Introduction Individual cognitive behaviour therapy for psychosis (CBTp) is a recommended treatment in the acute phase and beyond. However, less is known about the effectiveness of group CBTp in acute care. This mixed methods study explored the implementation and effectiveness of brief group CBTp with inpatients. Methods This prospective trial compared inpatients who received either a four week group CBTp program or treatment as usual (TAU). Participants (n=113 at baseline) completed self-report measures of distress, confidence and symptoms of psychosis at baseline, post-intervention and one month follow up. CBTp group participants also completed a brief open-ended satisfaction questionnaire. Results Participants who received CBTp showed significantly reduced distress at follow up compared to TAU and significantly increased confidence across the study and follow up period. Qualitative analysis of the satisfaction data revealed positive feedback with a number of specific themes. Conclusion The study demonstrates that brief group CBTp with inpatients can improve confidence and reduce distress in the longer term. Participants report that the groups are acceptable and helpful.

This thesis is submitted in partial fulfilment of a Doctorate in Clinical Psychology at the University of Liverpool. It focuses on the frequently reported finding of reduced specificity of autobiographical memory in participants diagnosed with depression (Williams & Broadbent; 1986, van Vreeswijk & de Wilde; 2004). That is, difficulty recalling the who, what, where and when, of a remembered event. The focus of investigation particularly within the thesis is that of executive functioning; a term describing a range of higher order cognitive functions that control and integrate other activities such as planning, sequencing, initiation. It is examined in relation to depression. The thesis is presented in paper form; Chapter 1 contains a systematic review of 9 research studies related to executive function in the memory specificity of participants with a diagnosis of depression. While executive functioning does appear to be related to reduced specificity the findings in the literature are not consistent highlighting the need for further research. The original empirical paper presented in Chapter 2 tests out hypotheses related to the claims of reduced specificity and executive functioning in participants with a diagnosis of depression (Burt, Zembar, & Niederehe, 1995). These hypotheses are based on the conclusions drawn from the review paper in Chapter 1. It concludes that while overall participants with a diagnosis of depression produce fewer memories overall, and particularly fewer specific memories, this difference can be reduced with modified materials which are more concrete and imaginable. These modified materials can also produce more specific memories overall. In addition, regardless of depression status, executive functioning has a significant impact on autobiographical memory specificity. These key findings are developed in an extended discussion in Chapter 3 and discussed in terms of their value and application to practices in clinical psychology. Chapter 3 also contains research dissemination for participants and a future research proposal expanding the scope of investigation from depression to trauma.

Dissertation submitted in partial fulfillment of Doctorate in Clinical Psychology. Includes three chapters; a narrative literature review of coping with minority stress in gay men, empirical study exploring the the benefits of self-compassion for well-being in gay men and a expanded discussion chapter.

Epilepsy, which affects 50 million people worldwide, is a chronic neurological condition characterized by a predisposition to generate spontaneous seizures. Antiepileptic drug resistance is a significant problem, the causes of which are poorly understood. Inflammation is purported to play a pathological role in the development of epilepsy following brain insult. High mobility group box-1 (HMGB1) has been implicated in the development of seizures and epilepsy in preclinical models and human studies. HMGB1 undergoes post-translational modifications, including acetylation and redox changes, which dictate its inflammatory extracellular function. Novel inflammatory blood biomarkers such as HMGB1 that are intricately involved in the epilepsy disease process per se may act as stratification markers to identify patients who may benefit from immunomodulatory interventions. This thesis aimed to characterise the role of HMGB1 in seizures and epilepsy and its utility as a clinical biomarker. Analysis of 24 healthy volunteers undergoing a 24-hour blood-sampling study did not demonstrate any significant circadian fluctuations in serum HMGB1. No intra or inter-subject variability was also observed in the biomarker. A further study involving patients with idiopathic intracranial hypertension (IIH, n=18), neuroinfection (n=15) and Rasmussen’s encephalitis (n=10) showed that there was no correlation between serum and cerebrospinal (CSF) fluid levels of HMGB1, regardless of blood brain barrier integrity. Subgroup analysis of bacterial meningitis showed that both CSF and serum HMGB1 was significantly elevated (as compared to IIH). Furthermore, CSF HMGB1 was more than 10-fold higher in those with bacterial (n=6) rather than viral meningitis (n=8). The expression pattern of HMGB1 acetylation and redox isoforms in brain and blood was examined in three distinct preclinical models of seizures and epilepsy including recurrent seizures and status epilepticus in the kainate-model, single seizure in the maximal electroshock test (MES) and chronic spontaneous seizures in the pilocarpine epilepsy model. In response to kainate-induced seizures, in both brain and blood, an early rise in non-acetylated and reduced HMGB1 isoforms was demonstrated consistent with functional chemotaxis. This was followed by a delayed 6-fold rise at 24 hours in brain of the acetylated, disulphide inflammatory form of HMGB1. In serum, significant expression of the inflammatory isoforms was seen after 14 days, possibly coinciding with the onset of spontaneous seizures. Inflammatory isoforms of HMGB1 were not identified within the first 24 hours following isolated MES-seizure in mice. Serum, but not brain, total HMGB1 was significantly elevated (by 311%) in chronic epileptic mice experiencing regular spontaneous seizures; however the contribution of the different isoforms remains to be elucidated. In humans with epilepsy, compared to both healthy controls (1.11±0.07ng/ml, p < 0.0001) and those with well-controlled epilepsy (1.25±0.15ng/ml, p < 0.0001), mean baseline total HMGB1 was significantly higher in patients with drug-resistant epilepsy (8.70 ±0.47ng/ml). Acetylated HMGB1 was observed in drug-resistant patients alone; with a subset expressing the disulphide inflammatory form. In conclusion, these studies have provided insight into the potential of novel, circulating isoforms of HMGB1 to serve as mechanistic biomarkers of established drug-resistant epilepsy in humans. There is a need for future studies to examine the prognostic value of HMGB1 isoforms following first seizure for the early identification of those at greater risk of developing drug resistance and ultimately, those who may benefit from immunomodulatory interventions.

