This thesis explores the question, what are the important change processes in the treatment of personality disorder in a male forensic inpatient setting? A number of empirically supported therapies for personality disorder stress the importance of the therapist-client relationship in the change process. Therapist-patient relationships are therefore an important focus in this thesis. However, given the lack of research into change processes in this population, the focus is not limited to the therapist-patient relationship, but also considers other relationships and other aspects of the treatment milieu. A model of change processes for this patient group is developed through a series of studies. The first study, in chapter 3, is a qualitative investigation of patients’ perceptions of the process of change and the factors involved. Twelve patients completed a semi-structured interview and the results were analysed using thematic analysis. The study concludes that the cognitive dissonance between how patients expect to be treated and how they are actually treated is an important factor in motivating them to engage in treatment. It also concludes that the therapist-patient relationship and the wider interpersonal environment are both important to therapeutic change with this population. Chapters 4 and 5 describe the process of developing an appropriate dependent outcome measure for the thesis. Social functioning was selected as the dependent outcome variable. Chapter 4 is a systematic review of social functioning measures used with people with a diagnosis of personality disorder and concludes that there is a need to develop a new self-report measure specifically for people with a diagnosis of personality disorder in inpatient settings. Chapter 5 describes the development and validation of this new measure, the Hospital Social Functioning Questionnaire (HSFQ). Fifty-four patients completed a range of measures including the HSFQ. The HSFQ shows good internal consistency, test-retest reliability and concurrent validity with other measures. It appears to measure different aspects of social functioning from the Global Assessment of Functioning (GAF), the most widely used social functioning measure, and the two measures appear to complement each other. Chapter 6 is a quantitative study using the HSFQ and a self-report measure of patients’ perceptions of therapeutic change processes to test the initial model of change developed in chapter 3. Fifty patients completed a checklist about how they had changed during treatment and the factors that had contributed to that change, as well as measures of social functioning. Self-reported levels of change were highly correlated with measures of patient functioning, though significant levels of change did not occur until the latter stages of treatment. The behaviour of therapists was particularly important throughout treatment, though participants in the final stage of therapy reported that the behaviour of other staff was as important as that of therapists, suggesting that, by this stage of treatment they are able to extend their range of supportive and therapeutic relationships. The results support a limited reparenting attachment-based model of therapeutic change. Chapter 7 is a pattern matching study that tests and refines the model of change. Ten patients completed a semi-structured interview about their interactions with their therapist. Their responses were analysed using a modified version of pattern matching to test hypotheses generated by the limited reparenting attachment-based model of change. The results support the limited reparenting model and suggest that patients’ attachment relationships with their therapists are an important change process for this population, particularly in the earlier stages of treatment. Chapter 8 presents a three-stage model of change based on the results of this thesis. On first admission, patients enter the orienting/ cognitive dissonance phase, in which they start to engage in treatment after perceiving a consistent improvement in how they are currently regarded and treated compared to how they have been regarded and treated previously, particularly in prison. Next, they enter the reparenting phase, during which their relationship with their therapist is the most important factor affecting change. Many features of the therapist-patient relationship during this phase parallel attachment processes between children and caregivers. Finally, patients enter the exploration/ generalisation phase in which they are able to explore from the secure base of their relationship with their therapist and develop supportive and therapeutic relationships with other staff members. This model provides a useful framework for working therapeutically with this patient group.

