Research has highlighted that a substantial minority of lesbian, gay, and bisexual (LGB) individuals are rejected (overtly and/or covertly) by their families because of sexual stigma. As such, LGB individuals may become estranged from their families-of-origin (LaSala, 2010). However, no rigorous qualitative research has focused on this issue. The present study addresses this gap in the literature and offers insight into the phenomenon of sexuality-related family estrangement, via a sample of eight LGB adults (aged 18-41) currently experiencing it. The data was collected through individual, semi-structured interviews (60-90 minutes long). A pilot (n= 2) was conducted first to ensure the interview questions were effective, clear and sensitive. The data was analysed using Interpretative Phenomenological Analysis (Smith & Osborn, 2007). The findings provide insight into individuals’ perspectives on estrangement, the consequences of estrangement, and coping with estrangement. The implications for Counselling Psychology practice with estranged LGB individuals is discussed. Ideas for future research are offered. Personal and epistemological reflexivity have been of paramount importance throughout this research (Willig, 2008) and are explored in detail.

One might presume that human beings would benefit in psychological and indeed relational terms from studying sexual behaviour. Yet research on the female orgasm only gained momentum in the mid – late twentieth century (Kinsey, 1953; Krantz, 1958; Masters and Johnson, 1966). The latter piece of research was conducted at the time of the second-wave feminist movement, which “took up arms” in the clitoral vs. vaginal orgasm debate (Freud, 1931, as cited in Rieff, 1997). It was advocated by feminist writers that female orgasm resulted from clitoral stimulation, which controversially challenged the notion that it occurred in the context of heterosexual penile-vaginal stimulation, through sexual intercourse for reproductive purposes. Since this time the body of research on female orgasm has grown, but it is still limited, and has primarily taken a quantitative approach. This research was conducted in part, and in response to the paucity of qualitative research in this area, as well as the more recent medicalization of female sexual “problems”, and the continued oppression and abuse of female sexuality through pornography and practices such as female genital mutilation (FGM). A non-clinical sample of eight women were recruited and semi-structured interviews were conducted in order to answer the following research question: “What is the lived experience of reaching female orgasm in the context of a sexual relationship?” An interpretative phenomenological analysis was carried out on the data. Three superordinate themes emerged; “Anticlimax”, “This is my orgasm”, and “The challenge of our orgasm”. The women experience this phenomenon through a sense of control and restriction related to painful emotions including anxiety, anger and shame; through a developed sense of freedom in understanding and learning how to satisfy their own sexual needs; and through a contradictory experience of personal freedom versus a female – male relational power dynamic experienced as dominated - dominant respectively. The phenomenon is also made sense of through the concept of romantic love. This study has been successful in answering the research question and highlighting the need for further qualitative research on the female orgasm. The research is applicable and important for the field of counselling psychology because it highlights this complex phenomenon as both an intrapsychic and inter-psychic experience, which can be made sense of through the “lens” of multiple psychological theories. It has implications for psychotherapeutic practice, e.g. sex and relationship therapy, and will also be of interest to other sub-disciplines such as evolutionary psychology and feminist psychology. Limitations of the research are discussed as well as recommendations made for further research.

