Background: There is some evidence to suggest that computerised Cognitive Behavioural Therapy (cCBT) is effective for reducing adolescent anxiety and depression. However, most studies have used samples of young people in the general population or those who are 'at risk' of anxiety or depression, and so less is known about the usefulness of cCBT for adolescents with clinically significant levels of distress and impairment. Aims: This study aimed to investigate the feasibility of using a novel computerised cCBT intervention, 'Pesky gNATs,' with adolescents aged between 13 and 18 years old who had clinically significant symptoms of anxiety and/or depression. Method: Eleven participants were recruited from a Tier 3 Child and Adolescent Mental Health service (CAMHS). Six participants were allocated to the intervention group and received the intervention immediately, and five were allocated to the control group and received the intervention after a delay. Outcome measures were completed pre- and post- intervention. Qualitative data were also obtained during the final session. Results: A high participation and retention rate was found for the intervention and the majority of participants described the programme as helpful and identified several benefits of completing the programme. No differences in overall self-reported symptoms of anxiety and depression, self-concept and functioning were found when comparing the intervention and control group on pre- and post- intervention scores. However, decreases in parent-reported symptoms of anxiety and depression and the impact of symptoms on functioning were found across both groups. Conclusion: This study demonstrates the acceptability of using a cCBT programme in a Tier 3 CAMHS setting, but shows limited evidence that this intervention is effective at reducing self-reported symptoms of anxiety and depression. Therefore, 'Pesky gNATs' may not be appropriate as a standalone treatment for young people with more severe clinical presentations.

Post-stroke depression (PSD) is highly prevalent and influences recovery from stroke. Psychological intervention is a recommended treatment, but the limited understanding of psychological mechanisms underlying PSD means that current guidelines do not recommend specific psychological therapies. Oddly, previous research exploring this area has excluded people with a history of depression. The present study compared PSD in people with (n=9), and without (n=11) a history of depression to determine whether there were differences in PSD phenomenology, in terms of depression profile, lesion location, anxiety and interpretation of performance. PSD appeared to be less prevalent in this study's population than indicated in the literature, leading to the small sample size. Participants with a history of depression were significantly younger and reported more severe depression and poorer quality of life than those for whom this was their first episode of depression. In terms of depression profile, scores on most measures were not found to be different, nor were there significant differences in lesion location between groups. Participants without a history of depression performed worse on the Brixton cognitive task, and in this group, higher health anxiety scores were associated with poorer self-evaluation of performance. As the present study was underpowered, further research with a larger sample is required to explore this more comprehensively, including the addition of qualitative methodology.

Sport performers encounter various stressors as part of their involvement in competitive sport, and their ability to respond effectively to these demands is likely to dictate whether they thrive, manage, or succumb in competition. The purpose of this thesis was to provide the first systematic exploration of thriving in sport. To achieve this, extant thriving literature is first reviewed and a conceptualization of human thriving proposed. Namely, it is suggested that thriving is the joint experience of development and success, which can be realized through effective holistic functioning and observed through the experience of a high-level of well-being and a perceived high-level of performance. Four empirical studies are then presented which examined and compared the experiences of sport performers who thrived in competitive encounters to those who did not. In Studies 1 and 2, results of factor mixture analysis (see Chapter 3, N = 535) and latent class growth analysis (see Chapter 4, N = 175) supported the presence of a unique thriving group and identified possible relationships with personal enablers (e.g., resilient qualities) and process variables (e.g., basic psychological needs satisfaction; BPNS). Study 3 (see Chapter 5, N = 51) extended these findings using a diary study design, demonstrating that pre-game levels of BPNS and challenge appraisal positively predicted in-game functioning; although no evidence was found to support the presence of biomarkers for thriving. Study 4 (see Chapter 6, N = 18) utilized mixed methods and revealed that, although many of the themes were similar for sport performers in thriving and non-thriving groups, substantial differences existed in the expression of these codes and in the relationships between them. Overall, the findings in this thesis make a meaningful advancement to the human thriving literature, and provide psychologists with an initial foundation upon which they can develop interventions to facilitate thriving in sport performers.

