor quality of life that are appropriate targets for treatment. Clinical and research implications are discussed.

Mental Imagery (MI) and implementation intentions (II; creating concrete plans for when, where and how a goal is to be achieved) have shown promise in enhancing performance and goal achievement. As depressed mood is often characterized by loss of interest and reduced engagement in previously rewarding activities, the aim of this study was to investigate whether MI and II strategies could be used to enhance rates of goal achievement in participants presenting to services with low mood/depression. An experimental three-group comparison was used, with random allocation to the levels of the independent variable (MI, II, Control). Each participant (N = 44) devised three idiosyncratic goals, with the researcher guiding the participants in the MI/II groups through the relevant cognitive strategy in relation to their first goal. Those in the MI group reported a significant increase in the perceived likelihood of achieving their goals post-strategy. There were no significant differences in the achievement of goals amongst the three groups, although higher rates of goal achievement were apparent in the MI group. The current study suggests that generating specific goals and using MI may represent a valuable technique for improving individuals’ beliefs that their goals are attainable and within their reach. Further research with larger samples is recommended to explore the impact of techniques on actual goal attainment. Service Improvement Project Background: Clinical guidance recommends that multi-family psychoeducation groups) should be offered as part of the stepped-care model of intervention in early intervention for psychosis services. This results from the recognition of the important role that families play in supporting the recovery of service users experiencing a first episode of psychosis. Aims: This study aimed to evaluate and improve a series of multifamily information sessions within the North Somerset Early Intervention for Psychosis Team. Methods: Following the initial running of a multifamily psychoeducation group (Group 1), telephone interviews were conducted with six family members who attended to evaluate and identify recommendations for the improvement of the group. This feedback was used to inform the format and content of a second running of the group (Group 2). Three further participants provided evaluative qualitative feedback on this revised group. Results: Following collection of feedback from Group 1, four key themes were identified including the positive aspects of group attendance (e.g. receiving relevant information, opportunity to meet the team and other families), challenges of groups (e.g. accommodating the needs of different families), impact of caring (e.g. feeling isolated and unknowledgeable) and recommendations for improvement (e.g. additional content for siblings, simplifying information). This information was used to develop Group 2, which was adapted to make the information more family-friendly (e.g. simplifying information), with the inclusion of some further information. Conclusions: The positive feedback received from those who attended the group supports the continued use of family information sessions within the service. The use of feedback and the development of this aspect of the service were perceived positively by the team. Systematic Review of the Literature Background: Cognitive behavioural therapy for low self-esteem (LSE) has shown promise as a trans-diagnostic model for treating mental health difficulties in adults. To ascertain the potential value of this treatment approach in working with young people with internalising disorders, we need to develop our understanding of LSE within these mental health conditions. The aim of this review is to explore 1) the co-occurrence of clinically significant anxiety/depression and LSE in young people, and 2) the association between LSE in childhood and adolescence and mental health difficulties in later adolescence and emerging adulthood. Method: A systematic search of two electronic databases (PsychInfo/Pubmed) was conducted to identify relevant studies. Results: Ten studies examining the association between LSE and clinically significant anxiety/depression in young people met the inclusion criteria, as did eight studies investigating the association between LSE in under 18 year-olds with internalising difficulties in later adolescence/emerging adulthood. Conclusions: Although relatively few studies investigating ‘clinically significant’ anxiety and depression were identified, the located studies consistently supported the co-occurrence of LSE and internalising disorders in young people. This was found to be particularly true for young people with depression and co-morbid mental health difficulties. There appears to be less evidence for the association between reported LSE in childhood and adolescence and anxiety/depression in adolescence/emerging adulthood, potentially due to the complexity of confounding variables. Further research investigating Fennell’s cognitive model as a trans-diagnostic treatment model for young people with LSE is indicated.

