Literature Review : A critical review of the literature was made to investigate what influences an individual’s intention to seek psychological help for mental ill health. Nineteen articles were retrieved that met the inclusion criteria. The articles were reviewed, critiqued and synthesised to answer the review question. Four key themes were identified: ; a) mental health services are underutilised and understanding help-seeking intentions and behaviour is of paramount importance for mental health professionals, b) current measures of help-seeking have significant shortcomings and comprehensive, theory driven instruments are needed, c) help-seeking is more likely to be a global concept and does not vary in relation to type of problem, although it may vary with population specific characteristics, and d) instruments used to measure help-seeking intention should be constructed with the development of interventions in mind. Clinical implications and direction for future research are discussed. Research Report : In order to understand psychological help-seeking intention for mental health problems in medical students the Theory of Planned Behaviour (TPB) model was used. Thirty-nine medical students took part in an elicitation study to obtain attitudes, subjective norms, and perceived behavioural control for psychological help-seeking. Eighty medical students took part in the quantitative TPB questionnaire that was developed as part of the methodology. The TPB model was found to significantly predict help-seeking intentions. The limitations of the research are discussed and suggestions for future research presented Critical Appraisal : Finally, an appraisal of the research process as a whole was made with a critique of the research methodology. The author’s reflections on conducting an independent research project are presented and learning points highlighted.

The present study has three constituent parts. The first is a critical literature review, the second is a self-contained research report and the third is a critical appraisal of the research from the researcher’s perspective.

Literature Review: Purpose: To determine differences in Duration of Untreated Psychosis (DUP) and Pathways to Care (PtC) between ethnic groups for service users with first-episode psychosis. Method: Literature searches were conducted using the online databases PsychInfo, Medline, Science Direct, Web of Science, Scopus and ASSIA. Keywords selected for searches included the terms Duration of Untreated Psychosis, Pathways to Care and Ethnic* or Cultur* or Diversity. Results: Ten relevant articles were identified. Five were cohort studies and five were cross-sectional studies. Conclusions: Mixed evidence was found regarding the influence of ethnicity on DUP. Findings on PtC were clearer, with minority ethnic groups often reported as more likely to access care via negative pathways, such as criminal justice agencies. Research Report: Objectives: 1) To explore the effects of ethnicity and other variables on DUP and PtC in an EIP service in Leicestershire and Rutland. 2) To develop an understanding of the barriers GPs experience when presented with a service user with first-episode psychosis. Method: A mixed methods design was adopted. Firstly, a naturalistic cohort study involving 426 individuals from an EIP service was analysed. Semi-structured interviews were also conducted with six GPs and one focus group. Interview data was analysed using Thematic Analysis. Results: No associations were found between ethnicity and any DUP variables. Ethnic differences were reported for three PtC: Criminal Justice Agencies; Accident and Emergency services; and Inpatient services. Thematic Analysis of GP interviews indicated three key themes. These were ‘a grey area’, ‘dilemmas’, and ‘more in depth mental health training’. Conclusions: Ethnic differences were only observed with specific PtC, which supported evidence by Ghali et al. (2012). GP and public education programmes were perceived as necessary in reducing delay, and minimising the impact stigma and shame have on service users’ and families’ help-seeking behaviour. Critical Appraisal: A reflective account of the research process and learning outcomes are described and discussed.

Part One: Literature Review : Introduction: The current paper provides a systematic review of the current evidence into the impact of sharing the formulation with clients. Method: A systematic literature search using five databases was carried out. Resulting papers were screened leaving fourteen papers to be included in the final review Results: Evidence to support the claim that sharing formulation impacts on clients is limited and the picture is complex. There was some evidence that differences in the content and process of formulation, and the quality of a person’s interpersonal functioning, could have a differential impact on outcome. Discussion: There is some evidence that formulation has a differential impact on different people. This suggests a level of clinical judgement should be used when deciding what to share, based on therapists’ understanding of the client. Part Two: Research Report : Introduction: The aim of the current study was to use grounded theory to produce a model of how clinical psychologists use formulation in sessions with clients who have experienced ‘psychosis’. Method: Two therapy sessions between a clinical psychologist and a client were audio recorded and analysed. The clinical psychologist was then interviewed about their use of formulation within the sessions. Results: A model of formulation was produced with a core category of formulation as purposeful action. Discussion: Many current definitions of formulation do not sufficiently capture the active purposeful process identified in the current research. Extensions to definitions of formulation are discussed. Part Three: Critical Appraisal The critical appraisal describes a reflexive account of the research process.

