Childhood sexual abuse (CSA) is a complex form of trauma that can have long-lasting effects on how an individual copes with stress and adversity in their daily life. CSA has been associated with a number of sequelae, one of them being eating disorder (ED). This thesis focuses on the coping styles of CSA survivors and explores the link between CSA and ED, through the lens of coping and trauma-related cognitions. Due to a gender imbalance in the current literature, a systematic review of studies measuring the link between ED and CSA in males was carried out. Half of the studies included in the review found support for the relationship between CSA and harmful eating patterns in males. A case study of a male CSA survivor presenting with difficulties coping with emotions, expressed as self-injury, binge eating and physical and sexual aggression towards others, revealed that a coping-focused intervention successfully reduced harmful behaviours. An empirical study (N=295) investigated coping styles and early maladaptive schema as mediating variables in the link between CSA and ED, using the EAT-26, the Young Schema Questionnaire (YSQ-S3) and the Brief COPE. The sample included participants recruited from social media platforms (n 118), as well as ED (164) and CSA support forums (13). Only early maladaptive schema were found to mediate the relationship between CSA and ED. An interpretation may be that ED itself is a coping mechanism. A psychometric review of the Brief Coping with Problems Experienced (COPE) scale, highlights difficulties in the measurement of coping and explores potential benefits of a conceptualisation focusing on flexibility in coping, rather than style of coping. It also indicates a need for more trauma-sensitive measures when assessing coping strategies in this population. Future research should focus on the specific early maladaptive schemas or schema domains that may influence the relationship between CSA and ED. Future efforts should also aim to better understand the relationships of these variables in male survivors. Clinical implications are discussed, along with limitations of the thesis.

Evidence suggests that Antisocial Personality Disorder (ASPD) is highly prevalent amongst young males involved in the criminal justice system; however effective psychological treatment options for people with the disorder is limited. This thesis therefore explores psychosocial factors implicated in the development of the disorder, with the view to identify specific treatment targets for psychotherapeutic interventions. In the first instance, a systematic review and meta-analysis was conducted to examine the efficacy of Mentalization Based Therapy (MBT), a psycho-dynamically informed intervention. MBT was originally developed to treat people with Borderline Personality Disorder (BPD), yet to date no meta-analysis has evaluated the efficacy of MBT alone. Furthermore, emerging evidence suggests that MBT can be effective for people with ASPD, however at present, there are insufficient studies to examine the effectiveness of the approach with this population. Therefore, MBT was examined with the view to assess treatment outcomes for adolescents with emerging BPD and adults diagnosed with BPD. In accordance with the specific inclusion criteria, five primary articles were retained and analysed. In relation to the MBT group, there was a significant improvement in symptoms. Furthermore, effect sizes for other problems (anxiety, depression, suicidal attempts/self-harm) were found to be large to very large. When considering interpersonal functioning, interestingly, analysis revealed no effect favouring either the treatment or control group. Regarding impairment, a large and significant effect size was found in favour of the control group. Overall, adolescents derived greater benefit from the treatment when compared to adults. Limitations relate to the number of available studies in this review. In order to identify treatment targets for psychotherapeutic interventions, an empirical study explored the relationship between mentalizing capability, attachment style and schema as predictors of ASPD in 79 men recruited from a Young Offenders Institution (YOI). The results confirmed that anxious attachment style and specific Early Maladaptive Schema (EMS) domains relating to Disconnection & Rejection (mistrust-abuse); Impaired Autonomy & Performance (dependence), and Impaired Limits (entitlement) are associated with ASPD in young male offenders. Inferential analyses confirmed that intellectual functioning did not influence performance on any measures. Main limitations relate to the cross-sectional nature of the study and sample size. Following this theme, a single case study relating to the assessment and treatment of a young male with ASPD and comorbid diagnoses was undertaken using a firesetting offence focused treatment programme. Formulation, treatment progress and outcomes are discussed; and recommendations for further work are provided. Thereafter, a critical appraisal of the Revised Adult Attachment Scale (RAAS; Collins, 1996), a measure utilised in the empirical study was conducted. Consideration is given to the utility of the RAAS, particularly within forensic populations. The RAAS was found to be a reliable and valid measure for use with undergraduate, general, and clinical populations. Further research relating to the application within forensic populations is needed to test the reliability and validity of the tool with offenders. Finally, the thesis discusses limitations of the methodologies used and highlights how the overall aim of this thesis was achieved.

