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Understanding and managing emotion in psychological therapy is a complex and challenging problem for practitioners and clients. The traditional emphasis on verbal language as the mediating process in therapy is expanding with the inclusion of multimodal creative arts, based on visual, auditory, and kinaesthetic perceptions, to better support the reaccessing of emotion. This can be followed recursively by the use of words to develop narrative and meaning. The main research emphasis in this thesis was on visual art. Studies of other art forms may follow. Philosophical understanding, neuroscience advances and developments in psychological therapy underpin and explain this therapeutic expansion. A qualitative research approach is taken, engaging several different actions from within that research paradigm. The thesis is written as a metaphorical journey and conveys the experience of art dialogue and the experience of researching, as parallel stories. Psychological learning journeys undertaken by its author and a colleague, some clients, therapists and teachers, are described in three encounters. The first encounter explored visual art dialogue as a process addition to a developing experiential phenomenological approach using multimodal creative arts (The MIECAT Process � Lett 2001). The objective was for the colleagues to experience a lengthy creative arts sequence, developing and undertaking the process of visual art dialogue. Multilevel actions and outcomes were recorded throughout the collegial engagement. The collegial encounter required that the co-researchers pursue their own personal psychological meanings and report on their experience of the process. Personal narrative meanings exposed in exploring visual art dialogue, are not discussed, the emphasis being on confirming how actions occurred and their effectiveness for application. Actions stopped where direct verbal therapeutic engagement might occur. Following collegial experience, visual art dialogue was used with clients and other therapists and teachers, to question its broader relevance. The second inquiry, involving three clients of the author, asked how the process would support professional actions in a therapeutic situation. The third encounter engaged other therapists and teachers to expand on questions of by whom and how, art dialogue could be used. Psychological therapy theory suggests process location within a humanistic framework, in an eclectic focus or supporting the development of an experiential, phenomenological psychology process approach based on the known functions of mind and body. The associated personal and professional aspects of the experience of process exploration constituted a step in authorial understanding and may contribute to increasing knowledge of the creative arts applied to psychological therapy.

Diagnosis of psychological disorders is clearly gendered. To help explain these gender differences, previous research investigating actual and perceived gender differences in emotion will be detailed. Within a non-clinical setting, perceived gender differences in emotion appear larger and more consistent than actual gender differences in emotion. Gender stereotypes about emotions offer an explanation of this finding. The implications of these findings in a clinical setting are explored, specifically the impact of gender stereotypes about emotion on diagnosis and intervention.