There is a large body of research demonstrating that the dissolution of a romantic relationship remains a prospective risk factor for the development of a variety of emotional and clinical problems. Nevertheless, research into the factors that contribute to the variance in distress experienced between individuals has been relatively overlooked in terms of systematic enquiry. A literature review was therefore carried out with a view of understanding further those variables most salient in accounting for individual difference reactions following relationship dissolution. 21 studies examining correlates of relationship dissolution distress were reviewed. Results suggested that a range of variables significantly influence the distress experienced following loss including attachment orientation, personality characteristics, cognitive-behavioural variables and relationship-specific factors. However, it has not yet been examined how such variables may systematically be related and an empirically validated model of relationship dissolution distress has not yet been be proposed within the clinical literature. Twenty-seven participants reporting difficulties adjusting following the dissolution of a relationship were therefore interviewed about their experiences and completed self-report measures pertaining to attachment style and personality characteristics. The aim of the research was to assess for commonality of themes and contribute to the development of a theoretical model of relationship attachment, similar to those available in the research for other emotional disorders. Research objectives were met. Consistency of themes across individuals led to the proposal of a cognitive-behavioural model of relationship dissolution distress. The model is both theoretically and clinically derived and incorporates a number of factors hypothesised to exacerbate and maintain distress over time. The findings have useful clinical implications and point to promising targets of cognitive and behavioural intervention. A critical appraisal contextualises the researcher’s motives for wishing to investigate this particular area and provides a reflective account of the antecedents of this research, borne out of ‘bottom up’ clinical practice.

The disabling effects of schizophrenia, as well as the difficulty in addressing all the associated deficits through treatment are well documented. Recently more research has focused on characterising cognitive deficits related to schizophrenia, as due to their enduring nature, and relation to functioning ability they are viewed as a therapeutic target. The aim of this thesis was to investigate the ability of individuals diagnosed with schizophrenia, as well as in relation to the schizophrenia spectrum, to shift attention focus both within the visual field (covert attention) and by directing their eye-movements (overt attention). In particular the ability to use task information to modify strategies for better performance was examined. Participants, consisting of individuals with a diagnosis of schizophrenia, an age appropriate comparison group and students assessed for schizotypal traits, completed two covert cueing tasks, and two anti-saccade tasks, designed to measure both reflexive and voluntary attention shifts. Individuals with schizophrenia showed consistent impairments across the tasks, with lower sensitivity to targets and slower response time for the covert attention studies, and higher error rates and longer latencies for the anti-saccade tasks. Schizotypy scores were also related to some performance measures, with higher scorers exhibiting lower hit rates for the cueing study, and longer latencies in the classic anti-cue task. The inability to inhibit eye-movements was also consistently related to the schizophrenia spectrum. All participants, including those in the schizophrenia group, used the task information to change their attention strategies accordingly; this suggests that individuals with schizophrenia are able to use some degree of top-down voluntary control of both overt and covert attention. Thus strategic attention appears preserved in relation to the schizophrenia spectrum, but the basic deficits, which were shown to be consistent, could present a target for treatments as they are present even when participants are receiving medication.

People who hear voices can find the experience distressing. Largely speaking voice hearing is viewed by society, and some mental health professionals, as being a symptom of mental illness. In this way the experience of voice hearing is more often than not seen as being biological in nature which can preclude other possible explanations. A systematic literature review carried out in this study found that the most researched psychological intervention for use in schizophrenic spectrum disorders found was CBTp. The effectiveness of CBTp varied across studies but overall positive outcomes were reported. These included a reduction in relapse, improvement in social functioning and a reduction in symptoms. The evidence for the impact CBTp has on voice hearing as a specific symptom is less well established. The majority of trials place voice hearing within the wider category of positive symptoms. The majority of other interventions reviewed were found to be less effective than CBTp. There are some promising, albeit very limited, results to show that self-help groups have a positive impact for people who hear voices. This research project aimed to find out from voice hearers what their experiences are when it comes to talking about their voices. In total eight unstructured interviews were carried out with individuals from mental health services. Interviews were transcribed and analysed using Narrative Analysis. Results showed that some people want to talk about their voice hearing but, at times, a number of factors prevent this. These factors are external barriers, such as from services, and internal barriers, such as personal readiness to talk. In addition to this it seems that how people view themselves in their own story leads them to either being stuck within their difficulties or free to move on. Finally resources available to the individual, whether real or perceived, also impact on how able they are to manage their voice hearing. Clinical implications using the results in this study are discussed.

