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Section I: Literature Review A literature review examining the relationship between the formulation and the therapeutic alliance in cognitive behavioural therapy. Various 'definitions' of the formulation are reported, and the relative roles and merits of 'nomothetic' and 'idiosyncratic' formulations considered. The function of the formulation is considered in relation to its development in conjunction with the therapeutic relationship and alliance. Research and clinical case reviews are critiqued. Section II: Research Report An Interpretative Phenomenological Analysis of clients' experience of the formulation within cognitive-behavioural therapy. A sample of(N=8) of clients with depression and/or anxiety were interviewed following the 'acute phase' ofCBT during 'follow-up'. Interviews provided five master themes: Somebody that listened and understood - trust in therapist; Understanding what happens; A Foundation and Direction - Something to start from, something to work on; Working to a plan; and Effectiveness and Self -efficacy. These master themes and associated sub-themes represent clients' experience of progress through therapy and the experience and process of formulation. Section III: Critical Appraisal A critical appraisal describing the origin, planning and process of the research, personal reflection and experience gained.

Medical interventions have limited success when applied to individuals with chronic low back pain. Psychological interventions have been developed in order to offer a way of managing chronic pain. These are generally based on behavioural or cognitive behavioural theories. Research indicates that both behaviour therapy (BT) and cognitive behaviour therapy (CBT) are effective in the treatment of chronic pain. However, it is unclear whether CBT is effective as a stand-alone treatment or if it has an additive effect following the presentation ofBT. Chronic pain can affect individuals in a number of ways. Depression, disability and pain related anxiety were considered in the present study. Six participants took part in this single case design study, a multiple baseline was implemented followed by either six or 12 weeks of intervention. Three individuals received BT followed by CBT, the remaining three received CBT alone. Findings of the study were mixed. When BT was considered there were no consistent findings. There was no evidence that CBT added anything to BT when disability was considered. There was weak evidence that psychological distress may respond to CBT following the presentation ofBT. CBT showed mixed results regarding the daily measures of negative pain related beliefs. Phase change measures often showed a different picture to daily measures. There was limited evidence that CBT could provide a decrease in disability and psychological distress. While no firm conclusions could be drawn regarding negative pain related thoughts. Methodological and theoretical issues were discussed in relation to the findings. Suggestions for futures research were also presented.

This thesis investigated the relation between executive functioning and behavioural change in offenders following the Enhanced Thinking Skills (ETS) cognitive rehabilitation programme. A literature review was undertaken which investigated the relation between impaired executive functioning (IEF) and violent behaviour. It also examined and compared rehabilitation programmes available for both medical patients with impaired EF and for offenders. The review concluded that an increased propensity for aggression and violent behaviour is a possible consequence of impaired EF and that aggressive offenders are more likely than the general population to have impaired executive functioning. Medical rehabilitation strategies for aggressive patients and forensic rehabilitation strategies for violent offenders were both found to focus upon teaching skills related to executive functioning. It was therefore hypothesised that the cognitive skills rehabilitation programmes in use within the HM Prison Service may be particularly effective with offenders with IEF. An experimental study was undertaken to investigate whether behaviour change following ETS could be predicted by the offenders' IEF. It also addressed whether this predictive function was above and beyond that predicted by IQ, demographic information and social compliance. These factors were measured and entered into regression analyses, with the post ETS changes in the positive and negative scales of the Behaviour Rating Scale as the independent variables in two separate analyses. Aspects of executive functioning were found to be predictive of outcome, with those with poorer executive functioning showing the most improvement. Participantage and number of previous convictions was found to be predictive of reductions in negative behaviour but not of improvements in positive behaviour; with older participants and those with more previous convictions showing the greatest degree of improvement. The strengths and limitations of the study were then critically reviewed.