Current political drivers are set to increase the volume of people receiving a dementia diagnosis. However, there are problems with how diagnoses are being delivered, with people reporting it to be confusing, anxiety provoking, and being generally dissatisfied. Limited guidance exists that could help improve the delivery and steps are required to address this. Research has begun to explore the components of a good delivery of a diagnosis of dementia, however interventions to support clinicians to deliver diagnoses are limited. This project’s overarching aim was to develop a prototype tool that has future potential to be used by clinicians, patients, and companions who are involved in the delivery of diagnoses of dementia. A two-phase sequential design was undertaken. Phase one explored four Memory Assessment Service (MAS) clinicians’, five patients’, and five companions’ perspectives of what makes a good delivery of a diagnosis of dementia via 10 semi-structured interviews. Thematic analysis of this data produced four overarching themes relevant to a good delivery of a diagnosis of dementia: overcoming barriers; navigation of multiple journeys; and completing overt and covert tasks. Two paper based tools were devised from these themes. One tool for service deliverers to support reflective practice and skill development; and the other for service recipients. This contained three elements: an information guide containing an overview of MAS appointments and outcomes, introduction to choices, bringing a relative or friend; a notes sheet which supported consideration of main concerns and choices, provision of space to record answers; and a prompt sheet to use during appointments to prompt question asking, and recording information discussed. Phase two assessed the tool’s acceptability across four focused group discussions with seven service deliverers and six service recipients. Thematic analysis was used to explore the preliminary acceptability of the tools, as perceived by the participants, and guided revisions to improve the design of both tools. Overall feedback was positive and both tools were deemed to be acceptable. The tools were modified to remove the prompt sheet and incorporate the principles into the service deliverer’s guide. Some minor adaptations to improve acceptability of phrasing were also made. This project developed a novel tool for supporting clinical practice in the delivery of dementia diagnoses. It also contributes towards the knowledge of dementia diagnosis and provides an alternative narrative of quality diagnostic delivery, rather than diagnostic volume. The tool uniquely articulates clinicians' experiences of diverse and changing emotional responses to the process of diagnosis delivery and of their management of this to prevent impact on the recipient. It is suggested that by mastering these skills clinicians can facilitate cohesion with, rather than distancing from, the attendee’s emotions. It also highlights barriers to good practice and the management of power within diagnostic appointments, both considered to potentially extend previous guidelines. The next steps are to take the tools into further development work and then to evaluate the tools. This may include completing further focus groups to establish acceptability of the tools and contribute to further development. Formal evaluation of quality and usability could include field testing to assess feasibility.