Objective: To assess if adolescent perfectionism mediates the association between negative parental factors (anxiety, maladaptive perfectionism, critical and authoritarian parenting) and paediatric anxiety. Method: A cross sectional questionnaire design was used. Sixty-six 12-17-year-old adolescents and their primary caregiver were recruited from a local community school and child and adolescent mental health services. Self- and parent-report questionnaires measured anxiety, perfectionism and parenting style. Results: There was a significant association between adolescent perfectionism and anxiety and between parental perfectionism and anxiety. However, there was no evidence that parental perfectionism was associated with child perfectionism or anxiety. Conclusions: The fact that parental factors were not associated with adolescent maladaptive perfectionism implies that the processes associated with the development of maladaptive perfectionism and anxiety in childhood may be different in adolescents. Implications for treatment and future research are discussed. Service Improvement Project Abstract Background: The 5Ps model is a formulation tool which includes the mental health problem as well as predisposing, precipitating, perpetuating and protective factors. The 5Ps model was integrated into the assessment service in the community mental health recovery team by the first author (trainee clinical psychologist) with support from the service manager and clinical psychologist. Objectives: This research aimed to measure whether assessment staff in the community mental health recovery team were using the 5Ps model in assessment meetings and assessment letters to formulate service user’s mental health problems. This research also aimed to assess whether recommendations for mental health care addressed the 5Ps factors which were noted in the assessment letter and assessment meeting notes. Finally, the research aimed to recommend strategies to improve the use of the 5Ps model by assessment staff. Design: Assessment staff (n=6) were interviewed using semi-structured interviews. Assessment letters and meeting notes (n=36) were analysed using case note analysis. Methods: Percentage use of 5Ps in assessment letters and meeting notes and percentage of recommendations linked to 5Ps in assessment letters were calculated. The amount of 5Ps training staff received was also compared to staff members’ use of the 5Ps in assessment letters. Thematic analysis of staff questionnaire data was completed. Results: Assessment staff are using the 5Ps in their assessment work and some recommendations were linked to the 5Ps stated in assessment letters. Recommendations to improve the use of the 5Ps by assessment staff were based on staff feedback and case note analysis and included; updating the letter and assessment formats/processes to ensure that all of the 5Ps are linked to the mental health problem and recommendations made for treatment, completing the formulation section on the electronic notes system and further training for assessment staff in how to identify the 5Ps/how recommendations can address the 5Ps. Conclusion: Results suggest that the 5Ps formulation was operational to assessment staff as it was utilised to formulate service users mental health problem at assessment. However, results suggest that the recommendations need to be implemented to improve assessment staff’s acceptability and use of the 5Ps. The service agreed to adhere to the recommendations suggested to improve the use of the 5Ps and agreed that if recommendations are adhered to these results support the plan to integrate the 5Ps into other adult mental health teams across Bristol. Literature Review Abstract Objective: All studies of solution-focused therapy which included adults with a mental health problem are reviewed and research methodologies are summarised and rated according to the quality of the research methodology used. Method: Sixteen studies were found and data extracted on setting, mental health problem, modality, target and duration of intervention, research methodology, measures, sample size, method of analysis, comparison treatment and quality score. Results: 14 studies utilised quantitative research methodologies. Eight of the studies used a quasi-experimental design including control groups (n=6) and random assignment (n=3). One study used a post-intervention questionnaire follow-up design and one study calculated recovery rates. One study calculated whether or not the patient presented with self-harm within 1 year post intervention and pre-post intervention change on a solution-focused measure. Two studies were randomised controlled trials and another two studies were single case experimental designs. Two studies utilised qualitative research methodologies including transcribing a therapy session/post-intervention interview. Quantitative outcomes were measured using multiple questionnaire measures and multiple analysis methods. Conversation analysis and thematic analysis were used for qualitative studies. The quality scores of the studies varied from 4 (single case experimental design) to 14 (randomised controlled trial) and 15 (controlled quasi-experimental). Conclusion: This review shows that solution-focused therapy is being evaluated using many valid and reliable research methodologies and questionnaires. It is hoped that solution-focused therapists and researchers can use this review to complete and publish further research which measures the effectiveness of solution-focused therapy using research methodologies which produce valid and reliable results.