Background: Depression within the older adult population is common. Previous reviews of the literature have considered the efficacy of psychological therapies for older adults. However, they have exclusively focussed on evidence provided by randomised controlled trials neglecting emergent evidence from other therapeutic modalities. Despite the efficacy of psychological and pharmacological treatments many depressed older people go without treatment. The barriers to treatment remain unclear, however the literature has previously suggested that they may fall within three factors; patients, health care providers and health care organisations. This study focussed on patient related factors. The literature has suggested that older adults not be as accurate in recognising symptoms of depression than adults of working age. In turn, lack of recognition of the presence of a mental health problem may influence older adult’s attitudes to seeking psychological help. The literature suggests a number of factors may influence treatment seeking attitudes in older people. These may include accuracy of depression recognition, cognitive fusion; engagement in valued activities although these did not appear to have previously been considered. Aims: The aims of this thesis were addressed by the systematic review of the literature and empirical research paper comprising it. Systematic review aimed, in light of a recent efficiency target issued by the The Scottish Government to update the literature relating to the efficacy of standalone psychological therapies for older adults and to consider the efficiency implications of the results. The empirical article had two overall aims. It sought to determine the predictive effect of attitudes to ageing and degree of depression on older adult’s ability to conceptualise their symptoms of psychological distress as depression. This study also sought to consider, in light of a paucity of empirical evidence to date, the relative predictive effect of attitudes to ageing, depression, recognition of depression symptoms, cognitive fusion and engagement in valued activities on the treatment seeking attitudes of a cohort of depressed older adults. Method: A systematic review of the literature was undertaken to consider the efficacy and efficiency of psychological therapies in the treatment of late life depression. An empirical cross sectional survey recruiting older adults (n = 281), aged ≥ 65 years was undertaken to examine the effects of depression, cognitive fusion, attitudes to ageing, and valued behaviour on attitudes to seeking professional psychological help. Results: In the systematic review, of the 1493 articles identified 11 were retained for review. Papers reviewed considered the effectiveness psychological interventions including: Cognitive Behavioural Therapies, Reminiscence Therapies, Acceptance and Commitment Therapy and Problem Solving Therapy. The results of the statistical analysis in the empirical work suggested that a significant proportion of ‘depressed’ older adults (n = 43) recruited to our study were not able to recognise they were depressed at the time of their participation in the study. A binomial logistic regression suggested that depression severity rather than attitudes to ageing predicted depression recognition in this sample. A hierarchical multiple regression undertaken to analyse the predictive influence of depression, depression recognition, cognitive fusion, attitudes to ageing and engagement in valued activities suggested that non of these variables significantly predicted our sample’s attitudes to seeking professional psychological help. Conclusions: Our results demonstrate that there is increasing evidence that some psychological therapies could be offered as alternatives to antidepressant medication for older people and within an efficient model of stepped care. The results of the empirical element of this project suggest that attitudes to ageing and cognitive fusion are both predictors of attitudes to treatment seeking. The results further suggest that many depressed older people don’t recognise when they are depressed suggesting a lack of mental health. These findings suggest several implications for clinical practice, psychological therapies and public health.

The purpose of this study was to identify what women with primary breast cancer found helpful and unhelpful in psychological therapy. In-depth qualitative interviews were conducted with eleven women who had been supported post diagnosis, with psychological therapy. The women were, in the main, recruited from the Breast Cancer Voices network, set up by the national charity Breast Cancer Care. Data was analysed using Grounded Theory Analysis (GTA), from a social constructionist perspective. The women identified a range of helpful aspects in therapy: They all discussed their context, being thrown into the breast cancer world and analysis identified three helpful conditions; having the psychological need recognised by others, having easy access to ongoing flexible therapy and valuing the therapist's personal qualities. Three helpful interactions were identified; being enabled to express self safely, being treated as an individual whole woman and accessing the therapist's inner self. In addition, two helpful actions were identified, being helped to empower self and being taught new coping skills. The key theme was being helped to put active self back together again, which was the consequence of the therapy process. Analysis identified two unhelpful conditions, not having easy to access therapy and the therapist's personal qualities being cold and harsh. Two unhelpful interactions were also identified, being unable to express self safely and not being treated as an individual. One unhelpful action was identified, the therapy being too short. The consequence, when therapy was not set up in the right way, was that the women were re-traumatised and remained shattered. Whilst sample size was small, nevertheless the aim of generating rich in-depth data was fulfilled. The findings have theoretical implications: Treating women as whole individuals, helping the women learn individual coping skills from a pluralistic perspective and helping to empower women can be as important as the medical care. The methodological implications are experiencing a therapeutic effect of research participation, valuing the women as active co-researchers, ethically considering participant benefits alongside risks and using GTA from a social constructionist philosophy helped to understand individual experience and at the same time that breast cancer is socially constructed. The practical implications are: Referral pathways to identify women who need psychological support, a safe therapeutic space to express real fears, normalising experience post breast cancer diagnosis and putting in place a flexible therapy contract are all vital to support women with primary breast cancer.