This sociological study examines the origins, development and uses of the concept of 'therapeutic community' in institutional psychiatry. It is divided into four parts, the first two containing a survey of all the available literature referring to the use of 'milieu therapy' and 'therapeutic community 'strategies in the treatment of (functional) mental disorders, and the last two containing a description of the author's fieldwork, followed by a detailed analysis of the operational usage of the concept of 'therapeutic community' in selected British psychiatric institutions. Part 1 examines - and rejects - the claim for a distinctive sociological sub-discipline referred to as a 'sociology of psychiatry' and argues that 'dualism' in the theory and methodology of the social and medical sciences has served to confuse as well as delay the development of interdisciplinary cooperation between social scientists and the medical profession. In Part 2 the origins of the concept of the 'therapeutic community' are traced through a review of social medicine since 1790. Special emphasis is placed - in chapters 5 and 6 - upon 'milieu therapy' as a reaction to 'custodialism' in institutional psychiatry after 1939. Chapter 6 provides a general overview of the developing concept of 'therapeutic community' and argues that much of what has been taken for granted about types of social structure, treatment goals and modes of therapy, requires a more discerning evaluation. In its present form, the concept is both confused and misleading. Part 3 contains the results of the author's field research which was carried out in two stages over the period 1971-2. Stage 1 (Chapters 7 and 8) is concerned with establishing criteria of definition of 'therapeutic community' methods and shows that the staff of six selected psychiatric settings have a stereotyped image of the therapeutic community. The data suggest that the 'ideal type' community would consist of a relatively small unit (23 patients) that is located outside or away from the larger organisation to which it belongs, having semi-autonomous administration and the right to determine its own therapeutic policy. It would cater mainly for patients diagnosed as suffering from 'psychoneurotic' and 'personality disorders' although a 'therapeutic community' approach could be adapted to suit the needs of patients suffering from a wider range of disorders. Stage 2 describes a participant-observational study of a developing therapeutic community and evaluates difficulties encountered in growth and transition. Various techniques were developed for guaging changes in ward atmosphere and morale and these are explained in chapters 9-13 along with an account of the problems encountered by the author in attempting to compromise two different approaches - the search for an acceptable (i.e. empirically justifiable) research strategy and the need for full time personal involvement in the daily life of the ward. Part 4, contains summarial comments and general conclusions. It is the author's contention that the concept of the therapeutic community is seen to be progressive because it is ideologically opposed to traditional psychiatry. Due to its strong emotive overtones it takes on more the character of a 'symbol of progress 'rather than a blueprint for organisation. For this reason users of the term are advised to distinguish carefully between what is essentially a theoretical construct and specific applications of the concept to practical settings.

Implicit attitudes are thoughts and feelings that occur outside of conscious awareness and are therefore difficult to acknowledge and control. Implicit attitudes have been shown to predict socially sensitive intergroup behaviour not predicted by self-reported (explicit) attitudes. Consequently, negative attitudes towards certain demographic groups (e.g. women, older people, minority ethnic groups, gay people) may contribute to persistent disparities in employment, criminal justice, education and healthcare. The role of clinical psychologists (CPs) in the UK is very varied and CPs may be involved in direct or indirect clinical work and service development; and may be employed in leadership positions within the NHS. Therefore, implicit attitudes among CPs may have wide-ranging implications. However, very few studies have explored implicit attitudes among applied psychologists and none have considered trainee (TCP) and qualified clinical psychologists in the UK. Eighty-one CPs, 143 TCPs and 86 members of the general population completed between 1 and 5 Implicit Associations Tests (IAT) and self-report measures of attitudes towards age, sexuality, skin-tone, weight and gender/career associations via an internet application. The results showed that negatively biased implicit attitudes towards non-dominant groups were present among CPs and TCPs to a similar degree to those observed in the general population. Conversely, all groups self-reported neutral or positive biases towards all non-dominant groups, except overweight people. All groups showed a similar degree of implicit and explicit pro-thin bias. These findings were not associated with participant age and did not vary by location or religion. The results have implications for clinical psychology service provision and therapy outcomes (particularly for overweight clients), sex disparities in leadership within the profession and education and training. The findings require replication in a more diverse and representative sample and further research is required to determine whether implicit biases among clinical psychologists predict subtle, unconscious discriminatory behavior in this group.