Introduction: Staff in acute mental health settings work with voice hearers at times of crises, when experiencing high levels of distress. Research has demonstrated the importance of exploring the subjective experiences of voice hearing yet there has been little focus on staff experiences of working with voice hearers. The present study therefore sought to explore staff experiences of working with voice hearers in an acute mental health service. Method: Eight staff members (three mental health nurses and five healthcare support workers) from one acute mental health hospital were interviewed about their experiences of working with voice hearers. These interviews were transcribed and analysed using Interpretative Phenomenological Analysis. Individual analyses were conducted for each participant before conducting a group analysis. Results: Three master themes and seven super-ordinate themes were identified from the group analysis. Participants described ‘struggling to exercise control’ in their work with voice hearers, moving from positions of ‘powerlessness’ to ‘feeling powerful’. Participants experienced the ‘emotional impact of the work’ to different intensities, often going through an initial ‘startling phase’ and transitioning to feelings of ‘performance anxiety and self-doubt’. ‘Ways of managing feeling overwhelmed’ were described including going through a ‘process of making sense’, ‘forming relationships’ with voice hearers and feeling a ‘sense of duty and responsibility’. Discussion: The present findings relate to power literature and previous research on empowerment and control in mental health services. A parallel process was identified between voice hearers and staff, both experiencing an initial ‘startling phase’ but transitioning to an ‘organisational phase’ where they make sense of their experiences. The research findings were also consistent with previous studies demonstrating staff anxiety around opening up conversations about the content of voices, highlighting staff training and support needs.

This in-depth investigation into the nature and prevalence of adversity within late life involved a two phased study, employing questionnaire and interview measures with a mixed methods analysis. The larger (n=960) PHQ-9 and LTE-Q study showed depression prevalence of 12% in older adults, who most commonly experienced adversity involving health and bereavement. Depressed participants reported significantly more recent adversity, a finding observed particularly in the early stages of older adult life and amongst women. Logistic regression showed adversity to be a significant predictor of depression, accounting for 1.8% of the variance in depression. The smaller (n=19) LEDS study showed a significant prevalence of low threat difficulties across the sample, who also reported health, relationships and bereavement to be the most commonly experienced. Depressed participants were shown to report higher rates of marked difficulties and lower social emotional support than non-depressed participants, which may play a key role in the maintenance of late-life depression. Although the LTE-Q was shown to be a crude measure, only capturing a portion of LEDS measured adversity, the general pattern of life event characteristics maps well onto the LEDS data. This was mirrored in the qualitative accounts of older adults who preferred the LEDS and considered it to capture adversity in depth. Thematic analysis revealed themes around ‘self-redefinition,’ ‘being immortal,’ and ‘leaving in peace’ were pertinent to both adversity and coping in late life, which were experienced differently by depressed participants as ‘powerless in the face of reality,’ ‘threats to immortality’ and ‘leaving in disharmony.’ Further investigations are required to determine how adversity contributes to depressive experience in the elderly, in particular examining the roles of marked difficulties and social emotional support. Suggestions are made for psychological interventions to consider the social contexts of older adults, while facilitating the coping processes highlighted in the qualitative analysis.

This thesis will make a valuable contribution to our understanding of the phenotypic expression of psychotic like symptoms (PLEs) in adolescence and risk factors associated with these experiences, informing the extant literature in this field. Epidemiological studies have shown that PLEs are reported in the general population and that the differences between clinical and non-clinical samples are quantitative rather than qualitative (Johns et a1., 2004; Linscott & Van as, 2013). Importantly, PLEs are relatively common in early adolescence and for the majority are transitory, however when these experiences persist into later adolescence they have been found to predict a range of psychotic and non-psychotic disorders (Kelleher et a1., 2012). Evidence further suggests that PLEs share phenomenological and aetiological continuity with clinical psychosis and childhood trauma has been implicated as a risk factor for psychotic symptomatology in both clinical and non-clinical populations (Linscott & Van Os, 2013). To date loneliness has not been conceptualised in trauma-psychosis associations (and it is believed that this will add to the field by demonstrating the significance of adolescent loneliness in these associations). This thesis addresses a number of gaps in the knowledge base by 1) measuring the underlying structure of PLEs in a large adolescent sample using confirmatory factor analysis and factor mixture modelling; 2) examining the role of peel' victimisation, negative self and other evaluations and childhood feelings of threat and subordination in these experiences and; 3) exploring and conceptualising the role of loneliness in trauma-psychosis associations.