Introduction: Socio-emotional behaviour difficulties following acquired brain injury (ABI) have been shown to have a persisting negative effect on quality of life. A systematic review was carried out to look at the efficacy and clinical effectiveness of available psychological treatments for socio-emotional behaviour difficulties following ABI. Research was carried out to further understand socio-emotional behaviour by exploring the possible underlying cognitive aspects (specifically social cognition) in a traumatic brain injury (TBI) population. The study investigated the relationship between social cognition and socio-emotional behaviour post-TBI. Method: A systematic search of articles published between January 2008 and November 2013 was carried out following the Cochrane (2008) guidelines. Papers were quality assessed to identify strengths and weaknesses. In the research study, forty TBI participants were asked to complete tasks of emotion recognition, theory of mind, cognitive flexibility, processing speed, attention and working memory. Selfrated and proxy-rated behaviour questionnaires were also administered. Results: The systematic review revealed seven studies for inclusion; three papers looked at a Comprehensive Holistic Approach, two papers on Cognitive Behavioural Therapy, and two on Cognitive Rehabilitation Therapy. The findings suggested that CHA showed the best efficacy and generalization. However, there were also positive results within the CBT studies. The research paper found that the TBI group performed significantly poorer than the control group on measures of emotion recognition and three out of the four ToM tasks. The TBI group also performed significantly poorer on measures of processing speed and working memory (executive function). There was no association found between performance on any of the cognitive tests and socio-emotional behaviour. Conclusions: This is an area of limited research, likely due to the challenges of carrying out research in an ABI population. The systematic review highlighted the limited research available which has implications in clinical practice due to a lack of evidence base for potentially effective interventions. The research study results suggest that there is still a lack of understanding of socio-emotional behaviour and its underlying cognitive functioning. Further research would improve understanding and could also focus appropriate post-ABI interventions for socio-emotional behaviour problems.

The literature on depression is dominated by theories which focus on individualistic variables, including biological differences, personality, and individual cognition. Whilst the importance of social variables for depression risk and recovery has also been recognised, there has been a notable absence of a unifying theory explaining, how, when, and why they might impact on depression. In recent years, the Social Identity Approach (SIA) - a theoretical framework with roots in social psychology - has been used to provide a new understanding of the role of group processes in depression. The aim of this thesis was to add to a growing body of evidence in support of the SIA to depression by replicating previous findings using a sample, who on average, scored high on a measure of depression symptomology, and by identifying additional mediators of the relationship between social identity processes and depression. Specifically, it was theorised that optimism - a personality variable associated with depression, but traditionally conceptualised as a fixed trait - would vary along with group memberships and mediate the effect of social identity processes on depression. Participants who had experienced depression (N = 288) completed an online survey. It was found that in support of previous research, an increase in group involvement predicted lower depression scores. However, this relationship was mediated by increased optimism. Similarly, identifying more strongly with a specific group predicted depression indirectly through an increase in perceived social support, and increased optimism. For a sub-sample of participants with experience of psychological therapy (N = 135), the negative association between a good therapeutic alliance and depression was serially mediated by increased identification with the therapist, internalisation of the therapist identity between sessions, and increased optimism. The extent to which the therapist was perceived as prototypical of therapists in general also indirectly reduced depression via increased identification with the therapist category, and increased optimism. These findings are discussed in relation to the further development of the social identity approach to depression, with consideration of their implications for onset, maintenance and recovery.