Background Smoking during pregnancy is the leading preventable cause of poor birth outcomes for mothers and babies. In 2010, 26% of women smoked during or in the 12 months prior to pregnancy, and 12% smoked throughout pregnancy. 120 trials of nicotine replacement therapy (NRT) have shown that it is effective for smoking cessation in non-pregnant smokers. However, the 9 trials conducted in pregnant smokers, provide no evidence that NRT helps pregnant smokers to stop. In 2012, a large randomised controlled trial (RCT) investigating NRT used in pregnancy for smoking cessation reported that it initially doubled smoking cessation rates, but found no evidence that it enhanced cessation throughout pregnancy. Trial participants reported low adherence to NRT. One possible reason for this is that nicotine metabolism is much faster in pregnancy and so the doses of NRT which have been trialled in pregnancy may not sufficiently treat women’s nicotine withdrawal symptoms. This study not only found that children of mothers in the intervention arm had better developmental outcomes at 2 years of age, but also that a dose-response relationship existed between reported higher NRT use and the latter. Using data from this trial, this thesis aims to further explore factors driving/associated with both higher adherence to NRT in pregnancy and improved birth outcomes, and to raise hypotheses about ways in which NRT may be used effectively to help pregnant smokers attempting to quit. Methods The studies reported in this thesis used data from 1,050 pregnant women recruited to the Smoking, Nicotine and Pregnancy (SNAP) trial. Linear and logistic regressions, mediation analysis, factor analysis and structural equation modelling techniques were employed to answer the following questions: (1) which factors are associated with smoking cessation in pregnancy?; (2) which factors, if any, mediate the negative influence of social disadvantage on cessation in pregnancy?; (3) is greater NRT use is associated with poor birth outcomes?; (4) is adherence to NRT associated with greater odds of cessation?; (5) what are the characteristics associated with the rate of nicotine metabolism and does more rapid metabolism of nicotine reduce a woman’s chances of achieving cessation? Results (1) Within a trial of NRT used for smoking cessation, pregnant women who were more educated (Odds Ratio (OR) at one month post-quit date (one month): 1.82, 95%CI: 1.24-2.67, p=0.002/OR at delivery: 1.89, 95%CI: 1.16-3.07, p=0.010) and less nicotine dependent (OR for baseline cotinine at one month: 0.94, 95%CI: 0.91-0.96, p<0.001/OR for baseline cotinine at delivery: 0.96, 95%CI: 0.92-0.99, p=0.010) / (OR for HSI at one month: 0.50, 95%CI: 0.32-0.76, p=0.001/OR for HSI at delivery: 0.43, 95%CI: 0.23-0.79, P=0.006) were more likely to achieve cessation. (2) There was evidence that the observed relationship between social disadvantage and cessation was mediated by women’s nicotine dependence (17.1% of the effect of social disadvantage on cessation), but not by them living with partners who smoked. (3) In an analysis investigating the relationship between use of NRT in pregnancy and birth outcomes, greater reported use of NRT was not associated with either better or worse birth outcomes, either in a-priori analyses using birth weight (β: -0.46, 95%CI: -3.58 to 2.66, p=0.773) and being born small for gestational age (SGA) (OR: 1.01, 95%CI: 0.99 to 1.03, p=0.184), or in exploratory analyses using all other SNAP trial birth outcomes. (4) In the first ever detailed analysis of the phenomenon of adherence with NRT in pregnancy, women who adhered more completely had lower pre-treatment cotinine concentrations (β: -0.08, 95%CI: -0.15- -0.01, p=0.020), lower heaviness of smoking index (β: -0.27, 95%CI: -0.50- -0.05, p<0.001) and were more likely to have been assigned to active rather than placebo NRT (β: 0.51, 95%CI: 0.29-0.72, p<0.001). Greater adherence with NRT was positively and significantly associated with increased odds of smoking cessation (Adjusted OR at one month: 1.11, 95%CI: 1.08-1.13, p<0.001/Adjusted OR at delivery: 1.06, 95%CI: 1.03-1.09, p<0.001), but there was no treatment allocation (i.e. nicotine or placebo)-adherence interaction with respect to cessation (LRT p=0.151). Analyses could not exclude the possibility that the observed adherence-cessation relationship was caused by women who relapsed to smoking consequently also stopping use of NRT. It also remains unclear whether the adherence-cessation relationship may be due the characteristics of individuals who are more likely to adhere (i.e. women who are prone to following instructions to use NRT, might also be more likely to follow instructions to not smoke). (5) In another novel analysis, pregnant women who metabolised nicotine more quickly had reduced odds of cessation (OR at one month: 0.87, 95%CI: 0.76-0.99, p=0.043/OR at delivery: 0.79, 95%CI: 0.66-0.94, p=0.008); however, there was no evidence that NRT was more effective in slower metabolisers. Conclusions Having higher levels of education and lower levels of nicotine dependence were associated with cessation. Nicotine