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INTRODUCTION: People with schizophrenia who commit serious violence are detained in secure hospitals. The research presented in this thesis investigated the long-term outcomes of patients with schizophrenia detained in a high security hospital. LITERATURE REVIEWS: Epidemiological research points to a significant but modest relationship between schizophrenia and violence. But when followed-up, offenders with schizophrenia are less violent than those with primary personality disorders or non-psychotic violent offenders. A number of factors have been found to be associated with violence in people with schizophrenia. Many of these are the same as factors associated with violence in non-psychotic populations. Seventy-two studies of the outcomes of UK security hospital studies published before 2010 were reviewed. Most included mixed diagnostic groups, and only 3 were focused on patients with schizophrenia. The most commonly reported outcome was conviction in over half of studies. Readmission, length of stay, institutional violence, the discharge process and mortality were reported in up to a quarter of studies. Very few studies reported clinical or social outcomes. AIMS AND RESEARCH QUESTIONS: The aims were to describe the long-term administrative (including moving though services and levels of security), forensic (including violence, conviction, absconding), clinical (including course of psychosis, treatment received, mortality) and social (including employment, intimate relationships, accommodation, substance misuse) outcomes of patients with schizophrenia detained in a high security hospital in Scotland; and to ascertain the factors associated with certain of these outcomes. Research questions were formulated to address these aims. METHOD: The sample was 169 patients with schizophrenia resident at the State Hospital, Carstairs, between August 1992 and August 1993. In 1992-4 patients and their psychiatrists were interviewed and data were collected from case records. Patients were followed up until the end of 2001. Records covering the intervening period were examined, and patients and independent informants were interviewed in 2000 and 2001. A number of structured instruments were used at interviews and to interrogate case records. Analysis involved descriptive statistics, survival analysis, bivariate approaches and logistic regression. RESULTS: Baseline characteristics: Most patients were male, unmarried and from socially disadvantaged backgrounds. The average patient was in their mid thirties. Most had been admitted from criminal courts after committing serious offences, half were subject to restriction orders and a quarter had killed. Most had had psychiatric treatment previously. Comorbid substance dependence and personality disorder were common. Administrative outcomes: Most patients (79%) left high security, but a minority (48% of those who left high security) reached the community, and 17% of patients who left high security were readmitted. Clinical correlates of outcomes were: not leaving high security - psychopathy and chronic psychosis; not reaching the community - chronic psychosis, not having substance dependence and not having an index offence precipitated by psychosis; readmission to high security - psychopathy. Other associates of outcomes, in terms of baseline and follow-up variables, were in keeping with the clinical correlates. Forensic outcomes: Three-quarters committed at least one act of violence, but less than a quarter caused serious harm. There were almost 2000 violent incidents, mostly in high security. Violence in the community was rare. The rate of criminal conviction was 13%, 10% for serious offences. Clinical correlates of forensic outcomes were: any violence - antisocial personality disorder and on going positive symptoms; serious violence - psychopathy; persistent violence - chronic positive and negative symptoms; convicted offending - psychopathy and substance dependence. Other associates were in keeping with these findings. Clinical and social outcomes: A third had episodic symptoms, a quarter continuous symptoms and a fifth recovery with no recurrence. Positive symptoms tended to improve whilst negative symptoms persisted. Persistent positive symptoms were related to not having psychopathy or substance dependence; and to more frequent relatively minor aggression, but not serious violence. The mortality rate was 7%. Social outcomes were very poor, but few patients were misusing substances at follow-up. Comorbid substance dependence and personality disorder: Substance dependent patients were more likely to be convicted, but otherwise had better administrative, clinical and social outcomes. Antisocial personality disorder was associated with violence during follow-up. Psychopathy was associated with not leaving high security, readmission to high security, conviction, serious violence and better outcome of psychosis. CONCLUSIONS: The outcomes and their associates are reviewed in light of the available literature. Course of psychosis and comorbid personality disorders and substance dependence are important clinical factors in determining the administrative, forensic and clinical outcomes of these patients. A typology based on these factors and course of violence is suggested as a way of synthesizing the findings with the literature and as a way of understanding the current findings. The methodological strengths and weaknesses of the study, and implications for clinical practice and research are discussed.

A variety of structural abnormalities are consistent findings in schizophrenia. These include enlargement of the lateral and third ventricles and reduced volume of the frontal lobes, medial temporal lobes and thalami. These abnormalities are present in first episode subjects and may be detectable before the onset of clinical disorder. There is accruing evidence that substance misuse may contribute to an individual's risk of developing schizophrenia. Substance misuse is associated with similar brain abnormalities to those seen in schizophrenia and is often well established at the time of first presentation. This makes it difficult to ascertain if any of the structural abnormalities seen when individuals first present with psychosis are attributable to substance misuse. An understanding of the relationship between substance misuse and structural imaging abnormalities in people who are well but at high risk of schizophrenia is thus of great importance. It has the potential to yield important insights in to: (1) the role substance misuse may play in the development of structural brain abnormalities; and (2) how substance use may influence risk of developing the condition. A prospective cohort study with nested case-controlled comparison design was employed to examine the relationship between substance misuse, brain imaging abnormalities and the subsequent development of schizophrenia. Substance misuse history, imaging data, and clinical information were collected on 147 subjects at high risk of schizophrenia and 36 controls at point of entry to the study. Regions exhibiting a significant relationship between level of use of alcohol, cannabis or tobacco and structure volume were identified, this relationship being elucidated through the use of both volumetric and voxel-based morphometric image analysis techniques. Additionally, we established whether substance misuse up to the point of recruitment was associated with later risk of schizophrenia. In addition to the baseline scan, the first 57 high risk subjects recruited to the study also had a follow-up scan after approximately 18 months. As substance use between scanning points was known, this enabled longitudinal comparison of brain structural changes in high risk subjects who did and did not use the aforementioned drugs of abuse. This comparison was made using both volumetric and tensor-based morphometric image analysis techniques. In the baseline analysis, increased ventricular volume was associated with alcohol and cannabis use in a dose-dependent manner. Alcohol consumption was associated with reduced frontal lobe volume. Multiple regression analyses found both alcohol and cannabis were significant predictors of these abnormalities when simultaneously entered into the statistical model. The longitudinal analysis demonstrated that cannabis use between scanning points was associated with both bilateral thalamic and right anterior hippocampal volume loss. Alcohol and cannabis misuse by point of entry in to the study were associated with an increased subsequent risk of schizophrenia. This study provides prospective evidence that use of cannabis or alcohol by people at high genetic risk of schizophrenia is associated with brain abnormalities and later risk of psychosis. A family history of schizophrenia may render the brain particularly sensitive to the risk-modifying effects of these substances.