Reader groups involve the reading aloud of complex literature by a skilled facilitator in a group setting, followed by group discussion in relation to the text. They are delivered to a wide variety of populations within both physical and mental health and social care services, across community, residential and inpatient settings. A limited body of existing literature indicates that reader groups can produce positive therapeutic effects to enhance mental health and well-being, but research thus far is largely based on pilot studies with small samples. Further investigation is warranted to explore the experience of reader groups from the perspective of individuals with mental health problems and to consider possible psychological mechanisms underpinning potential therapeutic effects, since this is the first psychological study to be conducted in this area. The aim of the current research was to explore the experience of being in a community reader group for people with mental health problems, and to consider how participation relates to making sense of life experiences and relationships, both inside and outside the group. Eight participants took part in semi-structured interviews, which were transcribed and analysed using Interpretative Phenomenological Analysis. Five master themes pertaining to participants’ experience of reader groups emerged: ‘Literature as an Intermediary Object’, ‘Boundaries and Rules of Engagement’, ‘Self as Valued, Worthy, Capable’, ‘Community and Togetherness in Relational Space’, and ‘Changing View of Self, World, Others’. The findings were discussed in relation to existing literature, to provide an indication of possible psychological mechanisms underpinning participants’ experiences of reader groups. Clinical implications of the current research were considered, particularly in terms of mental health service provision and access to alternative therapeutic activity, and suggestions were made for future research.

Background: Patient-provider communication (PPC) influences patients’ health trajectories and general well-being, and its principles are taught and assessed during UK medical education. However, providers differ in their PPC, specifically of emotive issues. Two psychological characteristics have been proposed as potential influencers of PPC: attachment style and emotional intelligence (EI). Aim: To explore the relationships between providers’ attachment styles, EI and PPC. Procedures: Three empirical studies were conducted in one UK medical school/deanery. Study 1 investigated the influence of 1st year medical students’ (n = 200) attachment styles and EI on their PPC in an Objective Structured Clinical Examination (OSCE). Study 2 replicated Study 1 with 2nd year medical students, consulting in a more ‘demanding’ OSCE (n = 296). Study 3 studied junior doctors (n = 26) consulting in General Practice with real patients (n = 173). Attachment was assessed using the Experiences in Close Relationships: Short Form questionnaire, whilst EI was assessed with the Mayer-Salovey-Caruso Emotional Intelligence Test. PPC was assessed using OSCE checklists (Studies 1 and 2) and a patient satisfaction measure (Study 3). Consultations were videoed and coded with the Verona Coding Definition of Emotional Sequences, which quantifies patients’ expressions of emotion and associated provider responses. Analyses: Data were analysed using structural equation modelling (Studies 1 and 2) and multilevel modelling (Study 3). Results: In all studies, providers’ attachment styles and EI influenced their PPC. In Studies 1 and 2, EI mediated the influence of attachment on PPC, accounting for 7% and 14% of the variance in students’ OSCE scores respectively. In Study 3, doctors’ attachment and EI influenced the number of emotive cues received from patients; neither influenced patient satisfaction. Limited relationships were observed between providers’ attachment or EI and their responses to patients’ emotions across all studies. Conclusions/Implications: Attachment and EI independently influence PPC, but EI may mediate the negative influence of attachment. Whilst attachment is relatively stable throughout the life course, EI can be developed throughout undergraduate medical education, thus these data have potential educational implications. Further research is recommended to explore and validate these findings within the wider context of the clinical encounter.