dependence mediates the negative effect social disadvantage has on achieving smoking cessation in pregnancy. Greater reported use of NRT in pregnancy neither harms the foetus nor protects it from the harms of smoking, with respect to birth weight and SGA, but there is insufficient evidence to draw similar inferences for all birth outcomes. Adherence is associated with better smoking cessation outcomes, and women who exhibit greater adherence have differing characteristics compared to those that adhere less. It was not possible to determine whether or not these better outcomes were a function of women’s characteristics or if they were attributable to the treatment they received. The rate of nicotine metabolism appears to be important in determining whether or not pregnant smokers will manage to successfully stop smoking, but there was no evidence that NRT effectiveness was influenced by nicotine metabolism. Quitting smoking during pregnancy is important for both the mother and the child’s health outcomes. Socially disadvantaged women are less likely to achieve cessation but this thesis provides the first evidence to suggest that these odds may be improved by addressing nicotine dependence; NRT provides an eminently treatable way of doing this. This thesis’s findings suggest that use of NRT is at least as safe as continued smoking with respect to birth outcomes, although probably safer. This thesis also provides the first evidence on the associations between individual pieces of NRT and cessation in pregnancy, as well as the first evidence on nicotine metabolism’s association with cessation in pregnancy. Overall, NRT provides a promising way to increase the odds of cessation for disadvantaged pregnant smokers, however, there is a need for further research and the work in this thesis should provide a spur to investigate the effects that adherence to NRT and an individuals’ metabolism may have on NRT effectiveness in pregnancy.

Firefighters have a high likelihood of being exposed to a variety of traumatic events. The psychological cost of this exposure may be an increased risk of long-term problems such as PTSD symptoms, depression and anxiety. Saudi firefighters in Makkah province are often exposed to elevated levels of potentially traumatising events through the course of their work which can affect them physically and psychologically. However, providing sufficient mental health professionals is difficult due to the absence of psychological trauma care in Saudi Arabia and Saudi culture associated with the psychological support. The aim of this thesis is to understanding the psychological impact of being a firefighter and seeing whether narrative exposure therapy (NET) is an effective treatment for traumatised Saudi firefighters. Three studies were conducted In order to achieve these aims. The first administered questionnaires to 200 Saudi firefighters; the second was a qualitative study comprising of semi-structure life story interviews with 9 traumatised Saudi firefighters, whilst the final randomized control trial (RCT) examined the effectiveness of NET with 34 Saudi firefighters with PTSD. A high prevalence rate of PTSD (57%), anxiety (44.4%), and depression (53.3%) symptoms with limited mental health support were reported. Single firefighters reported PTSD symptoms and the use of passive coping strategies more than the married firefighters. The results also revealed that marriage was associated with low levels of PTSD, while high levels of PTSD correlated with anxiety, depression, and with passive coping strategies. The qualitative study illustrated themes and subthemes reflected family life, education, experience of being firefighters, traumatic, coping strategies. Two narrative analysis cases presented with the life plot trend with the positive impact of the individual’s life story interview which inform the using of narrative technique in the intervention study. The RCT study demonstrated a significant reduction in PTSD, anxiety, and depression symptoms after 6 weeks, but this was not sustained at 3 and 6 months. The research provides evidence for the applicability and effectiveness of a narrative intervention for traumatised Saudi firefighters. It tried to facilitate the wider dissemination of psychological intervention to promote recovery from traumatic stress for the first responders. Four sessions might not give firefighters sufficient time to process all the relevant information, and they therefore reported an increase in PTSD symptoms in the follow-up time. It would be preferable for firefighters to receive two or three NET sessions after a 3 and/or 6-month follow-up. The findings help advance current knowledge in the management of PTSD among firefighters, in-depth understanding the psychological, coping, and cultural backgrounds, in developing countries, contribute to the validation of PTSD theories, and inform future research. The implications of developing a multi-factorial and holistic approach to the treatment of first responders’ traumas are presented and a case is made for the use of narrative methods in the treatment of complex trauma.

