Case formulation within psychology and psychotherapy has often centred on this being the skill and task of the clinician. However, research into lay theories has identified that lay perceptions of mental illness are as varied as psychological theories and similar to mental health professionals. This study adopted a mixed methods approach to explore whether lay perceptions can be considered a formulation. Participants were shown a hypothetical vignette and asked to write a short statement as to what they believed was going on for the actress in the video. This was supplemented with suggestions asking participants to consider what the main issues were, how they may have developed and what may be keeping the problems going. Information was initially coded using template analysis which drew 'a priori codes' from the Case Formulation Content Coding Method (CFCCM). This helped to identify the relevant categories deemed important in case formulation and allowed for an 'overall quality' and 'comprehensiveness' score to be compared with previous research. Thematically analysing participants' responses within template analysis also allowed for the identification of new themes which aimed to offer the reader further context of the formulation ability of lay people. The results indicated that participants who have no prior experience or training in psychology or formulation appear to formulate. Participants' 'overall quality' and 'comprehensiveness' scores were comparable to mental health professionals from a previous study who had received formal training in formulation and significantly different to mental health professionals who had not. However participant formulations appeared to lack the depth of mental health professionals and further investigations are recommended. The findings are also discussed in terms of how this information can be used within clinical practice and the wider implications regarding lay psychological mindedness. 0809, RES, UofL: 08127478, UofN: 4092609, Thesis_resubmission 1

Adolescent self-harm is an international and national issue that is positively related to adolescent suicide. It has a major impact upon the lives of young people and their families and represents a significant drain upon the economic and clinical resources of the National Health Service. The research objective of this project was to investigate what might be happening in the minds of young people who self-harm. The project was designed to capture the micro-processes of adolescent self-harm in order to identify significant constructs for the purpose of theory generation and clinical application. It is a grounded theory study of 12 adolescents aged 13-16 years old (9 females and 3 males) presenting to hospital after an episode of self-harm. A single interview was conducted after episodes of self-barm and analysed using a narrative and construct based approach. Results: The findings of the project are presented as four cardinal constructs: (1) The Upset; (2) Who Cares? -The Mother-Adolescent relationship; (3) The Telling -Self/Other Relations; (4) Equilibrium Disequilibrium. These findings form the basis for an adolescent theory of self-harm with an over-arching and chief construct of Equilibrium. Conclusion: Disturbances and discontinuities in adolescent self-other relationships are major factors in adolescent self-harm.

This portfolio contains a selection of work completed for the Practitioner Doctorate in Counselling Psychology at the University of Wolverhampton. It contains three dossiers: Academic, Therapeutic Development and Research. The Academic Dossier contains papers that were submitted for the following • modules: 'Life-span Approach' and 'Issues and Ethics'. The Therapeutic Development Dossier contains an essay exploring three years of placements ('Supervised Practice') and an essay reflecting on my professional development (,Professional Issues'). Finally, the Research Dossier contains a literature review, a research report and critical appraisal. Confidentiality of clients, research participants and their families have been protected throughout the portfolio. Individuals' names and places have been changed and any potentially identifying information has been omitted or anonymised. Client studies, process reports and all raw data (including interview transcripts) are available in the Confidential Attachment which has been submitted separately and is not available to the public. The work within this portfolio demonstrates my journey from a theory-led, orientation-specific therapist to a client-led, integrative therapist who is continually learning and growing. Within the preface I hope to apply Prochaska and DiClemente's (1986) Stages of Change Theory to my own journey to help demonstrate this change (see Figure 1 below). This is a model I have increasingly attempted to use to inform my therapeutic practice, along with Egan's Skilled Helper Model (2002). The Stages of Change model provides a framework through which we can understand the different stages an individual goes through during the process of any change in attitudes, beliefs and behaviour. The notion of the stages demonstrates that for most a change in behaviour occurs gradually and over time. It must also be recognised that this is a dynamic process and that an individual can move between the stages at different rates and also return to earlier stages. When reflecting on my time completing the Doctorate, I feel that during the last three years I have changed in many areas of my life. My therapeutic stante, my way of interacting with clients and my understanding of working with different client groups have all gone through a process of change which I feel fits in with the Stages of Change model. The work throughout this portfolio will hopefully exhibit how changes have occurred and have helped me become the Counselling Psychologist I am today.

