Chronic kidney failure affects approximately 30,000 people in the UK (Stein and Wild, 2000). In addition to the physical impact this has, negative psychological consequences can also arise (Rodrigue, Mandelbrot & Pavlakis, 2011; Christensen & Ehlers, 2002). Treatment options involve either dialysis or kidney transplant, with living kidney donation being a viable option. The condition and its treatment affect not only the patient but also those close to them, potentially impacting on their relationships (Crombie & Franklin, 2006; Gill & Lowes, 2008; Reimer et al., 2006). This thesis is made up of three chapters:- Chapter one presents a critical review of the research on Cognitive Behavioural Therapy (CBT) interventions in renal patients. It discusses the areas in which CBT has been applied, highlighting the focus on fluid adherence behaviour, sleep difficulties and psychological aspects such as depression. Many of the articles report promising findings, suggesting CBT to be potentially beneficial to the renal population. The review highlights many of the limitations of the current literature and identifies directions for further research. Chapter two presents an empirical study exploring the experiences of living kidney donors, donating to a spouse or partner. The paper focuses on gaining an understanding of the donor’s experience of their relationship with the recipient, using Interpretative Phenomenological Analysis. Findings revealed four superordinate themes comprising of: transitions within the relationship, defences against distress, conflict of motivation to donate and reduction in uncertainty and return to normality. Clinical implications of the findings and directions for further research are discussed. Chapter three is a reflective paper highlighting some of the issues which arose for the researcher during the research process. This paper considers the development of knowledge and skills required for research and may be beneficial to future researchers in the area.

Many who suffer with anorexia nervosa (AN) lack the motivation to change, partly explaining why it is difficult to engage them with psychological services. This thesis explores whether it is possible to increase motivation to change and improve engagement with services, and how this might be achieved. More specifically, chapter one is a meta-analysis which attempts to identify whether interventions were effective at increasing motivation and readiness to change and whether there is a difference between certain treatment approaches in terms of this. Comparison between approaches other than treatment as usual (TAU) and motivational interviewing (MI) was not possible given the available evidence. Analysis showed that motivation to change significantly improved in the TAU and MI groups. This increased most in the MI group, but further research would be needed to establish whether any difference between treatments was significant. Chapter two describes a qualitative, grounded theory study, whereby the thoughts and opinions of eight participants across two inpatient units were sought about factors that help or hinder engagement with services. A dynamic model was developed to reflect some of the intra and inter-personal factors that participants described as influencing the process of engagement with services. The model included eight categories, namely: opportunity; self-awareness; self-efficacy; expectations; self-esteem; distress; safety and security of AN; and service. Within the service category, participants described various actions that teams could take to facilitate engagement with services, including involving other patients, demonstrating genuine interest, providing plenty of information and various types of support, as well as promoting the empowerment of service users. This manner of working should ideally impact on each of the factors that participants described as being important to engagement. The third chapter provides some of the author’s reflections on the process of knowledge accumulation, and limitations of research, including some of the political and contextual considerations that are likely to influence what is studied and reported.

Chapter one examines the literature concerning the potential consequences of selfstigmatisation in individuals with schizophrenia and related disorders. Eighteen international papers concerning the impact of self-stigma on a range of psychosocial outcomes are reviewed in detail. Methodological limitations of the research base are considered, including the inappropriate measurement of self-stigma and the need for a greater number of longitudinal studies incorporating more sophisticated statistical analysis. The clinical implications of the findings are considered including the need for greater awareness of the consequences of self-stigma amongst mental health clinicians. Areas for future research are also proposed. Chapter two reports on an empirical investigation into the experiences of young British Pakistani women recovering from psychosis. Five women were recruited from a UK Early Intervention Service to participate in semi-structured interviews. Interviews focused on the women’s beliefs about their experiences, the factors they believed had facilitated their recovery and the impact of their experiences on their sense of self and feelings about the future. Interview data was analysed using Interpretative Phenomenological Analysis. Four super-ordinate themes emerged from the data. These themes were largely consistent with findings from other qualitative studies in early psychosis. The clinical implications of the findings are discussed including the need for clinical staff to engage meaningfully with service users’ explanatory models of psychosis and to establish effective working alliances with their families. Methodological limitations of the study and areas for future research are considered. Chapter three contains therapeutic letters written by the author as part of an exercise in reflective writing. The letters contain personal insights gained throughout the course of the research and reflections on the emotional experience of conducting research interviews.