The emergence of recovery as an important philosophy in contemporary mental health care, alongside increasing levels of coercion has drawn attention to the potential for conflicting influences in mental health practice. This thesis examines how such conflicts may be situated in the historical, legal and professional foundation of mental health services, presenting an argument to suggest this exposes mental health professionals to tensions in decision-making. Inspired by my own experiences as a mental health nurse, this qualitative interpretive inquiry employed multiple case studies to explore whether and how mental health practitioners perceive and experience potential tensions that may arise from delivering care and enforcing control. Data was collected using interviews with mental health professionals and observations in an acute in-patient ward and assertive outreach team. Data analysis using a theory building approach in case study research was adopted to develop an explanatory model which suggests service users are constructed as objects of risk. Hilgartner’s (1992) theory has been employed to support explanations that people with mental health problems are defined and treated in terms of risk. Such a process is enabled by a spatial, narrative and moral distance that is created between service users and professionals. The construction of service users as objects of risk is influenced by professional, organisational and social contexts. However, displacement from the status of risk object occurred when some professionals maintained proximity to service users’ subjective experiences. The study has underlined the importance of raising awareness that recovery values are not being realised in mental health practice. It has highlighted problems with the language of risk and proposed strategies that may enhance opportunities for professionals to remain connected to service users’ narratives through dialogue.

Background: Smoking in pregnancy is a major cause of morbidity and mortality, with a significant cost burden to the NHS. An estimated 26% of women still report smoking at the beginning of, or just before, pregnancy, with 12% reporting smoking throughout. While economic evaluations of cessation interventions in the non-pregnant population are well developed, similar evaluations of within-pregnancy interventions are not. Because of the special circumstances associated with pregnancy, general smoking evaluations cannot be applied in these settings. This thesis outlines the development of an improved economic model designed to capture the healthcare costs and benefits associated with smoking and cessation within pregnancy. Methods: A series of scoping reviews of the electronic resource Medline were conducted to identify either within-pregnancy or childhood morbidities which had potentially causal associations with smoking during or after pregnancy, as well as the incidences of morbidities and health related quality of life (HRQoL) scores attributable to those identified. A systematic review appraised the previous economic literature on cessation during pregnancy, to determine where improvements were needed. To ensure that relapse to smoking could be accounted for, a second systematic review generated pooled estimates of abstinence from smoking in the postpartum period. This information was used to develop and construct the improved economic model. Results: 11 conditions were identified as having a causal association with smoking during pregnancy. The systematic review of previous evaluations identified 17 studies; however, only three were considered high quality, suggesting the need for an improved model. The pooled estimates of abstinence suggested that by two years postpartum, most women had restarted smoking, with most relapsing after three, but before 12, months postpartum. The Economic impacts of Smoking In Pregnancy (ESIP) model consists of two linked decision trees which capture the within-pregnancy aspects, while two linked Markov chains capture the post-pregnancy smoking behaviour for both the mother and her child. ESIP was also extended to control for uncertainty. Conclusion: ESIP improves on the previous literature since it directly captures the impact of the mother’s smoking behaviour on the health of her offspring, both within-pregnancy and childhood, using the most accurate data currently available. Future extensions to ESIP include an adult component for the infant to capture their smoking behaviour.

Purpose and Background This mixed methods study explored the importance of therapist body-confidence and gender upon the Eating Disordered client and recovery. Examination of previous literature highlighted a lack of research exploring negative treatment experiences from the perspective of individuals who have an Eating Disorder. With reference to socio-cultural theoretical models, initial findings in the literature indicate that aspects of therapist appearance may be an important factor in treatment experience. The potential sensitivity of exploring therapist appearance is considered as one reason that this topic remains largely unexplored in the literature. Method 143 males and females with self-reported current or historical experience of an Eating Disorder completed an anonymous, online survey which was designed by the authors for the purpose of the study. Questions exploring body-confidence and recovery were analysed using Thematic Analysis incorporating Saliency Analysis. Questions pertaining to therapist gender and body-confidence were analysed using statistical tests. Rationale is provided for the epistemological stance, methodological approach and design of the current study. Results Thematic Analysis revealed three overarching themes about body-confidence and three overarching themes about recovery. The body-confidence themes suggested that individuals who have an ED progress along a continuum of beliefs about body-confidence, initially believing that it is linked to body-size, before acknowledging that their Eating Disorder is unrelated to body-confidence and finally realising that body-confidence is possible regardless of size. The recovery themes indicated that individuals who have an ED go through a cycle where they feel restricted, begin to reconcile self and culture and achieve resilience on the path to recovery. Statistical analysis revealed that participants rated therapist body-confidence as highly important and showed a strong preference for a gender-same therapist. There was also some indication that participants judged the body-confidence of male and female therapists differently, although the effect size of this finding was small. The results are discussed within the context of previous literature and in keeping with the epistemological position of the current study. Conclusions These findings offer further support for the continued investigation of therapist appearance, in particular body-confidence and gender, and how it might impact upon the therapeutic experience of Eating Disordered clients. Further contribution is the addition of the perspective of individuals who have an Eating Disorder to the literature about recovery from an Eating Disorder. There are important implications for services, how they are organised and how therapists are trained to work with this population. Future research should further explore the ways in which aspects of therapist appearance impact upon therapeutic experience for Eating Disorder clients and whether there are mediating factors. Finally, the principle researcher’s critical reflection about theoretical, scientific and ethical aspects of the research process is provided.