Background: Socialising a client to the cognitive behavioural model is advised in almost every cognitive behavioural therapy textbook but there is limited evidence for whether socialisation is measurable or important in terms of outcomes. Aims: To determine whether socialisation to the model could be measured in a sample of young people who have completed CBT and to explore whether this construct is important in relation to clinical outcomes. Methods: Sixteen participants (mean age 14.9 years, 75% female) completed a semi-structured socialisation interview and a novel written measure of socialisation. They rated their subjective improvement using the Clinical Global Impression improvement subscale. Treating clinicians were asked to provide participant routine outcome measure scores, subjective ratings of participant socialisation and their Clinical Global Impression improvement subscale score. Results: A moderate but non-significant correlation was found between the novel written measure of socialisation and clinician rating of socialisation (r = .37) and greater total socialisation was associated with greater percentage change on routine outcome measures (r = .42) although simple clinician rating of socialisation was also associated with percentage change (r = .42). None of these correlations were significant, however, probably due to the small sample size. Conclusions: A small sample size precludes conclusions being made but useful ways of improving research in this newly developing area were learned and discussed.

Main Research Project Objectives: Chronic Fatigue Syndrome/ME (CFS/ME) and Irritable Bowel Syndrome (IBS) are known to be associated with poor quality of life and impaired functioning. Similar psychological drivers have been identified in these conditions, such as beliefs about symptoms (cause, consequence and management) and behavioural responses (withdrawal, avoidance and safety- seeking). The aim of this study was to compare CFS/ME and IBS groups regarding these factors to establish the extent to which they are similar (transdiagnostic) and different (disorder-specific). Method: Using a cross- sectional design, CFS/ME participants (n= 21), IBS participants (n=40), participants with co-morbid CFS/ME and IBS (n= 17) and healthy controls (n=65) were compared on a range of self-report questionnaires. This included measures of general psychological well-being (depression, anxiety, mental defeat, functioning). Novel measures were also developed to measure transdiagnostic and disorder-specific beliefs and behaviours, all of which were found to have good internal consistency. Results: Compared to the controls, the clinical groups reported poorer psychological wellbeing and endorsed more negative transdiagnostic beliefs and behaviours than healthy controls. The CFS/ME and co-morbid groups also scored significantly higher than the IBS group. Additionally, the CFS/ME group endorsed more disorder-specific beliefs and behaviours related to fatigue, while the IBS group scored higher on disorder-specific characteristics relevant to gastrointestinal symptoms. The co- morbid group showed characteristics of both CFS/ME and IBS. Conclusions: These study found similarities and differences between CFS/ME and IBS participants, regarding their beliefs about symptoms and behavioural responses to symptoms. This indicates that it may be appropriate to use a modular transdiagnostic cognitive-behavioural approach for these problems, whereby therapy would start by addressing their common features and become more tailored to disorder-specific features as therapy progresses. For patients with CFS/ME, potentially unhelpful fatigue-related beliefs and behaviours should be addressed. Similarly, IBS patients may benefit from a focus on relevant gastrointestinal beliefs and behaviours. Implications for future research are discussed. Service Improvement ProjectPeople with mental health problems in general and Obsessive Compulsive Disorder (OCD) in particular often delay seeking help and lack information about evidence-based treatment. Provision of such information has increasingly become a task led by third sector organisations. OCD-UK is a charity, led by people with personal experience of OCD that runs an annual conference to address these issues. It primarily aims to promote understanding of OCD and its treatment, and increase optimism regarding the ability to overcome OCD. It also aims to highlight the need for psychological treatment, specifically Cognitive Behavioural Therapy. The present study undertook a systematic evaluation of OCD-UK’s 2014 conference. Sufferers (n=50) and carers (n=41) completed questionnaires pre- and post-conference. Changes in their scores showed that the conference was successful in increasing attendees’ confidence in their understanding of OCD and knowledge of treatment options. Additionally, the following beliefs weakened: pessimism about the ability to overcome OCD and perception of OCD as a biological illness. Beliefs about perceived need for psychological therapy to overcome OCD strengthened. Generally, sufferers and carers did not differ in terms of the impact of the conference. The findings illustrate the value of third-sector organisations, like OCD-UK, in providing information and addressing beliefs that are considered barriers to accessing treatment. The implications of these findings are discussed, along with recommendations for future research. Critical Review of the LiteraturePurpose: Solution-Focused Brief Therapy (SFBT) has a growing evidence base for the general population. Several authors have recognised the advantages of applying this short-term, goal-focused and client-directed approach in intellectual disabilities (ID) and its evidence-base in this context is growing. However, it has not been critically evaluated. The purpose of this review is to summarise and critique the literature that has used solution-focused (SF) approaches in ID, and consider the implications for future research and