This thesis examines Body Dysmorphic Disorder (BDD) and body dysmorphic concerns in a clinical and non-clinical sample. The opening section of the thesis provides an outline of the clinical features, prevalence, onset and course of BDD and related concerns. This is followed by a literature review and examination of two related areas of research: (a) the evidence base for cognitive-behavioural psychological interventions for the treatment of BDD, and (b) studies investigating the potential role of internal and external perfectionism, shame and self-discrepancies in relation to the experience of BDD. The remainder of the thesis reports two empirical studies of aspects of BDD and dysmorphic concerns. Study 1 (n=4) reports a clinical evaluation of a cognitive-behavioural group therapy treatment of the disorder, employing both single-case experimental design methodology and analysis of average change pre- to post-therapy and at 6-month follow-up. Data indicated that BDD symptoms along with some problems such as depression and self-esteem responded favourably to treatment while problems like shame did not. Appearance-related and interaction-based social anxiety responded to treatment in two out of four clients. Study 2 (n=547) reports an investigation of the role of internal and external perfectionism, shame and self-discrepancies in relation to BDD. This employed an online survey methodology with a student sample, entailing completion of a number of self-report psychometric assessments. Results showed that external shame was the variable most strongly associated with body dysmorphic concern. Combined with discrepancies between actual and ideal self-concept, these two variables accounted for the greatest proportion of variance observed in dysmorphic concern scores. Outcomes are discussed in terms of the strengths and limitations of the study methodologies, existing literature on CBT and predictors of dysmorphic concern, and the possible need to include additional variables in the treatment of BDD.

Post-traumatic growth (PTG) is the experience of positive changes as a result of a traumatic event, where well-being and personal functioning exceed that of pre-trauma levels (Tedeschi, Park, & Calhoun, 1998). The occurrence of PTG following a variety of traumas has been examined, and a number of meta-analyses and reviews have attempted to summarise such literature and determine what facilitates PTG (e.g. Linley & Joseph, 2004). Some of these seek to establish whether there are differences in the experience of PTG dependent on the cause of the trauma (e.g. Bostock, Sheikh, & Barton, 2009). It has been suggested that the character of PTG following a serious accident may be different to that following physical illness, for example, with physical illness being experienced as an internal trauma and an accident as an external trauma (Hefferon, Grealy, & Mutrie, 2009). There are no reviews which explore the literature around PTG following a serious accident. Paper one of this thesis is a systematic review of the quantitative literature which aims to investigate the experience of PTG following serious accidents. A burn injury can be a traumatic event and can be challenging to recover from, both physically and psychologically (Blakeney, Rosenberg, Rosenberg, & Faber, 2008). Although the psychological impact of burn injuries is undisputed (Wisely, Hoyle, Tarrier, & Edwards, 2007), little attention has been paid to the benefits of such traumas (Fauerbach, Pruzinsky, & Saxe, 2007). Several qualitative studies exploring individuals’ experiences of a burn injury refer to positive changes which can accompany distress and trauma; however, only one quantitative study has directly explored the concept of PTG post-burn (Rosenbach & Renneberg, 2008). Paper two of this thesis is an empirical paper which aims to build on this, using quantitative methods to explore the concept of PTG following a burn injury.