Formulation has been established as a core competency in Clinical Psychology training. There is a small but growing evidence base demonstrating the benefits of its use from the perspective of clinicians. However, there are few empirical studies investigating formulation use with children and adolescents. In addition, there is little known about the client's experience of cognitive-behavioural theraphy (CBT) formulation. This thesis explores formulation in Psychological Therapy. The first paper reviews the use of formulation within the child and adolescent literature. The key components within a formulation, key factors of formulation which should be explored with children and the clinical utility of formulation are described and discussed based on the extant literature. The research highlights the need to consider developmental milestones, collaboration with families and to consider the child's wider system when formulating. Formulation appeared to be a trans-theoretical concept, occuring throughout the assessment-intervention continuum. However, more empirical research is needed to understand these findings further. The second chapter is an interpretative phenomenological analysis exploring CBT formulation with clients who have depression. Themes were identified highlighting how formulations were developed, that formulations were difficult to receive, although, after some time participants reported many positive feelings and reactions towards their formulation. It seemed that sharing initial difficult feelings with their clinician was difficult. Although several benefits of formulation were established such as, making a new sense of oneself, better control and perspective over feelings and thoughts. Research limitations and suggestions for future research are made. The final paper provides a reflective account on the challenges of working from a scientist and clinician perspective during the research process. The challenge of maintaining a balance between the two perspectives is discussed within the context of generating a research idea, recruitment, interviewing and writing up the empirical paper.

Anorexia and bulimia are serious mental health problems. Guidelines (2004) from the National Institute for Health and Clinical Excellence (NICE) highlight how disabling these eating disorders can be as they have an impact on mood, self-esteem, social relationships and physical health. Both disorders are associated with a higher risk of developing coronary heart disease (Lissner et al., 1991) and the mortality rate for anorexia is estimated to be three times higher than other psychiatric problems (Nieslen, 2001). This may partly explain why eating disorders are subject to extensive research. This thesis focuses on areas that have attracted less attention. Chapter one examines literature on the impact of fathers on daughters’ disordered eating patterns. Studies suggested that paternal personality traits and daughters’ perception of this relationship affect eating behaviours. It remains unclear whether paternal variables act as specific risk factors or are risk factors for the development of psychopathology more generally. Longitudinal research is needed to establish this. Chapter two explores how changes in emotional processes and emotions affect the trajectory of anorexia and bulimia. This study involved interviewing eight therapists about their experiences and creating a grounded theory that illustrated the trajectory of both disorders from an emotion-focused perspective. According to therapists, the eating disorder appeared to function as an emotional regulation strategy that helped clients suppress or avoid emotions. Clinicians reported that emotional processes and clients’ relationship to their emotions changed during therapy. Individuals appeared to find alternative ways of managing emotions and these changes seemed to support the journey of recovering. Chapter three offers a reflective account on pertinent issues which arose while conducting the research study. This paper includes reflections on methodological considerations, ethical issues and the impact of this study on my practice as a trainee clinical psychologist.

Although dreams have fascinated humans for millennia, the function of dreams and nightmares is a matter of ongoing debate in the fields of neurophysiology, evolutionary psychology and cognitive psychology. Some authors argue that nightmares are purely a by-product of neurophysiological processes that occur during sleep, whilst others suggest that they serve some kind of adaptive function. What is widely recognised, however, is the link between nightmares and psychological well-being. Research indicates that clients frequently bring dreams to therapy and that dream work can improve the psychological wellbeing of individuals who are experiencing distressing dreams. Clinicians do not have a great deal of training in dream work, however, and do not always know how to approach working with dreams. Chapter 1. The first chapter offers an overview of the theories proposing that dreams and nightmares play a role in affect regulation. Subsequently the empirical evidence for these theories is critically appraised and synthesised. Some support is offered for the overnight mood regulation theory of dreaming, and there is contrary evidence to suggest that nightmares negatively impact on mood and behaviour. Chapter 2. The second chapter reports on the findings from a mixed methodology design. Initially the prevalence of dream work across three NHS Trusts in the UK was investigated through a questionnaire-based survey. Secondly, the experiences of clinicians who use dream work in therapy in the NHS were explored through indepth semi-structured interviews. Five main themes emerged from the qualitative analysis of the data: benefits of using dream work, barriers to using dream work, dream work in practice, personal experience of dreaming and dream work and dream work in the wider context. Chapter 3. The third chapter explores the lead author’s own dreams over the duration of the research process, specifically examining these in light of dream and dream work theory.