Introduction: ‘Sex addiction’ appears to have been largely accepted within clinical fields and popular culture. However, despite its 30 year history, the concept remains ill-defined and lacking in empirical data. Indeed, proponents of sex addiction continue to debate its terminology, definition, nosology, and aetiology, with a coherent model of the ‘disorder’ yet to be offered. An alternative account presented by the social constructionist model argues that the reason for this contention is because, rather than a pathological disorder, sex addiction represents a social construction. Those who argue from this perspective suggest that sex addiction has been created to pathologize sexualities which fail to promote dominant sexual norms. Whilst this argument appears convincing, it is not clear why some may be more influenced by these dominant sexual norms and thus pathologize their sexuality, whilst others do not consider their sexuality to be problematic. The answer to this may lie in certain individual differences, in particular, personality, thinking dispositions, sexual attitudes, and religiosity. Aims: This was an exploratory piece of research which aimed to compare sex addicts (SAs) to ‘non-addicts’ (NSAs) on the dependent variables: sexual behaviour, the Big Five personality traits, categorical thinking, sexual attitudes, and religiosity. Design: A convergent parallel design was employed, using questionnaires to collect quantitative and qualitative data. Method: A self-selecting sample (N = 214) was recruited via poster and online advertisements placed in general public sites such as pubs and clubs, and sex addiction and sexual interest forums. Participants completed an online questionnaire comprising: a) an assessment of ‘sex addiction’ via participant’s self-identification and a clinical screening tool (the Sexual Addiction Screening tool; SAST); b) a free text box in which participants explained their self-identification; c) a questionnaire collecting demographic data and assessing the variables under investigation. Results: Participants’ constructs of sex addiction largely mapped onto the dominant model of sex addiction. This was particularly evident within SAs’ responses. Conversely, a number of themes within NSAs’ responses diverged from the sex addiction model and expressed a positive view of sex. Subsequent statistical analyses comparing self-identified SAs to NSAs found SAs reported a greater frequency of solo sex and evidenced more categorical thinking. No other significant differences were observed, with the exception of neuroticism whereby SAs scored higher when samples were matched for sexual activity. When the SAST defined the groups, SAs reported a greater frequency of solo sex and anal sex, and reported a higher number of partners for oral sex and anal sex. These SAs also scored significantly higher in neuroticism and were less satisfied with their current sexual activity. Discussion: The study demonstrates the immersion of the dominant model of sex addiction within sociocultural norms and suggests that SA participants in particular have internalised these norms into their interpretive frameworks. The subsequent comparison between the groups suggests that idiographic factors may interact with these discourses, meaning some are more influenced than others by these discourses. In particular, those with a propensity to think inflexibly (categorical thinking) and/or a predisposition to respond with negative emotionality and worry (neuroticism) may be more likely to appraise their sexuality as problematic and this identify as a SA. The study also lends support to the idea that the SAST tools may unduly pathologize sexual behaviours which are considered ‘unconventional’.

