Section A: The effectiveness of acute phase psychological therapies for chronic major depression: A literature review. This review critically evaluates the literature pertaining to the use of psychotherapy for people experiencing moderate to severe chronic depression. It concludes that people with chronic major depression (CMD) experience a greater reduction in depressive symptoms from extended periods of treatments and from combined therapy, both in the form of psychotherapy and pharmacotherapy, but also integrative therapies which combine different therapeutic models and modalities. Section B: This study explored participants’ experiences of ways in which group person based cognitive therapy (PBCT) for people with chronic major depression facilitated or hindered therapeutic change. Qualitative methodology was used to explore the experiences of six participants who had completed the 12-week group. Transcripts of the semi-structured interviews were analysed using Interpretative Phenomenological Analysis. Five super-ordinate themes emerged: experiences of depression before the group; the group experience; perceived changes; role of external factors; desire for more. Participants reported a changing experience of depression with regard to the way in which they related to and managed their symptoms, viewed themselves, and managed challenging situations. This study indicates that PBCT may be a suitable intervention for adults with CMD, and enhances previous findings which suggest that briefer mindfulness practices may be more acceptable to people experiencing current symptoms of depression. Section C: In a critical appraisal of the study described in section B, this section discusses the author's learning and reflections pertaining to research skills developed, applying the findings to clinical practice, and gives consideration to further research.

Evidence highlights the need to support people with dementia and their family caregivers together as a dyad and mindfulness has been suggested as one intervention. This research aimed to explore dyads’ experiences of attending an eight-week MBSR intervention. Five couples were recruited, using a mixed method multiple case study design with follow-up. Data was collected using self-report standardised measures, group observations and semi-structured interviews. Thematic analysis and descriptive statistics were used to analyse the data. Although quantitative analysis was inconclusive, qualitative analysis suggests some participants found the intervention a positive experience, benefitting from completing the intervention as a dyad and attending with people with related problems. Specific mindfulness benefits were also reported. Further larger scale research is needed to support these findings and explore specific benefits mindfulness interventions has over other interventions, before being suggested as a helpful clinical intervention.

To date, no research has evaluated the efficacy of a web-based Compassion Focused Therapy (CFT) intervention for young people. The current pilot study aimed to begin the process of evaluating the effectiveness and acceptability of a web-based CFT intervention by creating an online website youngmindbekind.com, and obtaining an initial effect-size estimate for a full scale randomised controlled trial (RCT) trial. A two-arm, pilot, RCT comparing a web-based CFT intervention to a waiting list control condition (WL) was carried out with young people aged 16 to 25 from a non-clinical population. Participants had asynchronous contact from the researcher once a week, solely via the internet, to provide instructions for modules. Self-report measures of self-esteem, self-compassion, mental health and quality of life were completed at baseline and post-intervention/wait-list. In addition, the intervention group received them again at a 4 week follow-up. A total of 40 participants were randomised to either web-based CFT (n=20) or to the WL group (n=20). Study attrition was 12 with 70% of participants completing the post-intervention/wait-list questionnaires. Pre-post change scores on all measures did not significantly differ between groups. The estimated, post-intervention, between groups, effect size for the primary outcome measure, namely the Rosenberg Self Esteem Scale, was d=0.17, with a 95% confidence interval of (0.92, 0.57). Qualitative feedback from questionnaires identified several themes relating to understanding compassion, activating compassion, finding the intervention acceptable, and future recommendations for the website. YoungMindBeKind.com appears to be an intervention capable of engaging young people. Given the relatively small effect size estimate, further pilot work to improve the intervention and/or target young people with lower self-esteem may be helpful prior to a full-scale RCT.