clinical practice. Methodology and findings: A narrative literature review identified 12 studies that described or evaluated the application of solution- focused approaches; six used SFBT with individuals with IDs and six used Solution Focused Counselling (SFC) with staff and families. Research implications: The evidence-base primarily consists of case studies, and while they were generally of good quality, this limits the conclusions that can be drawn regarding the effectiveness of SF approaches in this context. There is a need for further controlled studies, with valid and reliable outcome measures, larger samples and longer follow-ups. Practical implications: Overall the reviewed studies offered preliminary evidence for the effectiveness of SFBT for individuals with mild ID and SFC for care staff working with individuals with moderate and severe ID, in particular in cases where clients’ behaviour challenges. ID services should consider offering SF approaches on this basis. For individuals with ID, SF techniques should be modified to accommodate for their cognitive abilities and carers should be involved in sessions where possible. The ‘miracle question’ technique was consistently considered too abstract and unhelpful, regardless of whether it was used for individuals with ID or their family and carers. Hence, it should be re-phrased so that it is more concrete and focused on coping, strengths & competencies.

Background – Psychosis is one of the most stigmatised mental health problems. Individuals who experience psychosis can internalise this stigma, resulting in self-stigma where an individual’s self-concept is eroded with a negative impact on recovery. Conversely, peer support has been shown to impact positively on recovery and theory suggests that this may be achieved through challenging stigmatising attitudes. Aims – The aim of this study is to further investigate one potential mechanism underpinning peer support, that is the impact of peers on challenging self-stigmatising attitudes. Methodology – 20 people with first episode psychosis were recruited and randomised to watch a psycho-educational video delivered either by an individual with experience of psychosis (a peer) or a health professional. Levels of self-stigma were measured before and after the video. Results – The findings of this study did not support the hypothesis that psycho-education delivered by a peer reduces internalised stigma to a greater degree than someone without this, however, the results are underpowered and require a larger sample before conclusions can be drawn. Conclusions – Further research is needed to better understand the effective components of peer support and to better understand the relationship between peer support and internalised stigma. Service Improvement Project Abstract Pulmonary Arterial Hypertension (PAH) is a chronic disease, which is monitored by a series of complex treatments including cardiac catheterisation (CATH). Evidence suggests that patients can experience CATH as anxiety provoking, however, most undergo this procedure without any formal psychological support. The current study aimed to explore patients’ beliefs about the CATH procedure and to better understand adaptive coping and self-management skills. It was hoped that this knowledge would inform recommendations to improve the psychological experience and coping resources of those undertaking CATH. Ten participants were recruited through purposive sampling and completed a qualitative interview, which explored their beliefs about CATH and factors which enhanced coping resilience. Findings suggest that factors which increase an individual’s understanding of CATH and sense of control were associated with positive coping. The results also suggest that whilst perceptions of the CATH procedure are very individual, the importance of relationships with health professionals and trust in their expertise was highlighted across participants. The findings informed service recommendations, including the introduction of a patient experience leaflet aimed at promoting positive coping in those attending the CATH procedures. Critical Literature Review Abstract Background – Stigma is a global phenomenon affecting many health conditions. Stigmatised attitudes can become internalised (internalised stigma), a process that can negatively impact on an individual’s sense of self, their emotional wellbeing and wider life. Recently interventions have been developed to reduce internalised stigma, including interventions led by people with personal experience of health conditions (peers). Aim – This review aimed to draw together literature on peer-led interventions for stigmatised health conditions, which have included internalised stigma as an outcome. The review aimed to synthesis interventions and their components; relate the findings to social identity theory and summarise what is known and not known about the relationship between peers and internalised stigma. Method – Using specific search terms and inclusion criteria, this review yielded 13 papers in total. The papers were examined in terms of their methodology and findings, and common components of the interventions were collated across the papers. Results – The results revealed methodological limitations amongst the papers and highlighted the need for replication. However, the findings suggest there is evidence that peer led interventions can impact positively on internalised stigma, if designed in the right way for the people who receive it. The key components include sharing experiences, narrative components, information provision and problem-solving. Conclusions – Peer-led interventions present an empowering way of countering the stigma surrounding certain conditions through role-modelling recovery, sharing hopeful experiences and enhancing positive identity. Current evidence shows promise, however, more high quality research is needed to better understand this relationship and to develop effective, accessible interventions.

