The research literature reveals a widespread reluctance on the part of therapists to work with older people therapeutically as it is believed to be an unrewarding experience and of little benefit for this cohort. This is in contrast to empirical research which shows that therapeutic interventions can be effective and beneficial for older people. There is little literature that looks at the lived experience of therapists who work with older people and none from a counselling psychology perspective. It is therefore hoped that gaining a phenomenological understanding of the experience will provide insight and understanding into the lived experience of therapists who work with older adults. The research question was: 'What is the experience of working therapeutically with the older client?' A qualitative methodology, Interpretative Phenomenological Analysis (IPA) (Smith and Osborn, 2003) was employed for both the conduct and the analysis of the research. Purposive sampling enabled the selection of seven participants for whom the research question was relevant. Semi-structured interview were carried out with three counselling psychologists and four therapists. The age range of the participants was 31-68 years; there were two males and five females. Three master themes emerged: (1) in respect of age - doing therapy differently; (2) the impact of the older client on the therapist; and (3) the reluctant therapist. A description of the master themes, and related constituent themes, is presented and discussed. Although these findings are consonant with the relevant research literature, the research is unique in capturing not only the therapist's lived experience but that of the counselling psychologist as well. It is therefore an important and significant contribution to the field of therapeutic work with older people and a vital addition to the counselling psychology literature. The results of the analysis and implications for counselling psychology are discussed.

Distal radius fracture is a common injury. The majority of people recover well but a proportion have ongoing pain, stiffness, deformity and functional limitation. Associations between these outcomes, injury characteristics and treatment methods are inconsistent, for example a deformed wrist is not always painful, stiff and functionally limiting. The psychological response to fracture and the role that psychological factors play in recovery are complex and poorly understood. Identification and treatment of those psychological factors that might influence disability and symptom intensity could improve outcomes in this large group of patients. The aim of this thesis is to explore the influence of psychological factors on outcome following fracture of the distal radius. To investigate these relationships further a literature review was carried out looking at the association between psychological factors and outcomes in distal radius fracture patients. Prospective studies were then performed in order to identify associations between demographic factors, injury severity, treatment and psychosocial factors and symptom intensity and disability after fracture and to identify predictors of psychological response to injury. A prospective randomised controlled trail (RCT) was then carried out to compare the impact of an additional psychological workbook intervention versus an information workbook in the otherwise routine management of distal radius fracture. The literature review identified evidence to support the association between psychological factors and outcome after acute injury in general but limited evidence specifically pertaining to distal radius fracture. The first prospective study of 216 patients found psychosocial factors to be more strongly associated with disability (Disability of Arm Shoulder and Hand score, DASH) and pain intensity after distal radius fracture than any injury or treatment factor. The second prospective study of 153 patients found that psychological traits are relatively stable in this cohort and that no demographic, injury or treatment factors were associated with the small changes in psychological scores up to 10 weeks following injury. The RCT demonstrated that use of a psychological workbook did not significantly improve disability six weeks after injury compared to an information workbook in a cohort of patients with distal radius fracture (DASH 38 vs 35, p = 0.949). The importance of psychosocial factors in recovery from distal radius fracture has been demonstrated. Following this injury, psychological factors remain stable over time or fluctuate to a small degree with distinct trends. In cohorts with stable psychological responses to fracture, the individual psychological response cannot be reliably predicted by demographic, injury or treatment factors. Use of a psychological workbook intervention does not improve outcomes in patients with a good initial psychological response to injury. Future work should investigate less psychologically stable and well adapted cohorts, establish how best to identify patients at risk of poor outcome and whether, indeed, these specific groups are amenable to treatment and if so what form this intervention should take. It should address limitations identified in this work, primarily, reduce questionnaire fatigue with more focused psychological questionnaires. Ultimately, it should work towards creating a structure where patients can be screened with a recognised psychological scoring system at initial presentation to fracture clinic and allow a sub-group of psychologically mal-adpted patients to be referred on to a dedicated psychology service, that would work to optimise the psychological conditions for recovery.