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Although it is still possible to encounter the view that medication is the only method of treatment for bipolar disorder, research shows that there is a significant need for a comprehensive and integrative approach to this complex disorder. The current thesis firstly describes the rationale and development of a new, psychological intervention specifically directed at bipolar disorder, and secondly reports on an evaluation of this approach to treatment. Using a longitudinal design with replication across 13 participants, combined with the use of multiple case study methodology and qualitative data collection strategies, which allowed for triangulation between multiple data sources, it is concluded that the newly developed Therapeutic Instability Model approach to treatment had a significant and positive impact on factors of importance when treating bipolar disorder. These factors included hopelessness, known to be predictive of suicidal behaviour, and perceived control over internal states, a central aspect of bipolar disorder. As part of the evaluation, insights into which factors are important for client satisfaction and perceived usefulness of a treatment were also gained and it is argued that these should be borne in mind when attempting to develop interventions with high effectiveness and low dropout from treatment. The study further-more found positive changes occurring as a result of the intervention in thoughts, feelings, behaviours and illness related knowledge, and began a mapping of the participants' understanding or subjective models of their disorder's aetiology and maintenance. Further, two distinct patterns of change in important variables were observed during treatment and appear to be related to the participants' general attitude to having future episodes of mania. In relation to this, it was noted that specific interventions, such as behavioural experiments, may be more important for outcomes of treatment for individuals with a positive/ambivalent attitude to mania compared with individuals who do not share this attitude to manic experiences. It was argued that these findings could have potentially important clinical implications and a number of suggestions with regards to further research in this, and other, areas relating to the study were finally made.

Many in the caring professions consider spirituality to be a fundamental dimension of human experience and identity. Consequently, some claim that this dimension cannot be ignored in disciplines such as psychotherapy that deals with the human being and with human experience. Moreover, the increase in secularisation and the emphasis on the subjective and the personal in people's experience of spirituality and religion, have led to an increased interest in psychotherapy, counselling and other forms of activities and professions that deal more closely with the personal and subjective. Other themes that connect spirituality and psychotherapy include: spirituality is related to a person's mental health; people make meaning which assumes that they are spiritual beings; and spirituality and psychotherapy both involve enlightenment and meaning-making. For some, spirituality is manifest in psychotherapy either because of spiritual concerns that are raised by clients in the psychotherapeutic process, as a resource, or as a form of pathology. For others, therapy is a spiritual encounter. The research is a qualitative exploratory study of the experience and perception of the spiritual dimension of psychotherapy of Maltese practitioners. The study was held with two groups of Maltese psychotherapists and clinical and counselling psychologists. Each group attended a series of four focus/study group sessions. Key areas explored include the participants' conception of spirituality and religion and their understanding and experience of the spiritual dimension in counselling and psychotherapy. Broadly, the study focused on the ways in which spirituality may become manifest' and express itself in the psychotherapeutic process, the roles and experiences of the therapist and the client regarding spirituality in counselling and psychotherapy and the identification of the factors that may contribute to the spiritual dimension of counselling and psychotherapy. The findings are presented as two main domains, that of 'understanding spirituality and religion in a postmodern context' and 'spirituality and psychotherapy'. The latter is divided into four themes that are facets of the domain 'spirituality and psychotherapy'. These are a) understanding spirituality and religion, b) the therapeutic relationship as sacred space, c) the being: it is who the therapist is that counts and d) applications in clinical practice. The findings are discussed in relation to the literature and to the Maltese context.