Background: Holmes et al (2008) posited that mental imagery acts as an 'emotional amplifier' in bipolar disorder, leading to the shifts in mood that are a hallmark of the condition. Evidence for this idea comes largely from retrospective studies. No study has, to the author's knowledge, explored experiences of mental imagery as they occur in the day-to-day lives of individuals with bipolar disorder. This approach has the advantage of greater ecological validity, minimising confounds associated with retrospective recall. Method: Twelve individuals with a diagnosis of Bipolar I or II disorder and 20 non-clinical controls completed a diary of intrusive mental images and verbal thoughts twice-daily for seven days. Thoughts and images were rated on a number of dimensions, including 'intensity' and 'vividness'. Results: Individuals with bipolar disorder reported significantly more 'intense' experiences of intrusive mental imagery compared to controls, but there were no significant differences in frequency or intensity of verbal thoughts, although the small number of participants in the bipolar disorder group means the study may have lacked power to detect significant group differences. Vividness of mental images was also higher in the bipolar disorder group. Conclusions: The findings provide support for Holmes et al's (2008) model, using assessment of intrusive verbal thoughts and mental images in a naturalistic setting. The main benefit was greater ecological validity compared to previous retrospective studies. The study also demonstrated that it is possible to elicit reports of these phenomena using diaries in a bipolar disorder population.

Objectives: Reports of tiredness and poor quality sleep are common to both Chronic Fatigue Syndrome (CFS) and insomnia, despite evidence that sleep structure is not objectively impaired in these groups. Similar vulnerability and maintenance factors have been identified in both conditions, such as perfectionism, unhelpful beliefs and misattributions about symptoms. The aim of this study was to compare CFS and insomnia groups in terms of subjective sleep and fatigue symptoms and associated cognitive factors. Method: Using a cross-sectional design, CFS patients (n=18), community insomnia participants (n=18) and healthy community controls (n=19) were compared on a range of self-report questionnaires, including measures of psychological wellbeing (depression, anxiety, worry), insomnia, sleepiness and fatigue severity, cognitions about sleep and fatigue, and other cognitive variables associated with CFS and insomnia. Results: Between-group analyses identified that CFS and Insomnia participants did not differ significantly on the majority of variables. Compared to controls, both groups reported poorer psychological wellbeing and higher levels of insomnia, sleepiness, and sleep-related cognitions. Both groups also reported elevated perfectionism and unhelpful beliefs about emotions. Compared to the Insomnia group, CFS participants reported higher levels of fatigue, fatigue-related cognitions, and pre-sleep somatic experiences. Conclusions: This study found similarities between CFS and insomnia participants in terms of cognitive processes known to maintain insomnia. This indicates that it may be appropriate to use a transdiagnostic cognitive-behavioural approach to treating sleep disturbance in CFS. The results also indicate the importance of assessing for unhelpful fatigue-related beliefs and pre-sleep somatic complaints when working with the CFS population. Implications for further research are discussed.