Research indicates that premenstrual syndrome (PMS) can have a negative impact on various areas of life, including interpersonal relationships, productivity and emotional well-being. Existing research in the area of PMS is largely quantitative and has been conducted using a positivist framework; the few qualitative studies undertaken have examined women’s individual experiences of PMS. Further, studies highlighting the relational impact of PMS have largely focused on marriage quality and have employed quantitative methods. These studies have investigated relational experiences of PMS from an individual perspective, or have looked at non-heterosexual relationship contexts, including lesbian relationships. Little attention has been paid to examining in depth, the relational experiences of heterosexual couples who experience PMS. The current study, therefore, aims to provide insight into the lived experiences of PMS among heterosexual couples by taking a qualitative approach. Interpretative phenomenological analysis (IPA) was used to explore the experiences of seven couples (14 participants) who either identified themselves or their partner as suffering from PMS. Semi-structured joint interviews were undertaken, in which the experiences of couples living together with PMS were discussed. The interviews were analysed using IPA and three superordinate themes emerged from the data: (1) The “curse” of PMS; (2) Connection and disconnection: the importance of communication and intimacy; and (3) Beyond the couple: social influences on the relationship. These themes support the conceptualisation of PMS as an overwhelming emotional experience that leads to confusion and isolation within the couple. It can also be seen as creating difficulties in communication, empathy and intimacy, which are reinforced by the social norms and stigma surrounding PMS. The current study aims to give a detailed relational account of PMS, which can be argued is missing from the existing literature. A perceived limitation of this study is its reliance on the joint accounts of a small sample of self-selecting cohabitating heterosexual couples. This could lead to various other couple relationships being excluded from the study. Nevertheless, the importance of the current findings and the implications for future research are discussed and suggestions for the clinical practice of counselling psychology are highlighted.

Mental health problems are common and complex in children in care and most have mental health needs that resemble clinic referred groups. Deficits in relationships and poorer educational outcomes are identified in the population yet services are often poorly matched to levels of need. The mental health and relationship problems of 39 children in family foster care, aged 6 to 13 (mean age 8.4 years) was assessed on Teacher and carer report as well as concordance in service use and mental health need. 1 in 10 children in care had significant mental health problems compared with 1 in 20 peers. Social problems occurred more frequently than any other mental health problem, identified in two thirds of boys and over half of girls in foster placement and one third of boys and less than one in ten girls in school. More externalizing problems were detected than internalizing problems suggesting emotional distress can be missed in the population. Relationship problems were a significant concern for one in four children in care in school and one in five in foster placement and associations were found between relationship problems and mental health indicating the potential buffering role of relationships for emotional wellbeing. The low to moderate concordance in mental health need and service use and the few contacts with mental health agencies suggests that problems are not being sufficiently targeted in the population while the high rate of contact with GP raises questions about the health of the sample. Almost a quarter of children had no contact with their caseworker suggesting unmet social service need and the unavailability of an important gateway for children to access supports. 36.6% of children in care needed extra educational supports yet only 2.4% received educational psychology provision confirming high educational risk and unmet educational needs. Findings confirm the importance of including school systems in mental health assessment and intervention in the population. Other research implications include the need for systematic studies with representative samples to capture the mental health of the looked after population in general, the need for multi agency supports and tiered entry to services to address the critical gaps identified in existing service provision for children in the looked after system.

There is a plethora of literature on older adults and psychological counselling. The literature reveals many assumptions and opinions of healthcare professionals and academics regarding older adults’ decision to enter into counselling or not and advice on how counselling should be conducted with older adults. Yet, there is an absence of the voices of older people in narrating their counselling encounters. This qualitative study explored how six older women constructed their decisions to enter into counselling and their experiences of counselling. Although the study was open to both older men and women, only women expressed an interest in participating. Narrative interviews were therefore conducted with former female clients of a mental health charity aged between 66 and 74. Interviews elicited individuals’ stories of counselling and a critical narrative analysis approach was used to examine each narrator’s story. From this analysis, three overarching themes and corresponding subthemes emerged across the six narratives. Accounts highlighted the significance of generational and cultural factors in narrators’ expectations of counselling and subsequent decision to enter into therapy. Narrators revealed long-standing patterns of projecting an outward image of wellbeing whilst struggling to manage difficult circumstances and emotions. This was often linked to generational attitudes of selfsufficiency, independent problem solving and emotional reticence. Narrators also worried about burdening loved ones with their problems. Decisions to enter into counselling were constructed within this context of emotional isolation. Furthermore, findings highlighted the significance of people or services influencing narrators’ access to counselling. Counselling was constructed as an opportunity to focus on hearing one’s own thoughts, without outside voices impeding. Narrators also constructed identities from passive patients at the start of counselling to emerging active agents of change both in the therapeutic context and in their wider lives. Dominant cultural narratives of mental health problems and counselling were also discussed with reference to narrators’ stories. The implications of the study’s findings for referrers and counselling psychology practice were explored.