This thesis examined influential factors in the development and maintenance of eating disorders. The first chapter investigated homosexuality as a predisposing factor in the development of anorexia and bulimia nervosa in males by considering the published literature on this subject. The implications of the role of homosexual culture in the treatment of males with eating disorders are examined. The main study used techniques from grounded theory to examine the subjective experiences of women with anorexia and bulimia nervosa regarding the influence of media in the development and maintenance of their disorder. Semi-structured interviews were conducted with nine women and data collection and analysis were carded out until a point of saturation was reached. A model was developed to explain the relationship between media influence and eating disorder development and maintenance. Clinical implications and avenues of further research were explored. The brief paper examined the stories of women with anorexia and bulimia nervosa about the development of their eating disorder using narrative analysis techniques. Three semi-structured interviews were analysed and the ways in which the women made sense of their eating disorders were examined. Clinical implications were also discussed. The final chapter explored the researcher's reflections on the research process focusing on methodological considerations and personal reflections of the researcher.

Eating disorders are notoriously difficult to treat, and anorexia nervosa has the highest mortality rate of all the psychiatric illness (Gremillion, 2003). Therefore this client group can present challenges to clinicians working with them. Those working in the area of eating disorders require research with clear clinical implications, to improve treatment and outcomes. The thesis will attempt to provide such research, with clearly stated clinical implications for treatment. The first paper in this thesis reviews the literature on the link between shame and eating disorders. This paper defines shame, then explores studies identifying the differences or similarities between shame and other self-conscious emotions, such as guilt, embarrassment and humiliation. The paper then explores the link between shame and eating disorders. The second and main paper is an empirical paper exploring shame and pride in a clinical population with a diagnosed eating disorder. The third paper explores 'pro-anorexia' websites to access whether such sites offer any advice or support that could be considered positive. The final paper is a reflective paper which explores my research journey.

Background: Obsessions and compulsions are the two core features of Obsessive-Compulsive Disorder (OCD). Mild and infrequent obsessions and compulsions are common. Persistent and distressing obsessions and compulsions of the kind seen in OCD occur in far fewer people. As is the case with other psychiatric disorders, many people with OCD do not seek help. Clinical observation suggests that help-seeking delay in OCD is substantial, averaging eleven years. A proliferation of research studies of non-OCD patient participants has arisen from the observation that some people in community settings have clinically significant obsessions and compulsions. Conversely, there is little research that considers why people with obsessions and compulsions delay help-seeking and why this morbidity may be missed. Aims: This thesis examined attitudes to obsessive-compulsive (OC) problems, the existence of obsessions and compulsions in non-psychiatric groups, the profile of OC features in a clinical OCD group, and the help-seeking and treatment experiences of people with OCD. Its primary focus was to discover barriers to disclosing obsessions and compulsions in order to seek help. Findings: Dermatology and obstetric outpatients and students exhibited obsessions and compulsions comparable to those evidenced by people with OCD. The content of an OC problem influenced judgements of fear and shame about disclosing the problem. People with OCD delayed seeking help because of fear, shame and lack of knowledge. Concealment had occurred in the hope that the problem would go away, or from fear of the reaction of others. Feelings of embarrassment and shame were pervasive. Implications: Continued research on public attitudes to OC problems and on the help-seeking experiences of people with such problems is necessary. Raising public awareness of obsessions and compulsions and their treatment may reduce stigma and fear. Ultimately, concealment is problematic for the person with obsessions and compulsions, and for the conceptualisation of OCD.

This thesis describes the first British empirical study in relation to therapist-patient sexual contact. North American research has suggested that a substantial minority of mental health professionals engage in such contact with their patients, and that both situational and characterological variables contribute to the sexualisation of the therapeutic relationship. A number of theoretical models are relevant to developing an understanding of this problem, including reversal theory, psychodynamic theory, and Finkelhor’s (1984) four precondition model of sexual abuse. A national random survey of clinical psychologists produced 581 usable responses. Under 4% reported sexual contact with patients in therapy or who were discharged. A substantial minority reported that they had treated patients who had been sexually involved with previous therapists, or that they knew through other sources of clinical psychologists who had engaged in sexual activity with their patients. Logistic regression analysis revealed that homosexuality, sexual involvement with educators during postgraduate training, and longer postqualification professional experience predicted sexual involvement with patients. Responses to a small number of open-ended questions suggested that whilst the majority of respondents did not view sexual attraction to patients as inappropriate, a minority actively avoided it for ethical reasons. The majority of respondents who had not engaged in sexual contact with patients refrained from such behaviour for ethical reasons, but the responses of a minority suggested that were the opportunity to arise, or were negative consequences removed, they might engage in such behaviour. A minority of respondents were unaware of their duty to report colleagues engaging in such behaviour. It is concluded that efforts to prevent therapist-patient sexual contact should focus on education, particularly in respect of codes of conduct, and that further research is required to enhance our knowledge of predisposing factors.