Background: Social Role Valorisation (SRV) is a social science meta-theory about social devaluation. its innovative technologies are designed to promote valorisation (norinalisation). SRV had a major impact on learning disability services in the 1980's but has had limited exposure in mental health. Its effect on policy is evident however. SRV has developed reliable, valid ecological assessments of normalisation in service enviromnents. Life-style Planning operationalises normalisation goals for individuals. Its reliability and validity are unknown. Life-style Planning has two goal domains designed to ensure universal basic needs are met and address unique individual needs arising from primary disabilities. SRV also identifies revalorisation needs, to compensate for prior devaluation. In a previous study an instrument designed to assess universal basic and unique individual needs was standardised on a representative population of people with severe and enduring mental illness. Aims: To validate the goal domains of the assessment instrument and develop an understanding of the user perspective on SRV and revalorisation. Design and participants: Factor analysis was used to explore the underlying structure of the assessment instrument. In a second, qualitative study, "expert" mental health user/survivors were interviewed and their transcripts analysed using Interpretative Phenomenological Analysis. Results: The instrument's factor structure matched its design intentions and supported the validity of its goal domains. The qualitative results compared favourably with similar studies from the user, empowerment and recovery literatures. Participants painted a graphic picture of devaluation and revalorisation and illuminated what is required to promote "psychological revalorisation"'. This took the form of a return from a false identification of themselves, based on the internalisation of ignorance and social prejudice stemming from societal fear and blame, to a new identification with a class of proud and empowered mentally ill people. Implications. The discussion considers revalorising adaptations to psychological therapies for people with significant devaluation histories.

This thesis has been prepared in the paper based format and includes a systematic review, a novel empirical piece of research and a critical reflection. The thesis focuses on the implementation of the National Institute for Health and Clinical Excellence’s (NICE) guidance recommendations for the psychological interventions for those people suffering from schizophrenia. Papers 1 and 2 have been prepared for submission in ‘Psychology and Psychotherapy: Theory, Research and Practice’ and the ‘Journal of Mental Health’ respectively. Paper 1 includes a systematic literature search and narrative synthesis exploring if the recommendations for psychological interventions for schizophrenia were being met. Rates of implementation for Cognitive Behavioural Therapy (CBT) and Family Intervention (FI) were compared. The barriers against implementation and the strategies aimed at improving implementation were reviewed. Rates of implementation varied from 4% to 100% for CBT and 0% to 53% for FI. Previously reported barriers to implementation were found, with organisational barriers being most common. Implementation strategies discovered included training packages for CBT and FI. Rates of implementation are below recommended levels suggesting inequalities in the provision of psychological interventions for schizophrenia are present. Strategies to improve implementation that are comprehensive and supported from all levels of the NHS are considered to be most effective. Paper 2 reports a quantitative piece of research exploring if behaviourally specific and plain English language guidance can improve healthcare professional intentions to perform actions in line with recommendations for schizophrenia. An independent measure, single blind, randomised controlled design was used to disseminate guidance in two formats; the ‘original’ and ‘alternative’. Self-report measures revealed no significant results when comparing the original guidance to the alternative for the cognitive determinants of behaviour, actual behaviour change, or comprehension and satisfaction with the guidance. Behaviourally specific and plain English language does not affect intentions or behaviour to implement recommended guidance for the provision of psychological interventions for schizophrenia. A more multi-factorial approach including organisational culture may be required. Paper 3 is a critical reflection of the submitted papers and research process as a whole. Strengths and limitations of the included studies, the findings in the context of wider research, implications for clinical practice and future research are discussed.

