Objectives: Theoretical models have helped conceptualise how individuals appraise and make sense of chronic illness and its psychological impact. Little attention has been given to the impact of uncertainty on this process. The objective was to investigate the relationship between levels of uncertainty, illness representations, coping, psychological and physical functioning in two chronic illnesses. The Self-Regulatory Model (SRM, Leventhal, Meyer & Nerenz, 1980) was used as a theoretical framework. Design: A cross-sectional design was used. It was hypothesised that a clear medical diagnosis would reduce levels of uncertainty and increase illness representations regarding control of symptoms. It was also hypothesised that high levels of uncertainty would independently predict increased psychological distress. Method: Patients suffering from chronic spinal pain and rheumatoid arthritis were recruited from local clinical departments. The levels of uncertainty, illness representations, coping strategies, mood and physical functioning of 85 participants were assessed using standardised questionnaires. Results: Chronic pain patients were found to have greater levels of uncertainty and psychological distress than rheumatoid arthritis patients. Rheumatoid arthritis patients had stronger beliefs about control of their condition. Uncertainty was not found to be a significant independent predictor of anxiety or depression. However, there appeared to be a degree of overlap between the variables of uncertainty and control beliefs. Conclusions: The findings highlight a complex relationship between the aspects of the SRM and uncertainty, with many components impacting on each other. Although levels of uncertainty were not found to be predictive of psychological distress, it is an area that warrants further investigation in order to understand how patients manage uncertainty. Within a clinical setting, issues of uncertainty should be addressed at all levels of care, maximising the patient's control beliefs, reducing the impact of uncertainty on their cognitive, emotional and physical functioning.

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This thesis develops the Effects of Power Model to explain why some power users come to behave in anti-social ways and what can be done about it. The model shares an analytical focus on the effect of the exercise of power on the power user with the Metamorphic Model of Power (Kipnis, 1976), but overcomes limitations in the Metamorphic Model by using the integrating framework of Social Cognitive Theory (Bandura, 1986). This theory guided the identification of the Effects of Power Model's main variables and their relationships, and provides a powerful framework for designing normative applications based on those variables and relationships. The Effects of Power Model describes a self-regulatory process which begins with a consideration by the power user of whether and what type of power or influence tactic he or she should use. To make the decision, the power user considers both internal standards and experiences (either vicariously gained or directly). Having acted, the power user then evaluates his or her action against both feedback and internal standards. If evaluation indicates that the action was contrary to either internal standards and/or to expected outcomes, there are two possible reactions. One is to feel bad and to plan to choose another course of action in future. The other is to rationalise the action through the use of disengagement mechanisms. The latter enables the power user to excuse his or her action and maintain a commitment to the action in the future. Over time, repeated use of disengagement mechanisms to excuse behaviour leads to a change in internal standards and to a rising commitment to the behaviour. The model's descriptive power is tested using a two-stage laboratory experiment with between subject manipulations and random allocation of subjects. A range of analytical frameworks are used to test the data including correlation, regression and Chi square analyses. Results strongly support the model. The model's prescriptive power is also considered by developing a program to enhance pro-social behaviour among power users, particularly professionals. Examples are identified that support key propositions of the model, relating to how the circumstances of professionals may influence their anti-social behaviour and how changes in circumstances could promote pro-social behaviour.

Objectives: Psoriasis is a long-term inflammatory condition associated with considerable psychological and social morbidity. There are multiple psoriasis treatment modalities and regimens making medication adherence particularly demanding. The Self-Regulatory Framework has not been widely applied to investigate adherence by people with psoriasis. This thesis reports research into psychological factors associated with medication adherence in psoriasis. Methods: A systematic review of adherence to treatments (Phase 1) was followed by a qualitative investigation of measures of adherence and treatment beliefs (Phase 2). A large-scale multisite quantitative survey of levels and determinants of adherence to systemic psoriasis treatments was carried out by linking new psychological measures with data from a national treatment registry (Phase 3). Finally a mixed-methods investigation into self- regulatory approaches to the understanding of adherence was undertaken (Phase 4). Findings: i) Adherence difficulties are prevalent in psoriasis, however poor methodology quality of previous studies limited conclusions of the systematic review ii) Patients using topical preparations described significant day-to-day variations in medication use as well as complex treatment decision-making processes; however, key behaviours and cognitions were not accurately reflected by corresponding scores of the standardised scales iii) Patients using systemic treatments reported high levels of adherence which were associated with: biologic rather than a traditional systemic; fewer concerns about systemic treatments; and lower PASI and DLQI scores. Unhealthy lifestyle behaviours were also prevalent iv) Effective treatment usage in psoriasis conflicted with the management of the physical and psychological demands of living with psoriasis. For patients using topical preparations, non-adherence was a strategic decision to reduce distress and gain control. Patients using systemic treatments expressed strong beliefs in the necessity of their treatment, yet reported high levels of anxiety and depression. Systemic treatment usage conflicted with the management of illness controllability and psychological adjustment. A more negative illness belief profile and greater appearance concerns accounted for the most variance in both anxiety and depression, even after controlling for disease severity. These findings have major implications for the measurement of adherence and treatment beliefs, as well as researchers’ ability to determine clinical outcomes and treatment response. Conclusions: Psoriasis treatment adherence can be practically challenging as well as emotionally charged. The construct of self-regulatory failure proved to be illuminating and improves understanding of the psychological processes that underpin medicines adherence and other aspects of self- management in people with psoriasis.