The therapeutic relationship within psychotherapy is well recognised as a pertinent component of successful treatments. In particular, the alliance component of the therapeutic relationship has demonstrated a moderate and robust correlation to positive outcomes. The alliance is considered the change mechanism within the more relationally focused therapies (e.g., psychodynamic). In contrast, therapies that focus on specific techniques related to underlying theory regarding the development and amelioration of mental health difficulties, prioritise the protocols as the change mechanism. Mental health services can be seen to have moved towards offering more time-limited, protocol driven therapies (e.g., CBT) to widen access to therapy and to meet financial incentives. EMDR is a relatively new psychotherapy which has amassed evidence of efficacy since its development by Francine Shapiro in the 1980s and is now recommended within the NICE guidelines. EMDR is predominantly a protocol driven therapy based on its underlying theory which suggests that mental health difficulties are a result of dysfunctionally stored memories. Currently, little is known about the role of therapeutic relationship within EMDR and whether additional focus on relational aspects within the therapy could enhance outcomes. A single-case design with two therapist-client dyads was used to explore the therapeutic alliance within two EMDR therapy cases in a primary care setting. The study had three aims; to investigate the relationship between the therapeutic alliance and outcome; to investigate the fluctuations of the alliance throughout EMDR; and to explore how the alliance is experienced by the client and therapist during EMDR treatment. The principal findings, presented via visual analysis, display a strong alliance and positive outcomes in the two EMDR cases, suggesting the presence of the alliancewithin a predominantly protocolised therapy. This is further supported by the qualitative data, in which the alliance was a highly valued aspect by therapist and clients in both cases. Whilst this study is limited by generalisability given the small sample size and correlational design, it draws researchers’ and clinicians’ attention to the paucity of information guiding the practice of EMDR in terms of the relational imperative.

This thesis explores crimes related to online dating. After an introduction to online dating crimes (chapter 1), a systematic literature review (chapter 2) looks at current studies considering online dating romance scams. Studies indicate several factors that make victims more vulnerable to these scams, such as their romantic beliefs. Techniques used by scammers are also discussed. Chapter 2 collates what is known so far and highlights gaps in the literature: namely the lack of research. Later chapters focus on crimes occurring on face to face dates with an online partner. Chapter 3 provides the first empirical look at these crimes, and explores potential ways of predicting when these crimes will occur. Results indicate that sexual, pressuring, arrogant, or self-deprecating message content is more likely to indicate risk. Chapter 4 uses interpretative phenomenological analysis to obtain rich qualitative information on the experience of sexual assault on dates. It reveals that this experience triggers a range of negative emotions in the victim, and indicates that better education on consent may be an important prevention technique. Finally, chapter 5 presents a critique of the Romantic Beliefs Scale (Sprecher & Metts, 1989), which has been used to measure romantic beliefs of online dating crime victims. The review suggests the scale is adequate for use in predicting who may fall victim to online dating crimes. These studies are then summarised in chapter 6 to provide implications for prevention of online dating crimes and suggests areas of further research.

This thesis provides a broad and diverse investigation into the field of psychological treatment for child molesters. A range of methods including a systematic review, a single case study and a primary phenomenological investigation were used to explore issues in the field. Following an introduction in Chapter 1, Chapter 2 reviews the effectiveness of psychological treatment for reducing recidivism in child molesters. The results indicate that recidivism among treated and untreated child molesters is yet to consistently and clearly differ and that the treatment outcome literature is obstructed by weak studies using suboptimal scientific designs. In Chapter 3 the aetiology of a child molester’s offending is formulated using the Pathways Model of child abuse (Ward & Siegert, 2002). Treatment sessions addressing areas of criminogenic need are outlined and the impact of the sessions is determined using systems of clinical change on psychometric measures. The results indicate improvements in some of the targeted areas however these were not sufficient to indicate clinically significant changes on both systems used. Chapter 4 explores the lived experience of a sexual preference for children in a sample of five child molesters using the principles of Interpretive Phenomenological Analysis. Four themes were identified. (1) It Creates a Battle for Me, (2) I’m Always Going to Have These Thoughts, (3) There’s No Help Out There and (4) My Interest in Children is More Than Just Sexual. The results have implications for clinical practice and are discussed in the context of directions for further research. Chapter 5 evaluates the Sex with Children scale (Marshall, 1995) which was used as an assessment measure in Chapter 3. Finally, Chapter 6 provides a discussion and close to the thesis drawing together the implications of the research.

