Anorexia nervosa is a serious, life threatening mental disorder that is difficult to treat. Research suggests that the therapeutic relationship is an aspect of therapy that is valued by recipients of eating disorder services and viewed as essential in the quality of any treatment undertaken. Establishing a helpful therapeutic relationship can be equally challenging for both the therapist and the client. Additionally, what the nature of the therapeutic relationship needs to be is often unclear and there is limited research into this aspect of the therapeutic relationship from the perspective of adults with anorexia nervosa specifically. Therefore, the aim of this study set out to answer the research question: • What is the nature and context of the therapeutic relationship from the perspective of adults with anorexia nervosa? Following a constructivist grounded theory methodology, elicited written data were gathered from adults with anorexia nervosa using asynchronous online research methods via a bespoke confidential website. The participants were recruited through the eating disorder charity Beat. Additional existing autobiographical material including books and online blogs were also used as supplementary data. Data collection and analysis was carried out over three phases. Three theoretical categories were constructed that explicate the significant aspects of a positive therapeutic relationship: Balancing control in the therapeutic relationship; Developing trust; and “They just got me” - feeling understood by the therapist. The central category of individuality or “one size doesn’t fit all” underpins these categories, hence requiring a therapist to tailor the therapeutic relationship to the individual. In conclusion, this study offers a substantive theoretical understanding of the critical aspects of the therapeutic relationship as described by adults with anorexia nervosa. These factors have utility across a range of recommended psychological therapies for anorexia nervosa and could be usefully deployed by any health, social care or education professional.

Multiple sclerosis (MS) creates numerous ongoing challenges which, for some, result in negative outcomes such as depression, poor quality of life, and impaired functioning. This thesis aimed to investigate the nature of psychological adjustment to MS and elucidate factors that interventions could address in order to promote successful adjustment. A review of the theoretical literature on chronic illness and a systematic review of the empirical MS literature suggested that various theoretical approaches are useful for explaining aspects of adjustment to MS but no single existing theory offered a comprehensive framework. An integrative cognitive behavioural model of adjustment to MS was proposed and elements of this were examined in the empirical chapters. In an initial qualitative study, people with MS (n=30) were interviewed about their experiences of living with the disease. Inductively-derived themes characterised the context and process of adjustment and the resources, actions, thoughts and feelings that have a bearing on it. Findings supported and elaborated on the model, and new insights were used to revise it. The quantitative studies were nested within a trial of interventions for adjustment to MS (n=94). A cross-sectional study using pre-therapy data found that cognitive and behavioural variables explained substantial variance in distress and functional impairment. Unhelpful beliefs and behaviours relating to MS itself (illness perceptions and responses to symptoms) appeared most relevant for explaining functional impairment. Beliefs about the self and about experiencing and sharing emotions were important correlates of distress. In an analysis of change within the treatment trial, reductions in unhelpful cognitions and behaviours mediated the improvements observed within interventions. Cognitive and behavioural variables also moderated the effects of the interventions on outcomes. A final qualitative study (n=30) explored participants‘ experiences of the adjustment interventions. The set of interlinked themes provided insights into the broad range of positive outcomes of interventions, perceived therapeutic processes and factors that appear to promote engagement in interventions in this patient group. Overall, the suggested cognitive behavioural model appears to be a useful means of understanding adjustment. This thesis pinpointed a number of potential cognitions and behaviours which may be important targets for adjustment interventions. Continued research efforts to understand factors that determine a range of adjustment outcomes and to determine what people with MS find helpful and appropriate is necessary for a more complete understanding of successful adjustment to MS and how it can be promoted

Health and social care professionals at are risk of developing symptoms of trauma as a result of supporting traumatised individuals. This is termed secondary traumatic stress (STS; Figley, 1995). This paper reviews the predictors of STS in health and social care professionals followed by a study of the predictors of STS and burnout in paediatric nurses specifically. The literature review aimed to obtain an overview of the main risk and protective factors associated with STS. A systematic search of the literature was carried out, 68 studies met the inclusion criteria and a narrative synthesis was then conducted. The most consistent evidence suggested that increased empathy predicted STS whilst social support appeared protective. Current life stress was also associated with STS but the evidence was limited by methodological issues. Tentative evidence was found for the role of coping styles and compassion satisfaction, whilst evidence for exposure to workrelated trauma, a personal trauma history and emotional detachment was inconclusive. These are discussed in relation to clinical implications and directions for future research. The majority of research regarding predictors of STS and burnout has taken place in professionals working with adult populations and there is a lack of research regarding paediatric nurses specifically. The empirical study’s purpose was therefore to identify the predictors of these conditions in this specialist group and to clarify whether paediatric nurses working in high-mortality risk departments 3 were at greater risk. A cross-sectional survey was conducted and 84 members of nursing staff participated. Emotional empathy and current life stress significantly predicted STS, whilst both predicted burnout in addition to a lack of support and behavioural disengagement. No differences in STS or burnout levels were found between departments. Clinical implications are discussed and it is concluded that hospitals would benefit from implementing additional training to support their staff.

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