Social anxiety in learning: stages of change in a sample of UK undergraduates

Social anxiety in learning is prevalent amongst traditional-age students and has a marked effect on their engagement with higher education. It receives little attention from academic or support services and there is a presumption that students will manage their anxieties. Yet it is unclear what psychosocial resources they might bring to this task and how these may develop through the undergraduate years. This study sought to identify possible change processes in student social anxiety by analysing qualitative responses obtained from Level 2 undergraduate students (n=39) in relation to their experience of learning situations such as lectures, seminars and group presentations. Thematic analysis suggested a four-stage developmental progression for students in terms of their experience and orientation to coping with social anxiety. Implications for staff development and student support are outlined.


Introduction
Students in higher education are expected to discuss their subject with peers and tutors, to present their work for debate and assessment, and to acquire interpersonal skills for future employment. A degree of anxiety is a natural response to unfamiliar social situations (e.g. Purdon et al. 2001) but, while most students overcome the anxieties associated with academic discussion and presentation, a significant minority remain affected throughout their undergraduate years (Topham 2009). Persistent social anxiety in learning situations has an adverse impact on student engagement, retention and well-being and, if unaddressed, has an adverse impact on opportunities and quality of life after university (for reviews see Kessler 2003;Wittchen 1999). Students tend to be reluctant to seek help for mental health concerns (University of Leicester 2002), while the presentational and developmental aspects of social anxiety mean it is unrecognised by institutions as a focus for pedagogic or therapeutic support (Topham and Russell 2012). There is a need to establish what is helpful for students suffering from social anxiety in order to inform institutional support processes. One approach is to identify instances of remission in student social anxiety which occur without intervention, and to examine the student perspective on factors which contribute to that remission. This study aims to acquire and analyse data about students' experience of change in their social anxiety and in their approaches to coping with it.

Background Definition
Most studies of social anxiety use diagnostic criteria for social phobia or social anxiety disorder as the basis for enquiry and analysis (e.g. DSM IV TR [APA 2000]). The diagnostic features have been summarised as: [A] marked and persistent fear of social or performance situations. Affected individuals fear that they will be evaluated negatively or that they will act in a humiliating or embarrassing way. Exposure to social or performance situations invariably leads to panic or marked anxiety, and such situations therefore tend to be avoided or endured with extreme distress. (Veale 2003, 258) Anxiety is a constituent response which is expressed in varying forms and intensities across the lifespan, only some of which justify diagnosis and intervention. A qualitative study of social anxiety found that student participants' accounts were associated with themes such as a need for connection with and acceptance by others; experience of rejection and criticism by others; feeling different from others; feelings of isolation and lack of emotional support; being shy and sensitive; being inclined to harsh self-judgement and low self-esteem (Elliott et al. 2007). Students' experience of social anxiety may not meet diagnostic criteria but may still be distressing and have a marked impact on their quality of life. For these reasons, the term 'social anxiety' will be used generically rather than diagnostically.

Perspectives
From a psychodynamic perspective, social anxiety has its origins in early experiences of social embarrassment and criticism from caregivers and significant others. Affected children develop a lasting sense of inadequacy, self-consciousness and feelings of shame (Gabbard 1992); they fear that people will see the flaws that they perceive in themselves (Eckleberry-Hunt and Dohrenwend 2005), and their shame is associated with a tendency to mistrust other people, to be self-critical and to engage in self-defeating behaviour (Henderson and Zimbardo 2003). Current models of social anxiety have their origins in the behaviourist paradigm: people pursue social goals according to rules and monitor their performance in the light of feedback from the social environment (Trower et al. 1978). Anxiety about social situations is a conditioned response which can be unlearnt through training in social skills. In the self-presentation model of social anxiety (Schlenker and Leary 1982), the social goal of creating a good impression combines with low expectations of meeting that goal. The disparity causes negative affect, physical or psychological withdrawal from the situation and preoccupation with one's limitations. This inhibiting dynamic is elaborated in the cognitive model of social anxiety (Clark and Wells 1995). Based on early experience, individuals develop a range of assumptions in relation to their self and their social world (Clark 2001). They include rules about selfpresentation (e.g. 'I must always appear witty and intelligent'), conditional beliefs about social evaluation (e.g. 'if people get to know me, they won't like me') and unconditional beliefs about the self (e.g. 'I'm stupid'). These cognitions raise anxiety about social situations such that they are avoided or handled ineptly, or they may distort the interpretation of others' responses to indicate criticism of one's social behaviour. In either case the unhelpful, negative beliefs about self and social impact are confirmed.