Traumatic brain injury (TBI) belongs to a classification of injury called Acquired Brain Injury (ABI). ABIs are brain injuries that have occurred since birth with possible causes including stroke, haemorrhage and infection (Powell, 2004). TBIs are a result of insults to the brain from external forces. TBI can lead to altered states of consciousness along with impairment of cognitive, physical, and psychosocial functions (Dawodu, 2011). The current research base has often recruited people with a variety of ABIs . This has been a criticism of the literature as ABIs do not affect individuals in the same way, with survivors presenting with a wide range of impairments which family members must adapt to (Newby & Groom, 2010) . This thesis will focus on TBI as a distinct sub-group. Literature referring to TBI will primarily be used. The empirical study will recruit family members of those specifically with a TBI. The narrative review will review papers primarily derived from TBI literature alongside those that explicitly refer to TBI. Both ABI and TBI have significant psychological consequences for the individual and the wider family system (Panting & Merry, 1972; Lezak, 1986; Carnes & Quinn, 2005; Holm, Schönberger, Poulsen, Caetano, 2009 ; Braine, 2011). Research focused on the family in ABI/TBI has advanced in recent years , yet there is still much to learn about family functioning post injury, and equally how research can advance understanding of the best interventions to aid family members (Oddy & Herbert, 2008). This thesis will be divided into three sections and each will have a specific focus. The overarching theme will be considering how research and practice in TBI can be understood as a social phenomenon. Bowen, Yeates and Palmer (2010, p. 304) discuss that there is a need to see “ brain - 2 - injury as existing within the spaces between people. A focus on systemic thinking in conceptualising brain injury will first be applied to a narrative review. Section 2: Adult Traumatic Brain Injury (TBI): A narrative review of family therapy as a conceptual model in research with family members. The review addressed two research questions: • What are the essential attributes of the model of family therapy when applied to TBI? • How could this model be applied as a conceptual framework in TBI research? The findings will propose that, family therapy could provide a conceptual framework to guide research and give it greater coherence. A guiding conceptual framework is presented which is then discussed in relation to its implications for research and practice. Section 3: Sense-making through observation and action: A grounded theory study investigating how family members of traumatic brain injury (TBI) patients construct an understanding of injury. The study aimed to address some of the considerations for future research in the narrative review, primarily that there is a greater need “ to have an appreciation of the family as more than a collection of individuals living together in the same physical or psychological place” (Leaf, 1993 , p.3-543). Additionally, that current theory is stronger in terms of understanding the consequences of brain injury but relatively lacking in terms of understanding the family’s response (Perlesz, Kinsella & Crowe, 1999). The rationale for the study is outlined before the methodology is delineated. An epistemological position of constructivism was used to try and investigate a number of aims centring on how family members make sense of TBI. The paper will present a model of sense-making that developed from a grounded theory design as set out by Strauss and Corbin (1998). The empirical paper will discuss the findings in terms of their implications for practice and research alongside strengths and limitations of the study.

Major depressive disorder (MDD) is a substantial healthcare concern. Conventionally conducted meta-analyses support the efficacy of both psychological and pharmacological interventions for MDD, but methodological limitations of meta-analyses may obfuscate rather than clarify the clinical efficacy of available interventions. The thesis begins with a systematic review of meta-analyses of high quality psychological treatment studies for MDD. The results of the systematic review indicated that 48% of patients achieved remission after a course of psychological treatment. However, approximately 70% of remitted patients relapsed within 3 years after the discontinuation of psychological therapy. Consistent methodological limitations were identified in the primary outcome studies contributing to the meta-analyses. The primary studies typically published insufficient evidence on treatment fidelity. There was considerable variability in the overall treatment duration, the mean severity of samples and the definition of clinical significance. These factors pose a risk to the validity of meta-analytic results of psychological interventions for MDD. The next component of the thesis investigated the impact of idiosyncratic clinical significance definitions on the published conclusions of studies that used the Beck Depression Inventory (BDI) or Hamilton Rating Scale for Depression (HRSD) to assess outcome. The availability of individual patient data (IPD) for 7 published studies enabled the empirically-based Jacobson Method of clinical significance to be used as a standard definition of recovery across IPD studies. Comparisons of published and Jacobson method clinical significance rates for each IPD study showed that idiosyncratic outcome definitions typically overestimated treatment efficacy. Moreover, treatment efficacy was confounded with the definition of clinical significance employed. This indicates that to reduce the risk of bias in meta-analysis, a standard and empirically-based definition of clinical significance should be used across primary MDD treatment studies. Subsequently, the moderating role of pre-treatment severity on clinical significance rates was investigated via individual patient data meta-analysis. It was found that being male and having higher pre-treatment severity both predicted a significantly reduced likelihood of achieving clinical recovery. It is evident that between-study methodological differences means that even high quality conventional meta-analyses of psychological treatments for MDD remain at risk of bias. The novel finding that gender significantly moderated treatment outcome indicates that IPD meta-analyses are both more powerful and flexible than conventional meta-analyses based on summary data. Ideally, future meta-analyses of primary MDD treatment studies should be based on individual patient data.