Research suggests that people who experience mental health problems and people who hear voices are likely to experience stigmatising attitudes and discrimination. This portfolio considers the experiences and impact of disclosing these stigmatised experiences, both to immediate family, friends, and partners, and to people in wider society. The portfolio has three parts. Part one is a systematic literature review which considers the impact/effect of disclosing mental health problems by reviewing the literature base. Twelve articles which aimed to answer the research question were quality assessed, then compared and contrasted in order to provide conclusions and offer recommendations for future research and clinical practice. Part two is an empirical study which enquires into the personal experiences of people who hear voices using Interpretative Phenomenological Analysis (IPA). Six participants were interviewed about their experiences of talking about hearing voices with family, friends, and other people they considered close to them. Themes were developed from the interviews and conclusions were drawn about future research and clinical implications. Part three of this portfolio contains the appendices, consisting of supporting documents from the literature review and empirical study, along with both epistemological and reflective statements.

<p> Emotion dysregulation, or difficulties regulating one's emotions, has been increasingly identified as a transdiagnostic factor that can increase risk for and maintain a wide range of psychiatric disorders (Fernandez, Jazaieri, &amp; Gross, 2016). Emotion malleability beliefs represent a potent psychological factor that relates to emotion regulation and, relatedly, holds important clinical implications for our conceptualizations of and treatment for a range of psychiatric disorders. The current dissertation includes one literature review and four empirical investigations that used an array of methodological approaches and possess different clinical and theoretical emphases to deepen and broaden the established influence of emotion malleability beliefs on emotion regulation and mental health.</p><p> Chapter 2 provides a theoretical model and discussion of how emotion malleability beliefs could aid in our understanding of several clinical disorders and could be harnessed to enhance motivation for and engagement in psychological treatment. The study described in Chapter 3 is an experimental investigation in which we demonstrate that emotion malleability beliefs can be experimentally manipulated and such an induction can exert a significant influence on individuals' state emotion regulation when coping with unwanted negative affect. The study presented in Chapter 4 consists of a longitudinal investigation that examines how emotion malleability beliefs relate to emotional experiences, emotion regulation, and clinical symptoms in first-year college students. The investigation included as Chapter 5 is of a daily diary study that elucidates how emotion malleability beliefs are tied to daily emotional experiences and emotion regulation as currently depressed individuals. Finally, the experimental study described in Chapter 6 clarifies how beliefs about emotion's malleability relate to treatment willingness, perceptions of agency over depression, and beliefs regarding prognosis. Overall, the work presented in this dissertation complement and extend past work on the role of emotion malleability beliefs in how individuals navigate their emotional worlds and cope with unwanted emotional experiences with the ultimate goal of promoting psychological adjustment and attenuating psychological distress. Future directions for theoretical and empirical work in this domain are presented in Chapter 7.</p><p>

Making evidence-based treatment recommendations is very important for clinicians across all medical specialties. This becomes increasingly difficult when taking into consideration the specific characteristics of each individual patient. Most evidence-based knowledge comes from randomized control trials, which often overlooks unique individual concerns. A single case methodology, which assesses treatment responses in individual patients, allows clinicians to collect statistically rigorous data, but also assess improvement in individual patients. In our investigation we show that a single case methodology, using four different analyses, can be applied to assess the efficacy of a CBT intervention delivered to pediatric chronic pain patients. We demonstrate that such a methodology, when we combine results from multiple statistical tests, allows us to make conclusions about treatment responses. Furthermore, we show that our intervention targets several different issues chronic pain patients face, in particular the avoidance of painful activities. While we did see congruence of results across the different statistical analyses, there were also several examples of inconsistency. These inconsistencies seem to occur when patients show considerable variability in their responses to the questions on the daily measures, introducing ‘noise’ that made detecting ‘true signal’ (treatment response) quite difficult.

Human and non-human animal studies indicate that the reconsolidation of conditioned fear memories can be interrupted, and return of fear attenuated, using a paradigm of memory retrieval coupled with extinction called post-retrieval extinction (PRE). This series of studies examined the efficacy of PRE for attenuating the return of fear in healthy and anxious individuals in order to inform translation of PRE to the clinic. Study 1 was a meta-analysis of 16 comparisons of PRE versus extinction in healthy human participants. My hypothesis that PRE would be more efficacious than extinction in attenuating the return of fear was supported (effect size g = 0.40). This effect was moderated by factors potentially related to memory strength. Accordingly, in Study 2, I tested a strategy to strengthen fear memories using a compound unconditioned stimulus for use in a subsequent study of PRE (Study 3). I hypothesized that the use of a compound unconditioned stimulus would improve rates of acquisition and differential conditioning levels in healthy participants (N=143, M(SD) age=23.0 (9.8), 59% female). My results confirmed that the use of a compound unconditioned stimulus enhanced rates of acquisition, but contrary to my hypothesis, did not enhance differential conditioning levels among those meeting threshold values for conditioning. In Study 3, I tested the relative efficacy of PRE in 49 healthy and 43 anxious participants (M(SD) age=23.0 (8.0), 71% female) who received either one day of acquisition followed by PRE or extinction, or three days of acquisition followed by PRE. I hypothesized that PRE would be more efficacious than extinction in attenuating the reinstatement of fear for memories conditioned over one day, but not for stronger fear memories conditioned over three days. Contrary to my hypothesis, no effect of PRE was observed on reinstatement of fear for participants who received one day of acquisition. Furthermore, PRE was not more beneficial for anxious participants who received one day versus three days of acquisition. In sum, the PRE effect size from this study was near zero and at the 11th percentile of those observed by meta-analysis; future research should continue to examine moderators of PRE effects.