El proyecto consiste en dar solución viable, rentable y novedosa que no existe actualmente en el mercado. El problema que se ha identificado, es que existen aproximadamente 40 mil niños menores de 14 años que viven en Lima Metropolitana y padecen de algún tipo de discapacidad o limitación física y/o mental. Asimismo, la capacidad de atención del sistema de salud a nivel nacional en el Perú es menor al 50%, con solo una sesión de rehabilitación por paciente al mes. Para atender esta necesidad, se desarrolla el proyecto Therapy Kids, que ofrece terapias de rehabilitación para el desarrollo de las capacidades de estos niños. Los apoderados podrán solicitar servicios a través de los diversos canales de atención, en los que se les ofrecerá precios, horarios accesibles y promociones, con el valor diferenciado de que el servicio será brindado únicamente a domicilio y con una frecuencia de tres veces por semana. Las fuentes de ingreso para Therapy Kids serán las terapias a domicilio y las consultas del médico terapista., en el primer año, se espera un ingreso de S/5 682 600 sin IGV y la inversión a realizar en dicho año para lograr los objetivos trazados asciende a S/ 285,202.82, de los cuales el 73% provendrá de los accionistas y se buscará un financiamiento por el 27% restante. Therapy Kids busca evitar el malestar de hacer largas colas y viajes para conseguir una cita con un especialista. Asimismo, no solo busca apoyar a los padres de familia y generar utilidades para la empresa, si no también contribuir considerablemente en el desarrollo del sector salud del país. / Trabajo de investigación

The English Improving Access to Psychological Therapies (IAPT) programme is a government-funded initiative that aims to provide timely and equitable access to evidence-based psychotherapeutic interventions, within a primary care setting. Despite the many achievements of the programme, there are several issues regarding research to clinical gaps, as well as a high rate of variation between sites concerning outcomes and attrition. This thesis explores the implementation process of the IAPT delivery model to understand which factors are influential in the successful uptake and integration of evidence-based psychotherapeutic interventions. The aims of this thesis are:  To explore, identify and analyse the implementation process involved in establishing and delivering an IAPT service.  To uncover the factors that either facilitate or impede its development to provide a more in-depth and detailed account of the implementation and operation of services.  To develop an understanding regarding the applicability of evidence-based practice and the IAPT delivery model in a clinical setting, for the provision of psychological therapies. I conducted a series of semi-structured interviews with practitioners delivering and implementing services, across seven sites, and clients, across three sites. The design and analysis followed an Interpretative Phenomenological Analysis, focusing on personal meaning and sense-making processes. The objective of the interview was to understand the implementation process regarding the IAPT delivery model, exploring how this influences personal experiences and client engagement. Additionally, participant narrative was set in context using open-access data collected and published by the programme. The analysis generated three master themes for practitioners delivering and implementing services including: ‘A Call to Action’ describing how participants regarded this process as a genuine opportunity to make a real impact in mental healthcare; ‘Contextual Influences on Service Operation’ which explores the activities in becoming a locally determined, adaptable and relevant service; and a ‘Focus on Relationships’ outlining the relational and collaborative work involved during implementation. For the client group, three master themes were generated including: ‘A Personal Journey: From Discovery to Advocacy’ illustrating the changing experiences involved during service access and engagement; ‘Perception of Self’ which portrays how individuals made sense of their engagement by judging what it meant to them; 5 and ‘Outside Factors’ which explores the role of others and the physical journey made in getting to services. The analysis suggested that both groups made sense of their experiences in complex and varied ways. Heavily influencing the implementation of the IAPT delivery model is the over-arching need to boost throughput and quantity, possibly at a cost of quality. Additionally, it is argued that the use of routine outcome monitoring in services is useful for reflecting on the implementation process and engaging clients. The key to successful implementation appears to be about achieving integration, requiring a whole-systems based approach that considers the mediating pathways into and out of services. In light of the findings and literature, the thesis proposes several recommendations for future practice and further research.