The aim of this study is to explore how individuals with an acquired facial disfigurement (FD), following a traumatic accident or illness, psychologically reconstruct themselves using a narrative analysis. Whilst previous studies on visible difference have employed both quantitative and qualitative based methodologies, there is only a handful of research in the psychological literature that specifically explores the subjective experience of people with facial cancer and facial trauma. In particular, there is a lack of attention on how this population reconstruct their internal world and make sense of their FD. Narrative analysis was used as a way of gaining an insight into the ways that these individuals reconstruct themselves and make meaning of their disfigurement. Thus, a sample size of seven individuals who had acquired a disfigurement either as a result of an accident or facial/oral cancer took part. Participants were interviewed using semi-structured interviews. Findings revealed the following narrative genres: 'the outsider', 'the helpless prisoner', and 'the wounded survivor'. In the genre of 'the outsider', participants presented themselves as vulnerable and submissive protagonists who were humiliated, persecuted, and ostracised from the rest of society. The genre of 'the outsider' demonstrates how the consequences of living with a FD and of being a constant victim of social disgrace can leave a profound impact upon one's sense of self and identity. In the genre of 'the helpless prisoner' protagonists shared their stories of living a restricted life and their stories were characterised by stagnation, helplessness, and a sense of isolation. Finally, in the genre of 'the wounded survivor', protagonists portrayed their lives as a series of challenges that provided them with an opportunity for growth, acceptance, and compassion. The findings of this study are put in the context of counselling psychology and clinical implications are discussed.

Access to health care is a serious problem in Sierra Leone, more so in rural areas where living standards are low and there is absence of health care facilities. Health insurance, it is argued, will play an important role in giving access to medical care and reducing the high out of pocket (OOP) health expenditure, thus preventing unnecessary deaths and increasing well-being. It is however difficult to know the exact value households place on health and health care as they are not generally exchanged in the market place. For this reason, nonmarket valuation is increasingly becoming an important tool for informing policy makers. The Contingent Valuation and Discrete Choice Experiment (DCE) are the most widely used methods. However, due to its increased popularity, the ability to calculate incremental benefit of each attribute used, and it proving to be more appealing, this work therefore used the DCE method to collect data. This study provides the following: first, a review of the application of DCE to health outcomes including health insurance for the period 1990 – 2013; second it estimates the willingness to pay (WTP) for health insurance; third, it estimates the impact of corruption on participation in health insurance; and finally, it looks at ability to pay (ATP) for health insurance among informal sector workers in Sierra Leone using a DCE method. The four essays/papers (Chapters 2 – 5) represent the main outcomes of this research. Eight informal sector activities were selected namely – petty trading, subsistence farming, commercial bike riding (“okada”), cattle rearing, fishing, tailoring, alluvial mining and quarrying. More precisely, the first empirical paper used a random effect logit model to estimate households’ WTP for health insurance for an improvement in coverage, choice of provider and a reduction in waiting time. The second empirical paper on the impact of corruption introduces two definitions of corruption – perceived and actual (free health care). The study used the mixed logit (MXL) model to estimate the impact of corruption on households’ participation in health insurance. The final empirical paper on the other hand looked at ability to pay for health insurance. This paper is built on the assumption that simply perceiving need for health insurance is insufficient for someone to participate in it. Participation in health insurance is backed by the financial ability of the household to pay for health insurance. This study used two approaches: a univariate probit (naive) model and a recursive bivariate probit method (RBPM). We use data from discrete choice experiment to estimate ability to pay for health insurance. Conditional on a set of covariates, the findings of the thesis suggest the following: first, that households are willing to pay for health insurance for an improvement in coverage, choice of provider (public and non-public) and a reduction in waiting time; second, that corruption generates substantial additional cost to households, hence the higher WTP to participate in schemes with evidence of corruption, more so, actual (free health care) corruption; and finally, that households do not have the financial capacity to pay for health insurance. Our result also shows that households that perceived NEED do not only have the ability to pay for it but are also not likely to participate in the scheme.