Prevalence
Social anxiety is common in the general population (Furmark et al. 1999), with lifetime prevalence estimates in the US and western Europe ranging up to 13% (Furmark 2002;Kessler et al. 2005). In a survey by Russell and Shaw (2006), 10% of university students reported marked to very severe social anxiety on the Liebowitz Social Anxiety Scale (Liebowitz 1987). Using the same measure, Topham and Moller (2011) found that 22.6% of new undergraduates experienced quasi-clinical levels of social anxiety, while research reporting high to clinical levels in 19-33% of US university students is referenced by Parade, Leerkes, and Blankson (2010).

Impact
Social anxiety is a debilitating condition, with many sufferers experiencing academic and occupational difficulties (Bruce and Saeed 1999). It has been associated with reduced income and career progression (Wittchen 1999) and lower socio-economic status (Veale 2003). It often co-exists with difficulties in relationships, depression and alcohol use, all of which compound its impact on functioning and quality of life (Fehm et al. 2005;Keller 2006). In education settings, social anxiety has been associated with failure to complete school (Van Ameringen, Mancini, and Farvolden 2003), impaired academic performance (Wetterberg 2004), increased risk of exam failure (Stein and Kean 2000) and failure to graduate (Wittchen 1999). In the transition to university, it may be triggered or exacerbated by new demands for social interaction or educational performance (Bruce and Saeed 1999).
Interactive methods of learning are common: students are expected to interact with strangers, talk in groups and risk criticism of their work from peers and tutors. Socially anxious students find these methods uncomfortable and often cope through withdrawal and avoidance (Topham 2009). These strategies, together with excessive self-consciousness, reduce their social and cognitive engagement with learning. Failure to engage increases the risk of withdrawal from university, with significant costs to the student and the university (Yorke and Longden 2008).

Student development
Higher education is undertaken in the context of personal maturation, with most of the student population in late adolescence/early adulthood (HESA 2011). Developmental tasks include establishing personal relationships and the skills to maintain them (Erikson 1959), identity formation (Meilman 1979), material and emotional independence from primary attachment figures (Seiffe-Krenke 2006) and negotiating beliefs and values (Kohlberg and Lickona 1976). Thus traditional-age students may be vulnerable to social anxieties due to the coincidence of life-stage and academic challenges. 1

Treatment and remission
Although the effectiveness of therapeutic interventions for social anxiety is fairly well-established (Acarturk et al. 2008;Taylor 1996), they are underused by the general population (Coles et al. 2004). Diagnosable social anxiety can be stable for the age range 14 to 24 years (Wittchen and Fehm 2003), yet one-third of untreated individuals attain remission within 10 years (Keller 2006). In a study of the lifetime course of social phobia, 38% of participants no longer met diagnostic criteria at the time of interview (Chartier, Hazen, and Stein 1998), and in a survey of student social anxiety by Topham (2009), a proportion of participants reported that their anxiety improved during their undergraduate years. The occurrence of remission during a key period of development justifies an exploration of self-reported change in the experience of social anxiety.

Aims of the study
This study aims to analyse qualitative accounts of university students' experience of social anxiety in learning situations in order to identify: (1) How students perceive and make sense of their social anxiety; (2) How students understand and engage with change in their social anxiety.
The study will consider the implications for pedagogic and therapeutic interventions within the higher education context.

Method
Ethical approval for the study was sought and granted from the departmental ethics committee.

Researchers
All three authors and researchers are qualified counselling psychologists who have worked therapeutically with clients presenting with social anxiety, and two of the three authors have personal experience of social anxiety. We brought to this study a predisposition to view human experience in terms of personal development as much as pathology, and as a product of both intrapersonal and interpersonal processes.

Participants
The research was conducted in a large UK university with a diverse student population and a commitment to widening participation. Given the focus on change in social anxiety, participants were recruited from the population of year 2 undergraduatesfor traditional-age students the midpoint of their university career, around which indicators of change might be more evident.
An advertisement was placed on the website of the Department of Psychology's participant pool, inviting responses from students who had experienced anxiety in learning situations such as seminars and presentations. A total of 39 students from the year 2 population who self-selected against those criteria were recruited: five males and 34 females with an age range of 19-30 and a mean age of 20.

Source of data
Participants completed an anonymous online survey which asked about their experience of social anxiety, how they thought it had affected their student life, whether it had changed and what they thought might account for this change or lack of it (see Appendix 1).

Analysis
We adopted a realist approach to the data, assuming a linear correspondence between experience, meaning and language. Thematic analysis (Braun and Clarke 2006) was used to identify patterns and processes in participants' experience of social anxiety. All three authors were engaged in reviewing the analysis as it proceeded, and an audit trail documented the links in that process. From an initial review of the data, participants were assigned to one of four groups, each group representing a draft position along a presumed continuum of change in participants' experience of social anxiety. A group-by-group thematic analysis was conducted to identify the themes and supporting data that best described participants' experience and understanding of social anxiety.