This thesis critically examines a national programme in mental health which has been driven by the implementation of National Institute of Health and Clinical Excellence (NICE) guidance. Assumptions which underpin research method, drawn from the natural sciences, are critiqued in terms of their adequacy in accounting for human relating and expert therapeutic practice. The work of Dreyfus and Dreyfus (1986) is problematized in how they account for proficiency and expertise as intuition and the leap that they make from calculative to deliberative rationality. An alternative source of understanding, based on non-linear causality and complex responsive processes, is developed, building on the work of Stacey (2001, 2005, 2007). The ineffability of expert practice (or clinical judgement) is contrasted with competence based, rule governed practice, which necessarily underpins the early stages of learning. It is argued that because research practices undertaken in randomised controlled trials (RCTs) must be describable, measurable and focussed on predictable outcomes, then these cannot account for expert practice, therefore the assertion that the Improving Access to Psychological Therapies programme (IAPT) is wholly based on research based, evidence based therapies, cannot be substantiated. The work explores professionalism and specifically considers the role of psychiatrists, psychologists and psychological therapists in mental health and in increasing access to psychological therapies. The role of managers and managerialism are explored, specifically how the NHS has sought to manage 3 professional staff and multi-disciplinary teams in adopting corporate and new ways of working (NWW). This includes the importance of and difficulty in countering professional identity using competence based approaches. The performance management processes in the NHS are recognised as an equally relevant source of evidence (to that of NICE), despite there being a poor (traditional) evidence base for it (Stacey, 2010; Seddon, 2008). Power relating in human relationships is identified as immanent, using the context of a management group, and it is argued that Foucault’s concept of disciplinary power (1994) can account for what is considered to be knowledge and truth, drawing on specialist expertise based on science and research, with a forceful potential for rendering others silent as well as pervasively self-silencing, in processes of inclusion and exclusion (Elias, 1978). It is argued that these on-going processes of relating influence policy decisions at national and local levels and how these policies are implemented in practice. The inevitability of unpredictable outcomes is highlighted, despite strong centralised programme management along with the provision of an explicit blueprint for implementation.

Rationale: This study was conducted to help improve mental health care for Black and Minority Ethnic (BME) clients as previous research carried out in non-western countries has suggested that western-developed psychotherapies often need to be culturally adapted to become more effective in treating this client group. The aim of this study was to explore how CBT therapists deliver manualised CBT with BME clients and if they make any adaptations, how and to what extent are they implemented. Method: Interpretative Phenomenological Analysis (IPA) guided the conduct and analysis of one-to-one, semi-structured interviews with six CBT therapists working in an Improving Access to Psychological Therapies (IAPT) service. The inclusion criteria for participants was accreditation with the BABCP, completion of an IAPT programme CBT diploma and to be currently working in an IAPT service, at least two years experience as a CBT therapist and at least four cases of completed therapy with BME clients. Findings: Four master themes emerged (1) CBT is based on western principles, (2) The complex nature of CBT, (3) Changing practice of manualised CBT and (4) The influence of therapist factors. Conclusion: The participants experienced many issues in their practice of manualised CBT with BME clients which led them to make changes including adaptations to manualised CBT. They described their current practice as being integrative as they incorporated therapeutic approaches other than pure manualised CBT, making them more flexible and adaptable. The adaptations involved altering the cognitive and behavioural interventions to better suit the individual needs of the client. The adaptations took into account the client’s culture, religion, language, psychological mindedness, acculturation to their host country, education and age. The participants’ confidence in CBT and their self-identity as therapists also influenced their overall practice of therapy. Recommendations for practice are discussed in relation to therapeutic practice, training of therapists, supervision and policy makers.