The aim of this study was to qualitatively explore experiences of emotional suffering subsequently diagnosed as depression from the perspective of adults who had been diagnosed with depression at some point in their lives. The focus of the study was to unearth some of the rich experiences participants underwent at the time of their pre-diagnosed depression, with particular attention being paid to experiences not documented in depression classification manuals. Ten adults who had been diagnosed with depression and treated within the last three months participated in this study. Data was gathered through individual, face-to-face, semi-structured and recorded interviews and analysed with an interpretative phenomenological analysis (IPA). Eight superordinate themes emerged from the data relating to how participants experienced pre-diagnosed depression and to the connection of possible life events to it: 1. Totality of life at the time 2. Embodied distress 3. Trapped in head 4. Severed social and emotional connections 5. Transformation of identity 6. Dissociation 7. Belief in a higher force 8. Disciplining the self The research also discussed these themes in relation to possible triggers and maintaining factors in the participants’ pre-diagnosed depression, how prediagnosed depression was experienced and those aspects which led to development of coping strategies. This study has provided an insight to lived experiences of emotional suffering subsequently diagnosed as depression and can, therefore, be useful for counselling psychologists when working therapeutically with those emotionally distressed clients diagnosed with depression. Further studies can use the knowledge gained to further theory development in this area.

The portfolio examines the older adult experience of psychological therapy. The research study is from the older adult perspective and it provides a rich narrative and strengthens theory and practice links. This research explored older adult service users’ retrospective accounts of Psychological Therapy within a secondary care service. The aim was to enhance the knowledge base and understanding of what is known about older adults’ subjective experiences of the processes involved when receiving Psychological Therapy. A qualitative methodology was chosen to allow the older adult participants to express their thoughts and feelings using unstructured interviews. The Grounded Theory analysis revealed categories and themes which produced a theory that explains the process of therapy. Nine older adult participants volunteered to take part and a grounded theory analysis of the data yielded a core category of ‘moving towards equanimity’. The category can be understood as contributing to the older adult participants regaining emotional stability, mental calm and balance. Within the Professional Practice section the case study features the complexity of the therapeutic work with an older adult who experienced depression and insomnia. The case examines the flexibility in the use of the therapeutic model and the core skills required within a strong therapeutic relationship which helped the older adult hold onto hope. The final part of the portfolio is a critical review about older adults and the therapeutic alliance. The review examines studies that have explored this extensive research area to raise awareness of the factors that influence the development of the alliance with older adults.

Overview: Currently service users views are included as part of the diagnostic construction. The impact of mental health language is difficult to explore as terminology is shifting through the decades. The term madness has survived. Therefore constructions of this term and its societal and subjective consequences can be investigated. Objectives: The objective of the study was to investigate what constructions are held in regards the term ‘madness’, as well as the perceived ‘function’ of those constructions from the perspective of mental health service users. Design: A qualitative methodological approach was used to deconstruct the term ‘madness’ using Discourse Analysis. The term was chosen as it represents a long-standing construct that has not changed over time unlike current mental health terminology. Service users were asked to share their constructions of the term as current literature on the topic is lacking from the mental health service user perspective. Method: Following NHS Ethics approval, participants were selected from Service User Involvement Forums in West London using opportunistic sampling. Individual (n=3) and Group (n=4) semi-structured interviews were used. Discourse Analysis methodology formed the analytic procedure. Results: The term ‘madness’ can be placed within a continuum of similar terminology such as insane or crazy but the use of the term has varied functions: 1) Flippant, non-offensive, non-labelling term; 2) Labelling and harmful, with or without intention to do so; 3) An accurate description of ‘an experience’; and 4) Labelling but positive, indicating creativity/uniqueness. Conclusions: The term ‘madness’ is not clinical, though clinical terms may be translated as ‘madness’. The term can be harmful when misused (e.g. through the media). The term is most helpfully re-claimed and re-constructed by service users, in order to encourage acceptance. A change in clinical philosophy, re-thinking the use of clinical language as well as re-considering normalising, and suggesting opportunities to encourage transparent working are promoted.