This thesis portfolio comprises of three parts: Part one: a systematic literature review, in which the available research into personality disorders during the perinatal period is reviewed. A systematic search identified 11 studies for inclusion, the findings of which are reviewed in a narrative synthesis incorporating methodological critique. Conclusions are drawn and related to the wider literature, and implications for research and practice are highlighted. Part two: a qualitative study, in which the views of perinatal mental health staff were gathered to provide an insight into understanding of perinatal mental health problems and care. Three staff teams were interviewed using focus groups and thematic analysis was used to analyse the data, from which six themes emerged. These themes are discussed in relation to implications for practice and the wider research into perinatal mental health problems. Part three: appendices supporting the systematic literature review and qualitative study, including an epistemological statement and a reflective statement.

This study sought to investigate the construct of Relational Spirituality through: 1) identifying its correlates among demographic, spiritual, and parenting variables in a large, religiously and ethnically diverse sample of adolescents, and 2) investigating its associations with highly prevalent forms of psychopathology in adolescents. Participants were 615 adolescents representing a broad range of ethnicities (Caucasian, African-American, Asian-American, Latino, and multiracial, and other) and religious denominations (Catholic, Protestant, Jewish, Atheist, Agnostic, Buddhist, and other). The Brief-Multidimensional Measure of Spirituality/Religiosity, the Mysticism Scale, the Beck Depression Inventory and the Beck Anxiety Inventory were used to measure spirituality, depression, and anxiety, respectively, while frequency of alcohol use was ascertained with a single item. Parental relationship quality was measured using the Parental Bonding Instrument and the Parental Transparency Scale. Given that rates of depression, anxiety and spirituality have been demonstrated to be higher in girls than boys, gender differences in patterns of association were examined with respect to each type of psychopathology. Results of stepwise regression analyses revealed that exclusively in females, Relational Spirituality accounted for a significant portion of the variance in depressive symptomatology above and beyond demographic, parenting, and religious variables. Stepwise regression analyses also showed that Relational Spirituality contributed to a significant portion of variance in alcohol use above and beyond other correlated variables in both boys and girls. In contrast, Relational Spirituality did not contribute to the variance in anxiety; rather, the quality of religious social support was protective against anxious symptomatology. Findings suggest that Relational Spirituality is differentially associated with widespread forms of psychopathology in adolescents, and our understanding of these disorders may be enhanced through a spiritual perspective.

Posttraumatic growth (PTG) is a prolific construct under study within both trauma and positive psychology literature alike. Many of these studies rely predominantly on cross-sectional, retrospective self-report data. Recent studies have attempted to subject PTG to more rigorous scientific standards of measurement. In this study, we examined posttraumatic growth measured longitudinally among survivors of the September 11th, 2001 terrorist attack, in order to explore whether participants' reports of posttraumatic growth were associated with, supported or contradicted by friend ratings of improvement. In this context, participant-reported posttraumatic growth was consistently linked with friend ratings of deteriorating functioning, providing evidence that posttraumatic growth is undermined by friend ratings. These findings suggest that self-reported PTG may inadequately predict functioning as rated by alternative, more objective measures, and that PTG may reflect negative psychological adjustment.