Actualmente, frente a la pandemia, se visualiza una restricción de socialización que ha perjudicado, principalmente, a los jóvenes. Un ejemplo de ello es el aumento de enfermedades mentales que no han sido cubierto en su totalidad por terapeutas debido a la falta de conciencia de la importancia de la salud mental. Se ha realizado un estudio sobre la población de Lima Metropolitana del nivel socioeconómico A y B en jóvenes adultos de 20 a 35 años. Asimismo, otro segmento importante es de psicólogos y terapeutas que buscan una exhibición para la oferta de sus servicios. Por ello, se ha propuesto la creación de BeWell, una plataforma virtual que permite la interacción de profesionales competitivos con pacientes de manera sencilla y rápida. A diferencia de otros competidores, BeWell se diferenciará por brindar precios competitivos, una comunidad que comparta información de valor y talleres gratuitos que proporcionan una mayor accesibilidad a la atención psicológica. Por último, a través de este trabajo, se analizarán diversos factores como el modelo de negocio, planes organizacionales, herramientas de marketing y finalmente el análisis financiero. Con lo cual, se logrará demostrar que es atractivo debido a su rentabilidad y escalabilidad. / Currently, in the face of the pandemic, there is a restriction of socialization that has mainly harmed young people. An example of this is the increase in mental illnesses that have not been fully covered by therapists due to the lack of awareness of the importance of mental health. A study has been carried out on the population of Metropolitan Lima of socioeconomic level A and B in young adults between 20 and 35 years of age. Likewise, another important segment is psychologists and therapists who seek an exhibition for the offer of their services. For this reason, the creation of BeWell has been proposed, a virtual platform that allows the interaction of competitive professionals with patients in a simple and faster way. Unlike other competitors, BeWell will differentiate itself by offering competitive prices, a community that shares valuable information, and free workshops that provide greater accessibility to psychological care. Finally, through this work, various factors such as the business model, organizational plans, marketing tools and lastly the financial analysis will be analyzed. With which, it will be possible to demonstrate that it is attractive due to its profitability and scalability. / Trabajo de investigación

La pandemia del COVID 19 y el aislamiento obligatorio a nivel nacional como internacional ha generado estragos en las personas a nivel emocional es por ello que desde que empezó esta situación global, muchas personas desde niños, jóvenes hasta adultos han presentado problemas en el ámbito psicológico. Según un informe del MISA, se incrementaron casos de manifestaciones psicológicas negativas de mayor frecuencia como trastornos emocionales, depresión, estrés, apatía, ira y agotamiento emocional incluso síntomas de problemas de ansiedad. En el presente trabajo lo que se busca es poder mediante la creación y desarrollo de un aplicativo móvil llamado “VitalMente”, poder brindar terapias psicológicas a las personas de diferentes edades para poder superar estos problemas mencionados anteriormente. El mencionado aplicativo estará disponible inicialmente de manera nacional y podrá ser descargado tano en celulares con sistema operativo Android, así como también en iOS. Mediante este aplicativo, las personas que requieran pasar por terapias psicológicas podrán reservar y atenderse con los psicólogos todo dentro de VitalMente desde la comodidad de sus hogares haciendo que esta atención se más práctica y sencilla, cabe resaltar que VitalMente sirve para personas de diferentes edades y en ella podrán encontrar diversos servicios como terapias para niños por problemas de concentración, terapia para adolescentes por problemas de conducta, terapia de pareja, ahora que en pandemia se produjeron varias rupturas amorosas hasta terapias familiares, todas con la finalidad de servir a las personas y darles una vida mejor. Posteriormente se buscará la internacionalización de VitalMente replicado en otros países. / The COVID-19 pandemic and the compulsory isolation at the national and international level has wreaked havoc on people at an emotional level, which is why since this global situation began, many people from children, young people to adults have presented problems in the psychological field. According to a MINSA report, more frequent cases of negative psychological manifestations increased, such as emotional disorders, depression, stress, apathy, anger and emotional exhaustion, including symptoms of anxiety problems. In the present work, what is sought is power through the creation and development of a mobile application called "VitalMente", to be able to provide psychological therapies to people of different ages in order to overcome these problems mentioned above. The aforementioned application will initially be available nationally and can be downloaded both on cell phones with Android operating system as well as on iOS. Through this app, people who need to go through psychological therapies will be able to book and attend with psychologists all within VitalMente from the comfort of their homes, making this care more practical and simple, it should be noted that Vitalmente serves people of different ages and In it you will be able to find various psychological services such as therapies for children for concentration problems, therapy for adolescents for behavior problems, couple therapy now that in a pandemic there were several love breaks up to family therapies, all with the purpose of serving people and give them a better life. Later, the internationalization of VitalMente will be sought, replicating it in other countries. / Trabajo de investigación