Validation is a communication strategy, described by Linehan (1993) as part of dialectical behavioural therapy, which is used to communicate acceptance and understanding of the recipient. In contrast, invalidation communicates lack of understanding or acceptance of the individual, conveying that their thoughts, feelings or behaviours are somehow 'wrong'. This thesis examines the physiological, emotional and behavioural effects of validating and invalidating interactions, exploring the potential for validation in the medical consultation, particularly in the context of pain and distress. Three studies were carried out to examine validation both experimentally and in the context of the chronic pain consultation. In study one, 90 participants were randomly assigned to receive validating, invalidating or no feedback during a series of stressor tasks. Participants' physiological arousal, self-reported positive and negative mood, perceived safety and willingness to take part in the study again were measured. The experimenter-participant interactions were video recorded during the experiment and 42 video excerpts were later coded for participant social engagement behaviours. Seventeen participants also took part in semi-structured interviews to reflect on the experiment and the experimenter feedback that they received. Invalidated participants were found to have significantly lower levels of perceived safety, higher physiological arousal over time (in terms of heart rate and pre ejection period), increased negative affect over time and reported less willingness to take part in the study again compared with validated and control participants. In addition, invalidated participants showed significantly less social engagement behaviours whilst interacting with the experimenter than validated participants. These findings are examined using Porges' polyvagal theory as a framework to conceptualise the possible underlying physiological mechanisms that may be involved. Study two examined potential factors which may shape how individuals respond to validating and invalidating feedback. 425 participants completed an online battery of questionnaires to measure emotion regulation skill , attachment style, early invalidating experiences, feedback believability and socially desirable responding, before receiving either validating or invalidating feedback online. Willingness to take part again, perceived validation, change in mood and change in perceived safety were measured. There were significant differences across conditions in perceived validation, negative affect and perceived safety. Findings also suggest that factors such as difficulties with emotion regulation and early validating experiences shape individuals' perceptions of the feedback. Moreover, believability of the feedback, and whether feedback is congruent with an individual's self-views are both intrinsic in shaping how people respond . This is discussed with reference to Swann's (1983) verification theory. In study three, five patients suffering from chronic pain took part in semistructured interviews to discuss their experiences of feeling understood and accepted during their consultations. Various themes were described: 1) 'coping with their condition' 2) 'communicating understanding', and: 3) 'the impact of feeling understood'. Four video excerpts from consultations with one consultant were also coded using the validating and invalidating behaviour coding scale (VIBCS, Fruzzetti , 2010). These excerpts were discussed with the consultant and the patients involved during semi-structured interviews, in order to ascertain whether the consultants perspective, the patients perspective and the VIBCS coding of the consultant feedback corresponded. It was clear that whilst patients were very responsive to validation strategies and reported feeling understood and accepted, the consultant's aims were not to communicate understanding, but to understand the patient and their pain. The findings from these studies suggest that validation, or at least lack of invalidation, have great potential for alleviating pain and distress. This is particularly relevant for patients suffering from idiopathic conditions such as chronic pain. Such patients, whose symptoms have no obvious observable physical markers, often describe feeling disbelieved and misunderstood. This research sheds light on the potentially detrimental impact of receiving such feedback on physiological arousal, emotions, thoughts and behaviours. It appears that feeling understood does matter, both within the laboratory setting and beyond.

There has been a growing interest in incorporating mindfulness into clinical interventions in medicine and psychology (Baer, 2003). One such approach is Mindfulness Based Cognitive Therapy (Segal et aL, 2002). The mindfulness component of this treatment approach has its roots in Eastern meditative practices, which has implicationsf or practitioners as well as clients. The focus of this research is the relationship between MBCT and mental health professionals' personal and professional development. This was explored in two related studies. Study 1 used a repeated measures design to assess changes in mindfulness and psychological well-being in mental health professionals 18 months after attending an MBCT programme. Results showed that some of the improvements found at 3-month follow-up (by Ruths et al., 2005) had persisted at 18-month follow-up. The relationship between these improvements and other variables such as meditation practice and life events was less straightforward. Study 2 was a qualitative study which used Interpretative Phenomenological Analysis to explore the personal and professional experiences of Clinical Psychologists after attending the MBCT programme cited above. Participants reported continued use of meditation techniques in an informal or ad hoc way and this was associated with improved psychological functioning. In terms of professional development, participants introduced mindfulness into their clinical work in a tentative way and spoke about the challenges and benefits of this integration. Separating mindfulness from its spiritual roots was not viewed as problematic, within the context of a credible evidence base. In conclusion, MBCT appears to benefit mental health professionals as well as clients. The relationship between the development of mindfulness and the need for formal practice is questioned by the research. The accounts of Clinical Psychologists provide useful insights into how a spiritual 'technology' is being integrated into the NHS. The implications for future research and clinical practice are discussed.

SECTION 1: LITERATURE REVIEW This paper reviews the qualitative literature exploring the experience of individual psychotherapy and counselling from the client's perspective. It considers the client's experience in three broad phases: pre-therapy feelings on becoming a client, the middle phase of therapy and the ending of therapy. It provides an updated synthesis of the available literature and presents a critique of that literature. The review demonstrates the rich diversity of experiences that are uncovered when exploring therapy from the clients' perspective. SECTION 11: RESEARCH REPORT This paper reports the findings of a qualitative study exploring clients' experiences and understanding of change processes in Cognitive Analytic Therapy (CAT). Using grounded theory methodology the study utilised a three stage design to develop a 'bottom up' theoretical model allowing for constant member validation. Within this process, a total of 15 end of therapy interviews were conducted with nine clients who had received a course of individual CAT. The core conceptual framework, 'doing with' emerged from the analysis and was conceptualised to represent clients' subjective experience of CAT. This framework subsumed four main inter-related themes each interacting and influencing the other; 'being with the therapist', 'keeping it real', 'understanding and feeling' and 'CAT tools'. SECTION III: CRITICAL APPRAISAL The first part of this paper presents a synopsis, with personal reflections, of the research process from its origins to write up. The second part discusses the main learning experiences gained from the study.