Background: Antisocial personality is characterised by impulsive behaviour and a pervasive disregard for the rights of others. Its consequences are often debilitating and its presentation poses considerable treatment challenges. While it may be associated with a range of neuropsychological deficits, the literature is often contradictory and no research has examined their effect on treatment. Method: A systematic review of the neuropsychological literature on male adults with antisocial personality was conducted to facilitate generation of hypotheses. Pooled evidence from 132 studies suggested robust cognitive deficits in motor regulation, affect recognition, and concept formation. Findings were less consistent for other functions and differences between operationalisations of the antisocial personality were present. To further investigate the neurocognitive deficits and examine their effect on treatment, the Cambridge Neuropsychological Assessment Battery (CANTAB) was administered on 102 adult male offenders (divided into those with antisocial vs. other personality disorders) and on 20 healthy controls in a between-subjects design. Two operationalisations were examined in parallel for the first time: Antisocial Personality Disorder (ASPD) and psychopathy. Progress in treatment was measured using a two-part, standardised instrument – the Progress Rating Schedule (PRS) – developed systematically via thematic analysis as part of the project. Results: ASPD demonstrated impairments in executive, memory, attentional, and visual processing functions while psychopathy showed primarily executive but overall milder deficits. Impairments in motor regulation, set-shifting, working memory, and visual perception appeared present in the antisocial personality (ASPD and psychopathy) but not offenders with other personality disorders. Regarding progress in treatment, the PRS showed good reliability (intra-class correlations: 0.63-0.92; internal consistency: 0.77-0.87) and concurrent and predictive validity. However, cognitive difficulties predicted outcomes only to a limited extent. In ASPD, fronto-temporal deficits predicted poorer progress through the forensic pathway. However, higher risk-taking (Cambridge Gambling Task) predicted better outcomes while intellectual functioning and presence of psychopathy mediated some effects. In psychopathy, only visual short-term memory and planning predicted progress; impairments in the former predicted slower progress but there were inconsistencies for the latter. Conclusions: A range of neuropsychological deficits appeared to characterise the antisocial personality and some may have adverse effects on progress in treatment. Further research is required in other, larger samples and cognitive functions not included in the CANTAB to confirm and extend these findings.

Offender characteristics are considered important in the prediction of future risk of re-offending and response to treatment. The psychiatric classification of offenders can therefore be an important variable influencing decision making. Although the relationship between personality disorder and offending is established in the literature, the relationship is complex. Recidivism of any type, particularly serious further offending that is violent or sexual in nature, has far reaching implications on the victims, the perpetrator, the criminal justice system and wider society. The identification and management of individuals with personality disorder is a priority for both mental health professionals and the criminal justice system. The overall aim of this thesis is to examine the relationship between personality disorder and further offending in adult forensic populations (prison and probation). Chapter one presents a general introduction to the topic. Chapter two presents a literature review following a systematic approach and poses the question: Is personality disorder associated with recidivism? The findings are generally supportive of the view that some personality disorders are associated with a greater likelihood of recidivism. The limited good quality research available indicates the need for further research. Chapter three presents a critique of a screening tool for personality disorder, the Standardised Assessment of Personality: Abbreviated Scale (SAPAS). It highlights that despite some shortcomings, the SAPAS is a simple, brief and useful first-stage screening tool for personality disorder that possesses adequate psychometric properties. It is proposed that a combined screening approach, using the SAPAS and Offender Assessment System Personality Disorder (OASys PD) screen, is necessary to improve the detection of antisocial cases, particularly in forensic populations. In Chapter four an exploratory cohort study examines personality disorder in a UK sample of offenders, that have committed a further serious sexual or violent offence, whilst under the active supervision of the London Probation Trust. The study investigated the prevalence and type of personality disorders using the SAPAS and OASys PD screen. Comparisons were made between serious further offence (SFO) offenders with and without personality disorder, and within the SFO group by type of SFO (violent or sexual). The SAPAS and OASys PD screen were also explored in relation to their ability to predict group membership (SFO vs. non-SFO). The study identified that personality disorder prevalence was higher in SFO offenders, particularly antisocial traits, and that the OASys PD and OASys risk of harm (RoH) classification are significant variables for predicting group membership. The study has added to the knowledge base and understanding of SFO offenders and has implications for the practice of Offender Managers/Supervisors in UK prisons and probation units. The findings support the efficacy of the screening approach used in the Offender Personality Disorder Pathway (DOH/NOMS, 2012), London Pathways Project. A single case study is presented in Chapter five which evaluates the utility of psychological therapy with a man on Licence, presenting with traits of antisocial personality disorder. The difficulties associated with working with this client group are considered. In Chapter six a discussion of the work presented concludes the thesis. Overall, the thesis identifies some interesting findings in relation to the prevalence of personality disorder in SFO offenders and the utility of some key tools used in the assessment of offenders in probation/prison, and how these could be used in relation to risk management.