Computerised cognitive behavioural therapy (CCBT) is a clinically effective method of delivering CBT which may help address the under – treatment of common mental health disorders (CMHDs) in the population. However, concerns regarding acceptability, attrition rates and the therapeutic alliance are obstacles to widespread population dissemination. This thesis aimed to address these implementation issues by applying concepts from human – computer interaction (HCI) and attachment theory to the field of CCBT. Chapter 1 presents a meta – analysis investigating the effectiveness of CCBT for CMHDs and moderators of this effect. Chapter 2 presents a systematic review and analysis conducted to examine predictors of CCBT engagement. A process – based model of engagement with CCBT developed from the findings of this review is also presented. Adult attachment is known to influence engagement and alliance in face to face therapies, but research has not explored whether these relationships are mirrored in CCBT. Four empirical studies intended to address this question. Study 1 used a student population based survey to explore the acceptability of CCBT in a student population and the associations with adult attachment. Results demonstrated adult attachment was not associated with acceptability of CCBT. Study 2a utilised an open trial of a supported CCBT program to investigate whether adult attachment would predict engagement and alliance in vivo. Results showed attachment did not predict these outcomes. Study 2b utilised an open trial with a non – supported online CCBT program. Results indicated attachment security was positively associated with program engagement and alliance. It is proposed a combination of attachment system activation and perceiving computers as social actors account for these findings. Study 3 used a randomised, experimental paradigm to test the benefits of security priming in CCBT. Security priming produced higher levels of program engagement and better working alliance compared to neutral primes. Furthermore these effects were not moderated by dispositional attachment styles. These results demonstrate something so uniquely human, dispositional attachment orientations, founded on the intimate bonds we form in infancy and in adulthood , extend their influence into the experience of unguided CCBT, a solely human – computer interaction. Unguided – CCBT, a highly cost effective intervention with the potential for considerable public health impact, may benefit from incorporating security priming techniques in program designs to maximise engagement and alliance. Engagement and alliance is attainable in CCBT and paying attention to the attachment styles of program users may present a distinctive opportunity to overcome these implementation barriers.

Section A: A review of current research literature relating to the impact of child ASD upon non-affected siblings and the utility of sibling group interventions. The first section summarises and critiques studies relating to the social, emotional and behavioural adjustment of siblings, including consideration of potential mediating factors and discussion of methodological issues. The second section considers evidence for one intervention for this group, ASD-specific sibling support groups. The review suggests that inconsistencies remain within the sibling research literature and that there is a clear need for UK-based outcome research. Section B: Background: Having a brother or sister with an ASD can be challenging for non-affected siblings. These children may experience reduced parental attention, isolation from peers and difficult sibling behaviours. This pilot study aimed to investigate the utility of support groups for siblings of children with ASDs. Methods: A within group, mixed methods design was used with a pre-intervention baseline. Participants were 35 children, aged 7-15 years, with an ASD sibling. All were attending ASD-specific sibling group interventions across the South East of England. Sibling rated self-concept, anxiety and anger and parent-rated emotional difficulties were collected at pre group, post group and follow up. One group also participated in a focus group. Results: Results indicated significant improvements in self concept and significant decreases in anger and anxiety following participation in an ASD-specific sibling group. Anxiety continued to decrease at 3 month follow up. Parent-rated sibling emotional difficulties did not change. All siblings valued the groups. Four main themes were identified from qualitative data: Siblings valued the opportunity to meet similar others, have fun, learn new information about ASD and apply this knowledge to their own situation. Conclusions: The present pilot study extends existing literature on ASD-specific sibling groups. This is one of the first studies to combine qualitative data with standardised outcome measures. Participation in an ASD-specific support group may be associated with more positive self concept and decreased anger and anxiety. Given inherent study limitations, further, controlled research studies are warranted. Section C: A critical appraisal of the study conducted in section B and a reflective account of the process. This includes consideration of research skills learnt, future adaptations, clinical implications and ideas for future research.

Mindfulness-based interventions (MBIs) such as Mindfulness-based Stress Reduction and Mindfulness-based Cognitive Therapy utilise a group format. Experts in the field of mindfulness endorse the group as beneficial to participants and professional practice literature promotes the need for mindfulness teachers to develop competence in group skills. However, the role of the group in MBIs has been largely overlooked in empirical research to date and the utility of existing group theory in this area is unconvincing. The current study presents a grounded-theory of the role of the group in MBIs. The theory was developed from semi-structured interviews conducted with mindfulness students, teachers and trainers (N=12) exploring their experiences and views related to the MBI group format. Through analysis, three higher-order categories emerged from the data describing five stages of group experiences, four group-based tasks the teacher attended to from a position of ‘embodiment’, and the impact of the MBI group. Findings were situated within existing group theory, facilitating differentiation between generic and MBI specific group factors. The sense of connection developed through non-verbal group meditation, the multi-layered experience of normalization, and the grounding of the teacher’s group-based responses in the embodiment of mindfulness, emerged as unique MBI group factors. The implications for clinical practice, research and theory are discussed.

Section A provides a review of empirical literature researching therapists’ experiences, opinions and attitudes towards the practice of model fidelity. Sixteen studies are reviewed, synthesized and critiqued, and findings are categorised into themes. Results of the review suggest therapists have complex relationships with model fidelity, shaped by multifaceted combinations of attitudes, values, personal, professional and skill development, clinical complexity, and experience. Findings are also considered in relation to pertinent theories. Clinical and research implications are discussed. Section B presents a grounded theory of model fidelity in clinical psychologists’ therapeutic practice. The theory was developed from semi-structured interviews conducted with 13 clinical psychologists with varying expertise. Through analysis, a hierarchy of categories emerged from the data, describing stages of therapeutic practice. The grounded theory suggests that clinical psychologists have evolving relationships with model fidelity, moving from model-centred practice to person-centred approaches with greater experience. Implications for clinical practice and research are discussed.

