Emma Kinnaird - thesis submitted in partial fulfilment for the degree of Doctorate in Clinical Psychology (DClinPsych)

Systematic Literature Review
Objective: If a psychotherapeutic intervention has the capacity to produce positive change, the “deterioration effect” theory holds that it must also have the potential for negative effects. However, the definition, measurement, and reporting of unwanted events in psychotherapy is a topic of ongoing discussion. At present this area is under-explored in interventions for anorexia nervosa (AN), a severe mental illness associated with high medical and psychiatric risks. The aim of this paper was to undertake a systematic review of published randomised control trials (RCTs) evaluating psychotherapeutic interventions for AN, and to assess how unwanted events were defined, monitored and reported alongside the trial’s key findings. Method: Using a systematic review methodology, this paper identified 23 RCTs through database searches meeting eligibility criteria. Results are presented using a narrative summary approach. Results: Unwanted event reporting varied widely, both regarding definitions of key unwanted events (such as non-compliance or symptom deterioration) and in the amount of detail captured in each paper. Discussion: The review identified two key issues: firstly, a lack of consistent definitions and unclear causality made it difficult to distinguish between unwanted events, and adverse events caused by the interventions. Secondly, it highlighted the difficulty of defining unwanted events where different studies have different populations and goals. Recommendations are made around how the area of defining, monitoring, and reporting unwanted events in RCTs for AN can be taken forward.

Service Improvement Project
Autistic adults are at higher risk of experiencing mental health problems compared to their neurotypical peers and are more likely to report unmet healthcare needs and poor service experiences. Research suggests that this is closely related to a lack of understanding of autism by clinicians working in this area. Therefore, there is an increasing impetus in the National Health Service (NHS) for staff working in mental healthcare to receive autism training. However, there is a lack of understanding around autism in older adulthood, and whether older adult mental health teams could benefit from specialised training that reflects the specific needs of this population. This project used clinical audit and needs survey methodologies to explore whether an older adult mental health team might benefit from autism training, and to understand what clinicians might find helpful from a training intervention. Whilst the audit identified that the team did see patients on the autism spectrum, it was rare for the team to work with patients with a diagnosis of autism. Rather, clinicians were more likely to work with patients where autism is suspected but unconfirmed. Most clinicians reported having never received training in autism, and highlighted autism in older adults, and autism and mental health, as specific training priorities. A training programme based on these responses was developed, implemented, and evaluated using pre- and post-training surveys. The training was rated as useful by attendees and resulted in non-statistically significant increases in self-rated knowledge. The findings of this study suggest that clinicians working in older adult mental health can benefit from autism training. However, instead of generic autism training, clinicians may particularly benefit from training specialised to their older adult context. Further research is required to better understand the area of older adulthood and autism, and to evaluate how to effectively enhance the capability of staff working in this area.

Theory Driven Research Project
Background: Whilst recovery from anorexia nervosa (AN) has traditionally been defined in relation to behavioural symptoms, the presence of cognitions, and weight, there is increasing research interest around understanding recovery from AN from the perspective of personal models of recovery, which emphasise factors such as personal growth and leading a meaningful life. Whilst previous research has suggested that clinical and personal recovery factors may exist in a complimentary relationship, with reduced clinical symptoms enabling growth in personal domains, to date this association has not been empirically explored. Understanding this relationship is particularly important in the context of proposals that there is a need to develop a universal definition of recovery from AN. Methods: The current study used a mixed methods approach to explore the relationship between personal and clinical models of recovery in AN. Eighty-one adults who self-defined as fully or partially recovered from AN were recruited into an online study and completed self-report measures of clinical and personal recovery. Participants were also asked questions about their views on the personal relevance of clinical criteria, and this data was analysed using thematic analysis. Results: The study found that there was good agreement between self-defined and clinically defined full recovery from AN. People who were clinically defined as fully recovered scored significantly higher on measures of personal recovery compared to those defined as not recovered, and there were strong positive associations between lower behavioural and cognitive symptoms, and personal recovery. However, there was a weaker relationship between personal recovery measures and BMI. Finally, qualitative data indicated that most participants felt that the clinical criteria were not a sufficient definition of recovery. Whilst participants suggested potential additional criteria, and raised ideas around how these might relate to traditional symptom-based approaches, the qualitative analysis also highlighted concerns around how far a universal recovery criteria-based approach can capture individual experience. Conclusions: Implications for the development of future universal clinical criteria for recovery from AN are discussed, including how a clinical approach can best be combined with personal understandings of recovery.

Advisor: Cooper, M
Anna, C
Evans, K