The aims of this study were to explore the nature of comorbid Tourette syndrome and attention-deficit/hyperactivity disorder (TS+ADHD), in particular whether additive, independent or symptomatic phenocopy models of comorbidity can explain the co-occurrence of these two conditions, and to investigate the impact of comorbid ADHD symptoms on cognitive functions related to the control of tic symptoms in young people with TS. Electrophysiological activity and behavioural performance were measured during three cognitive tasks designed to assess goal-directed reinforcement learning, habit-based reinforcement learning, and cognitive control and were compared between young people with TS, ADHD, TS+ADHD and unaffected young people aged 9 to 17 years. The extent to which severity of tics, ADHD and comorbid oppositional-defiant disorder (ODD) symptoms predicted behavioural and electrophysiological correlates of reinforcement learning and cognitive control was also examined. The TS+ADHD and ADHD groups were impaired in goal-directed learning and modification of new behaviours using reinforcement feedback. ADHD symptoms were negatively associated with adaptive changes in the feedback-related negativity (FRN) ERP that were indicative of compensatory strategies employed to improve learning in the TS+ADHD group. In contrast, the TS+ADHD and ADHD groups showed intact habit-learning performance compared with unaffected controls. The TS+ADHD and ADHD groups were impaired in the ability to withhold inappropriate responses to Nogo stimuli during the Go/Nogo cognitive control task compared with TS and controls. Both ADHD groups also showed greater intra-individual variability than TS and controls. Concurrently, the TS+ADHD group were enhanced in the ability to withhold inappropriate Nogo responses and showed enhancement of the error-related negativity (ERN) ERP relative to the ADHD group. The TS group exhibited enhanced ERN ERPs and post-error slowing, a measure of the ability to adjust performance following errors. These findings are consistent with an additive, but interactive, model of comorbidity, and indicate that comorbid ADHD symptoms introduce impairments in young people with TS that will negatively impact upon the ability to control tics.

Previous research into communication between care workers and care home residents with dementia has not utilised the experience of healthcare professionals who work with people with dementia on a daily basis. Previous research mostly consists of observational studies and the assessment of care worker training programmes. No study has yet attempted to establish the efficacy of isolated communication strategies, recommended by healthcare professionals, and administered by care workers within a residential care setting. This thesis first presents the thematic analysis of 16 semi-structured interviews with healthcare professionals who have experience of working with people with dementia. The participants discuss the personal characteristics required in a healthcare professional to facilitate communication, the verbal and non-verbal strategies they use and the organisational factors which can impact the delivery of communication as desired. Two of the recommended strategies, alpha commands and pacing an interaction, were then analysed experimentally. Three care worker-resident dyads were videoed during morning care routines in an ABAC design. Resident communicative behaviour was measured using an amended version of the Positive Response Schedule (PRS) (Perrin, 1997), the Resistiveness to Care Scale (RTC-DAT) (Mahoney et al., 1999) and compliance. It was found that the conditions containing a significantly higher percentage of alpha commands produced significantly higher PRS scores. This was shown within each dyad and across the dyads (r=+0.65, p<0.05). The results for the pacing condition were inconclusive as the residents responded quickly after instructions were given. This exploratory study found a significant effect of alpha commands on the communicative behaviour of care home residents with dementia. The implications for future research and care worker training are discussed.