Biological explanations of depression have been found to increase professional perceptions of the effectiveness of medical treatments and reduce the perceptions of the effectiveness of psychological therapy. Studies in lay populations have shown that biological explanations reduce perceptions of self-efficacy and control over depression symptoms. There is a lack of research examining the impact of causal models on clinicians’ attitudes. The current study aimed to explore whether clinicians’ causal models of a client’s depression can be biased by aetiological labelling and, in turn, whether clinicians’ causal models impact clinical judgements and attitudes. An experimental design was utilised, with one independent variable (labelling of the client’s depression) with three levels (biological, psychosocial and neutral). Outcomes measured causal beliefs, treatment effectiveness, control, clinical attitudes and perceived stigma in relation to a client vignette. Observational data were analysed to explore the effects of clinicians’ primary causal models on the outcome variables. Over 200 trainee clinical psychologists, across England, Scotland and Wales, took part in an online survey, presented using surveymonkey®. Where appropriate data were analysed using ANOVA. There was a small effect of the manipulation; labelling the depression as biological increased biological causal attributions and increased perceptions of the effectiveness of medical treatments. The exploratory analysis demonstrated substantial effects of strongly endorsing biological causal beliefs on judgements of medical treatments and client engagement. The results suggest that clinicians’ causal models of a client’s depression may bias clinical judgements. These findings are preliminary and further research is needed.

Negative change occurring during psychological therapy is under-researched. There is currently no theory which unifies correlates identified by previous research. This study aimed to generate a theory of negative change by interviewing clients and therapists about their experience of therapy when reliable score deterioration on outcome measures had been observed. In-depth interviews were conducted with eight clients and four therapists about the process of therapy. Analysis was based on a positivist Grounded Theory methodology. The emerging model identified three major themes postulated to explain negative change as experienced by this sample. A context of adversity, the therapeutic process and help withdrawn, within the context of positive outcomes. Process issues incorporated categories around; feeling there was not enough helpful advice, talking about distressing issues, difference, the challenge of no change, relationship difficulties, ambivalence, losing hope and goals around getting support instead of change. The importance of paying attention to context and life events was highlighted. Many clients wanted further input and some did not think there had been a negative outcome, or noted that change was not instant. Varied process issues highlight the need to adjust interventions for clients and review outcome measures used.

Section A situates female clinical psychologists with children within the wider socio-historical context of working-mothers. Theoretical and empirical evidence of modernist and post-modernist approaches on the development of the working-mother identity is provided. This is followed by the literature on mothers employed in the caring profession and in psychology. The review highlights the need to further explore the relationship between social, professional and personal for female clinical psychologists with children within a socio-constructionist perspective. Section B investigates the social and professional challenges encountered by female clinical psychologists with children. Clinical psychology is an increasingly female profession, and many clinical psychologists are or will be mothers. Yet, proportionately fewer reach consultant positions (Band 8c and above) compared to their male colleagues. Existing historical professional structures, and traditional societal ideologies about motherhood and employment might be continuously negotiated within broader social positionings of working-mothers. This study aimed to explore the constructions of a sample of clinical psychologists who are mothers (CP-Ms) of their social identity. Foucauldian discourse analysis was used to explore the discourses available and drawn upon by CP-Ms to construct their professional and motherhood identity, and what were the subject positions they occupied. Ten qualified female clinical psychologists with pre-school children employed in a local NHS Trust were individually interviewed. CP-Ms’ identity was constructed as either a mother or a clinical psychologist, as being similar and different to other working-mothers. CP-Ms discoursed psychological knowledge and practices as potentially damaging their motherhood experience and their social relationships; they also discoursed motherhood and psychology as mutually enriching. Motherhood and professional identity were discoursed in opposition to one another, and yet the participants also constructed their CP-M identity as a continuous dynamic journey of reframing, of which they were agentic. This study suggests that the construction of CP-Ms’ identity is complex as it involves actively negotiating contradictions and overlaps between motherhood and clinical psychology. Further research is needed. Professional and clinical implications are discussed. Section C aims to elaborate on the research skills learnt during the research process, and on the abilities that need to be further developed. It continues with a critical appraisal of the study, before reflecting on possible clinical recommendations. Lastly, a potential new project is presented.