M.A. (Clinical Psychology) / The nature of hypnosis and trance is investigated in the context of Western psychology, and traditional African healing practises. The historical development, definitions of nature of hypnosis and trance, and theoretical background of both these phenomena are described. Similarities and differences between Western hypnosis and African trance are described. Western hypnosis and African trance are found to be embedded in the context which provides their meaning. The similarities and differences between the African healing trance induction process and the Western context of hypnotherapy are discussed in terms of the ecosystemic theories. The content and characteristics of hypnosis in these two spheres are not seen as important as is the context and process of these phenomena. It is found that the expected characteristics of hypnosis in Western psychotherapy, and traditional African trance states, and the similarities and differences between them, are not absolute realities, but rather culturally shaped experiences which people come to expect.

Prevalence rates for mental health problems amongst drug and alcohol service users in the UK were 74.5% and 85.5% respectively (Weaver et al 2003). 44% of people with psychiatric problems also had a substance misuse problem (Weaver 2003). Aims and objectives: This study aims to identify what service users with dual diagnosis and practitioners who work in this area perceive to be the factors that foster and inhibit their recovery (a meaningful quality of life). This is a narrative study using unstructured interviews to develop a framework for understanding the experiences of people who have a dual diagnosis and to guide those that help them. Methodology: Ten service users and ten practitioners were interviewed using a narrative approach. These were then transcribed and analysed using Langdridge’s (2012) Critical Narrative Analysis framework (CNA). Goffman’s, Link and Phelan’s and Sayce’s theories on stigma and Frank’s discussion of the role of narrative storytelling in illness were used as hermeneutics of suspicion to study meaning within the narratives. Findings: The study explores how four key themes Stigma, Motivation, Recovery and Tension narratives provide an explanatory framework of recovery and identity for both service users and practitioners. It uncovers the interrelationships between the spoiled identities (double jeopardy) of service users and the influence this stigma has on practitioners. The study develops a perspective of how narrative storytelling can help articulate and reframe identities to aid recovery amongst people with a Dual Diagnosis. Relevance: There have been very few studies that explore the lived experience of people with a Dual Diagnosis or the practitioners who work with them. Meta analyses of randomised controlled trials in Dual Diagnosis have found little conclusive evidence of interventions that are effective. The study suggests that in pursuing empiricist research standards, previous studies have missed the holism provided by seeing individual experience as an important factor in affecting the course and effect on people who experience Dual Diagnosis and those around them who try to help.

Introduction: Despite a growing body of intellectual disabilities literature around the transition into adulthood, most studies have focused upon physical aspects of the transition e.g. from school to employment or into adult services. My study sought to explore the transition into adulthood from a developmental/lifecourse perspective in order to address this current gap within the literature. Given that parents are often regarded as primary witnesses to their child’s transition into adulthood, their views were explored in order to access knowledge around this particular transition. Objectives: My study used a grounded theory approach to explore parents’ views of the transition into adulthood of their child with a severe intellectual disability. A further aim was to understand whether and how parents made psychological adjustments for their child’s transition into adulthood. This included an exploration of the emotional regulation processes that parents engaged in. Method: Twelve parents of 11 children with a severe intellectual disability were recruited from charitable organisations. A Straussian grounded theory methodology was adopted to analyse the data. Results: Parents viewed their child’s transition into adulthood as a process over time. The core process involved making frequent comparisons with their perceived “norms” of adulthood. Parents engaged in a further five processes which included “defining adulthood”, “noticing adult development”, “perceiving barriers to adulthood”, “worrying” and “making adjustments. My study highlighted that parents who defined adulthood as “turning 18” were likely to make adjustments to facilitate their child’s adult development (e.g., “encourage age appropriateness”). Those who viewed chronological age as being unhelpful/meaningless were more likely to be accepting of their child’s difficulties. Contrasting views appeared throughout these processes, demonstrating the diversity of parents’ experiences and adjustments made. Discussion: Parents engaged in a series of interactional processes for their child’s transition trajectory, which was likely to influence how they made adjustments. These processes were explained using existing psychological theory and/or relating them to findings from previous studies. With regards to a grounded theory model, I proposed a transition model of parents’ views and adjustment grounded in the study findings. The visual representation of this model helped to shift away from the staged/linear idea of transition. Future intellectual disabilities studies could seek to explore the types (and function) of comparisons that parents make with others. Additionally, further research could explore fathers’ views which are under-represented within this field. Clinical interventions may aim to challenge parent perceptions; encourage peer support; and embrace systemic working with parents through their child’s transition into adulthood.