Background: Guidelines for the treatment of Post-Traumatic Stress Disorder recommend 8-12 session of trauma-focused CBT or EMDR, however there is an extensive body of literature criticising the PTSD paradigm and usefulness of recommended therapies in treating PTSD in the 'real world', particularly with the complex presentations of refugees . Alternative models for 'complex' PTSD have been proposed, as have transtheoretical phased stages for treatment. To date there has been no research into refugees' experience of trauma-therapy. Leaving a significant gap in understanding of how trauma therapy works. Aims: With this gap in the research in mind, and in line with the current focus on service user involvement in research, this study aims to investigate refugees' experiences of trauma-therapy. Methodology: Semi-structured interviews were conducted with six refugees who were coming towards the end of trauma-therapy with a specialist trauma service. The transcripts of the interviews were then analysed using Interpretative Phenomenological Analysis (IPA). Results: Six master themes emerged from analysis: 'Therapy as a light in a dark place', 'Rebuilding a shattered sense of self', 'A changing relationship with the world and others', 'Escaping the past to pursue a future', 'A journey from sceptic to convert' and 'From an unknown mystery to a known mystery'. These master themes along with the subordinate themes are expanded into a narrative account of participants' experiences. Implications & Conclusion: Amongst numerous implications for clinical practice the need for support to engage in therapy, thorough explanation of therapy and pre-empting of possible conflicts and difficulties arising were identified. Allowing time to build a therapeutic relationship, the usefulness of the PTSD construct for individuals and the importance of the 'non-specific' factors of therapy in addition to the teaching of techniques to manage symptoms were also found to be of importance. This study has made an important contribution to knowledge about refugees' experiences of therapy for trauma.

This investigation utilized a novel, self-help, multi-element psychological program to manage chronic low back pain. A literature review indicated that this disorder was costly and prevalent, yet a large percentage of chronic low back pain patients did not respond to traditional treatment. Recent research has demonstrated that numerous psychological difficulties have been associated with this disorder, including depression and anxiety. It was hypothesized that these psychological concomitants of chronic low back pain maintain and promote further pain, as part of a vicious cycle. Self-help treatment attempted to break this tension-pain-anxiety cycle using various stress reduction, and cognitive and behavioral management strategies.

Purpose: The aim of the systematic review was to address whether psychological interventions were able to reduce fatigue severity or the impact of fatigue in individuals with Multiple Sclerosis. The empirical study aimed to evaluate the effectiveness of a CBT based self-help workbook at reducing perceived impact of fatigue in a clinical sample of MS patients. Methods: A systematic search of the literature was carried out between the years 1980 and February 2015 to review whether psychological interventions were effective for fatigue management in Multiple Sclerosis. A randomised controlled trial examined the effectiveness of a CBT-based self-help workbook for the reduction of fatigue impact in MS. Participants were randomly allocated to one of three groups treatment as usual (TAU), pure self-help (PSH) or guided self-help (GSH). Results: Eleven studies were included in the systematic review, which indicated that CBT based interventions aiming to reduce fatigue or depression were most effective at reducing the severity of fatigue. Impact of fatigue can be reduced through mindfulness, CBT, motivational interviewing and to a lesser extent acceptance and commitment therapy. The empirical study did not find any significant differences between groups, however satisfaction with the workbook was high. Conclusions: The review suggests that there is a clear role for psychological interventions in fatigue management in MS, although further robust research into different therapeutic modalities is needed. From the empirical study it appears that the low level CBT-based intervention for fatigue in MS was not effective at reducing the perceived impact of fatigue. This study reflects an inclusive, clinical sample, recruited from a specialist rehabilitation unit, with high levels of multidisciplinary input which may have diluted any potential effect of the workbook. Objectives: The aim of the systematic review was to address whether psychological interventions are able to reduce fatigue severity or the impact of fatigue in individuals with Multiple Sclerosis Data sources: A search was conducted of: Psychinfo, Medline, Embase, CINAHL between 1980 and February 2015. Review methods: All studies were evaluated against a set of quality criteria by author (KG) with a proportion of studies being independently reviewed by author (DP) to ensure reliability of ratings. Results: Eleven studies were included in the review. CBT based interventions with a focus on fatigue management and depression appear to significantly reduce fatigue severity with medium to large effect. Significant reductions in fatigue impact can be found from mindfulness groups, motivational interviewing and CBT. Effect sizes for CBT interventions ranged from negligible to medium. For the mindfulness and motivational interviewing interventions effect sizes were not able to be calculated. The acceptance and commitment therapy intervention did not find a significant reduction in fatigue but found a medium effect for the intervention. Conclusions: There is a clear role for psychological interventions in the reduction of fatigue management but more high quality research needs to be carried out.