OBJECTIVE: This study aimed to replicate previous findings regarding the influence of recovery style and attachment on engagement and help seeking in first episode psychosis (FEP). It also aimed to explore self-compassion and shame as new potential moderators of engagement, and in terms of their relationship with attachment and recovery style. DESIGN: A cross-sectional between groups design was used to compare 'high' and 'low' engagers on key variables. Whole sample correlational analysis was also undertaken to further explore associations with self-compassion and shame in FEP. METHODS: Twenty-two individuals with psychosis under the care of Early Intervention (EI) Services completed four questionnaires. Care Coordinators were subsequently sent a questionnaire on engagement to complete. RESULTS: No significant group differences on the predicted variables were found, with only time in service reaching significance. Although non-significant, avoidant attachment did result in a small to medium effect size whereby 'low' engagers scored higher on avoidant attachment, and a trend towards more non-white individuals in the 'low' engagers group was nearing significance. In the secondary analysis, avoidant attachment was associated with shame and problems help seeking, even when positive symptoms were controlled for. Anxious attachment was associated with lower self-compassion and higher shame. None of the variables were significantly correlated with recovery style. CONCLUSIONS: The small sample size limits the conclusions which can be made, however it is of interest that no significant differences were found between the two groups on the expected variables. Although self-compassion and shame did not appear to effect engagement in this sample, strong and distinct associations were found between these variables and insecure attachment dimensions, indicating a possible area for further exploration.

Critical Literature Review Indiscriminate friendliness (IF) is a concept that is poorly understood within the field of institutionalised and maltreated children. Theories as to its existence vary from IF being a disorder of attachment, to neurobiological theories proposing IF to arise out of the interaction between a severely deprived upbringing and genetically predisposed brain abnormalities. The current literature review aims to look at studies that have investigated the interaction between attachment and indiscriminate friendliness, in order to ascertain whether IF is, in fact, a symptom of disordered attachment. Findings were considered in relation to quality of studies and literature within this field. Using specific search criteria, 11 papers were found and evaluated. Findings concluded that IF was not a symptom of disordered attachment, due to the majority of papers failing to find a link between the two constructs. Studies were evaluated in terms of sampling, measurement, analyses, and design. The review pulls together the literature on indiscriminate friendliness, which has previously been confined to the area of attachment. The review highlights potential areas for exploration such as the background of families, as well as the assessment of quality of care, and how this impacts on the development of IF. The review also raises concerns around the measurement of this construct, and calls for further use of validated measures. Service Improvement Project This study describes the development of a new group using psychological approaches for caregivers of individuals with dementia. This follows consultation with the service and its users, to the implementation and running of this group. Thematic analysis was used to extract key themes on the utility of the group. Barriers to intervention have been identified, and further research recommendations have been made. Main Research Project Background: Metaphors are commonly used within clinical settings to communicate concepts to young people. Whilst theories of how metaphors work have been proposed, alongside ideas to implement metaphors effectively, there has been little research as to whether metaphors impact upon memory and understanding, in comparison to basic language. Aims: The current study aims to assess whether metaphorical explanations leads to improved memory and understanding for psychological concepts. Method: 25 participants took part in the study (10 boys and 15 girls). Individuals who were on the waiting list for Cognitive Behaviour Therapy (CBT) were given the opportunity to watch a video which explained the main concepts of CBT. Half of the participants watched a video with metaphorical explanations (Metaphor group); the other half watched a video using basic language (Psychoeducation group). The participants answered questions immediately after the video and then four weeks later, on psychopathology, memory and understanding measures. Results: T-tests were carried out to determine any differences between the two groups. There were no significant differences on all variables tested (memory, understanding, intention to change) immediately or after four weeks. Correlational data, looking at the link between age and understanding/memory between the two groups found that older individuals were more likely to understand and remember the content of the Psychoeducation video. Whilst this correlation did not differ significantly from the Metaphors group, there were no such trends for individuals exposed to a metaphorical understanding. Conclusions: Metaphors do not appear to enhance memory and understanding of young people, in comparison to basic language. However, it seems they are equally understood by younger and older children, therefore making them an accessible way of communicating complicated concepts. Definitive conclusions cannot be made due to the small sample size, so there is a call for further research in this area.