Background: Existing research findings provide evidence for the general effectiveness of paraprofessional counsellors. However, research into the effectiveness of paraprofessional counsellors with specific client opulations is lacking, and we currently know little about the processes of development in this group of practitioners. To address these issues, two empirical studies were carried out. Aim of Study 1: To evaluate the effectiveness of a group of 12 minimally trained/experienced volunteer mental health counsellors. Method: Data were collected over a one year period on 118 clients referred to a voluntary sector counselling agency. The CORE-OM was used to measure clients' levels of distress on a sessionby-session basis. Clients and counsellors also completed a range of additional selfreport measures before and after counselling. A benchmarking strategy was used to evaluate the outcomes achieved by participants in this study against three benchmark studies selected from published literature. Results: Paraprofessionals in this study achieved an effect size of .70 compared to effect sizes of 1.36, 1.39 and 1.42 in the selected benchmark studies. Conclusions: Minimally trained/experienced paraprofessional counsellors working in mental health settings may benefit from more targeted training before engaging in practice. Findings should be interpreted cautiously as the selected benchmarks may not reflect the organisational factors operating within all voluntary sector counselling agencies. Aims of Study 2: To explore the meaning and experience of becoming a paraprofessional counsellor. Participants: The sample included two men and six women. Method: Each participant was interviewed for approximately one hour at the end of their first year of practice. Data analysis: Data were analysed using a grounded theory approach. Results: Four main categories and a core category were identified. The core category of ‘finding a voice’ represented participant attempts to achieve and sustain an identity as a counsellor. This process involved four related experiences: 1) resonating with counselling and the role of counsellor, the agency ethos and values and the theoretical model employed within the agency; 2) learning the language of counselling; 3) putting the language of counselling into action; and 4) experiencing and resolving dissonant experiences. Conclusions: Findings contribute new understanding to existing models of counsellor development regarding the developmental processes that occur in counsellors prior to the period of professional training. Data from Study 1 and Study 2 were also examined to determine if individual differences existed among participants in terms of their effectiveness, personal philosophies, and counselling practice. Findings showed that counsellors varied in their effectiveness with effect sizes ranging from .96 for the more effective counsellor to .21 for the least effective counsellor. Differences in levels of effectiveness were most apparent at the extremes of the three more effective and the three less effective counsellors. Preliminary findings suggested that the more effective counsellors could be distinguished from the less effective counsellors by the emphasis they placed on the relational aspects of counselling, flexibility, working collaboratively with clients, and by the degree of ‘fit’ that existed between their personal philosophy and the model of counselling preferred with the MHSS agency. Implications of these findings are discussed in section 7.4 of Chapter 7.

The literature review critically evaluated research articles focusing on deterioration in psychotherapy published since a watershed review by Mohr (1995). This review adopted the recommendations made by Mohr (1995) as a framework for the literature. A total of 28 studies were identified and reviewed using a quality rating system derived from Mohr's recommendations according to the extent to which these recommendations were implemented in the identified studies. The review yielded a higher average rate of deterioration (9-17%) in comparison with Mohr's review (5-10%). It was concluded that research into deterioration generally has continued to suffer from methodological limitations. The intention of the research report was to investigate the phenomena of overall deterioration and sudden deterioration in a routinely collected data set collected from the Improving Access to Psychological Therapies (IAPT) initiative. Sudden deterioration was explored to determine whether it existed and how it may be defined. The rates of deterioration within the IAPT data were identified, and predictors of these were assessed. It was determined that an appropriate definition for sudden deterioration was a reliable between-session change using the Patient Health Questionnaire-9; PHQ-9), that was not allied to sudden gains. Rates of sudden deterioration and overall deterioration were found to be 3.4% and 3.1% respectively. It was concluded that sudden deterioration exists as a phenomenon, is closely related to overall deterioration and that rates of deterioration in the IAPT dataset were relatively low.