The primary goal of this study was to investigate how psychotherapists in training develop a professional identity. Specifically, the aims were 1) to generate a theory that could guide thinking about this subject; and 2) to apply the knowledge gained to formulate ideas about the education of future psychotherapists. Twenty-nine doctoral students, recruited primarily in New York and California, were interviewed about their professional development. Qualitative analyses of the transcribed interviews (utilizing multiple methodologies, including the Listening Guide method) revealed normative aspects of, as well as individual differences with respect to, identity formation. Specifically, within a professional and cultural context that poses specific challenges and demands, psychotherapist trainees continuously recreate their identities through the performance of four identity tasks: exploring, committing, feeling, and reflecting. Through engagement in these tasks, trainees develop a distinctive set of skills, ideas, ways of working, and professional attitudes, and a subjective sense of themselves as psychotherapists with a unique therapeutic style and presence. Conceptualized as a dialectical process of differentiation and psychological separation, this process appears to characterize the identity formation of all trainees. Differences in identity formation are conceptualized in terms of trainees' ability to flexibly shift among identity tasks in response to changing contextual demands and circumstances; this quality is termed fluidity and is seen as the result of the specific and changing interactions between trainees and the professional context within which they develop. Six different approaches to identity formation, termed identity configurations, were identified, reflecting varying levels of engagement in identity tasks. Specifically, two "dialectical identity configurations" were identified, representing the fluidity of identity that arises from shifts in engaging and coping with changing contextual demands. These dialectical identity configurations also promote the development of a therapeutic repertoire that is unique, reflective of trainees' abilities and interests, and deeply meaningful. In contrast, four "non-dialectical identity configurations" were identified, representing coping with contextual challenges via a narrow range of relatively invariant responses. As such, these identity configurations are likely to interfere with the development of a therapeutic repertoire that is personal and emotionally resonant. Six case illustrations are presented to exemplify these ideas. Findings are explored in relation to other theories and models in the areas of identity and psychotherapists' development. In addition, implications of these ideas for training, including specific recommendations, are discussed.

The primary objective of this study was to examine clinicians' fidelity to a promising new clinical intervention known as Listen-Empathize-Agree-Partner (LEAP) that addresses issues of poor insight, therapeutic alliance, and treatment adherence prevalent in the schizophrenia population. A secondary purpose of this study was to assess the factor structure of a measure developed to examine the core principles of the LEAP method. Forty-eight mental health clinicians working in Assertive Community Treatment (ACT) programs randomized into intervention and control groups were assessed for fidelity to the LEAP method via the LEAP Fidelity Measure (LFM), a self-report instrument. Results revealed a three-factor structure of this measure which were labeled "Reflective Listening, Delaying and Opining," "Partnering on Shared Goals," and "Client-Centered Listening and Empathizing." Multivariate Analyses of Variance indicated that clinicians who were trained in LEAP had significantly higher levels of fidelity to the "Reflective Listening, Delaying and Opining" and "Partnering on Shared Goals" components than clinicians who were not trained in this method. There were no significant differences between the groups on the "Client-Centered Listening and Empathizing" component. Analyses did not reveal significant gender differences or effects based on years of general and specific ACT clinical experience between the two groups. However, in a post hoc analysis, a modest correlation between gender and fidelity to the "Client-Centered Listening and Empathizing" component showed that male clinicians tended to report higher fidelity to this specific set of interventions when compared to their female counterparts. These results are discussed within the context of feasibility in training and implementing LEAP in real-world community mental health clinical settings. Additionally, limitations of this study and implications for future research are discussed.

The primary aim of this study was to explore affective manifestations of cultural countertransference toward English-speaking Asian American clients in psychotherapy and to investigate the roles of therapist race and therapist racial attitudes. Fifty-six therapist participants completed measures of affective cultural countertransference toward and clinical assessments of a current client who is either White or Asian American. Participants also completed measures of racial attitudes toward Asian Americans as well as demographic questionnaires about themselves and their client. For the qualitative portion of data collection, five White psychologists were interviewed to further understand the relationship of these variables in White therapist-Asian American client dyads, the primary cross-cultural therapeutic relationship of interest. Thematic Analysis was used to explore qualitative data. Statistical results failed to show moderate or larger effect sizes for overall differences in cultural affective countertransference based on therapist-client race combination. Results suggest that White therapists experience similar levels of both positive and negative countertransference toward clients, regardless of race. Although qualitative data on White therapists reflected themes of racial biases consistent with Asian stereotypes of high competence and lack of sociability, quantitative comparisons distinguished that White therapists do not experience any more racial bias toward Asian clients than do Asian therapists. In fact, there was a trend suggesting the latter may experience more. For Asian therapists, countertransference in intraethnic dyads was strongly associated with Asian racial biases. There were a couple trends reflected in the quantitative data that should be interpreted conservatively given this study's methodological limitations, but, nevertheless, warrant further investigation: Compared to Asian therapists, White therapists experience more negative countertransference toward both White and Asian clients. White therapists' negative countertransference also showed small to medium associations with their racial bias against Asians. Qualitative evidence supported and expanded upon these trends: There was a dominant countertransferential theme among White therapist participants to counter Asian clients' culturally-syntonic drives for achievement and performance. Independent of therapist-client race, negative countertransference showed significant negative relationships to GAF, prognosis, and working alliance, while positive countertransference was positively related to prognosis and working alliance, as expected. Countertransference was also found to be related to client diagnosis, but not therapist theoretical orientation. The clinical, research, and theoretical implications of these findings are explored and limitations discussed.