Group descriptions
The four groups were labelled Stasis, Dialogue, Engagement and Autonomy, each group label being chosen to summarise the developmental experience of participants in that group. The chosen labels were a product of discussion amongst the researchers and were not knowingly derived from other sources or previous research.

Stasis
Participants in this group (n=7) reported that their social anxiety had remained the same or intensified since attending university. Their experience was often distressing and avoidance was common: I had to give a group presentation to the rest of the seminar group. I was terrified, my hands went all sweaty and I could feel myself going red in the cheeks. (P35) Sometimes I get really bad anxiety feelings which make me feel ill and want to not attend classes again and am generally more nervous about every day situations. (P3)

Dialogue
In this group (n=9), participants' anxiety was still quite intense. They had begun to make changes, or had some awareness of what changes they might make, yet struggled to implement them: When in seminars I feel a lot of pressure; I want to participate but find I physically can't. (P18) … every time it happens I become more aware of it occurring. This makes me more determined to overcome these feelings, wanting to engage more and become an active member of activities. (P18)

Engagement
Participants in this group (n=8) were more socially engaged despite their anxiety, or were experiencing less anxiety in some situations. They had made efforts to manage their anxiety but did not feel in control of it: The next time I was in this (group) situation, I tried to control myself, by calming down and trying to answer questions which I know the answers to.
… I think in learning situations it varies as sometimes when I'm having a good day I will be fine, but other days it can be really bad and back to square one again. (P13)

Autonomy
In this group (n=15), the quality of participants' personal and academic lives was much less affected by social anxiety. They felt more confident about managing it across a range of learning and social situations, though not without exception. They were able to account for positive change in relation to personal and external factors: Fearful self-consciousness. Participants described how they had felt anxious and self-conscious when talking in front of other people. The intensity of feeling was most evident in the Stasis and Dialogue groups: During seminars I find it increasingly harder to speak due to the idea of making myself look embarrassed and by saying something wrong or stupid. (P3, Stasis) I still feel embarrassed and shy when I am asked to speak in public; especially when the topic is ambiguous because if I say the wrong answer I may look silly. (P34, Dialogue) They were concerned about how others might respond to them; were fearful of making mistakes and of being judged to be deficient in some way. Participants in the Engagement and Autonomy groups were more able to articulate these thoughts and their impact: In seminars I sometimes feel an overwhelming feeling of anxiety where it feels like everybody's eyes are burning on me. I quite often think of points to make but feel unable to say them and then feel annoyed at myself. I'm really disappointed in myself for feeling this way because it feels like I can't get the most out of the university experience. Dialogue. Avoidance in this group was more nuanced, with strategies including over-preparation, disengagement from or limiting contributions to social situations and drinking alcohol. Participants continued to manage social anxiety by minimising its impact rather than by trying to restructure their experience: Often I feel uneasy and do what I can to avoid the system, so in the case of a seminar presentation, I will be the first to say I won't be talking and presenting and ask others to do the presentation, although I will contribute to the making of the presentation if I work with my peers. There was an increased tendency to reflect on social anxiety and its causes: … during my first year and first couple of weeks, my timetable brought me a lot of anxiety and discomfort. However I think this is mainly to do with the fact I didn't know anybody. (P28) … now that I am at university I am no longer one of the most intelligent so I feel less capable than my peers, leading to my lack in confidence. (P39) Participants recognised internal cues for social anxiety but did not see these as a focus for change, being more inclined to attribute alleviation of their anxiety to external factors: Engagement. Participants in this group remained distressed by experiences of social anxiety but were hopeful about, and actively engaged in, making changes. They were aware of the personal and educational cost of their social anxiety, with the implication that this was a motivation for change: My high levels of anxiety caused me to fail my second year of university as I put off going into practicals and even lectures, meaning I missed so much work and was therefore unable to catch up. It also had an impact on my ability to make friends within my course due to how little time I spent there… Failing last year has had a big financial impact with having to take out more loan than I was planning, also denting my confidence in other areas of my life. (P10) They were able to identify reductions in anxiety and to recognise what had been helpfulmaking friends with people, self-soothing, exercise, better preparation and more practice: In contrast to participants in the Stasis and Dialogue groups, they could acknowledge the challenges and benefits of choosing to expose themselves to anxiety-provoking situations: My fear of being asked a question I cannot answer in a group situation forces me to listen more carefully to the teacher, because if I concentrate, I am less likely to get the question wrong… I feel that by putting myself into situations I am uncomfortable with, I will learn to cope in these situations, and therefore not get so worried about them in the future. (P19) Autonomy. Participants in this group demonstrated a marked ability to reflect on their social anxiety within the context of their university experience. They conveyed a more complex appraisal of its impact, of the limitations of their initial coping strategies and of factors that were contributing to its remission: I used to worry that I wasn't 'good' or 'cool' enough for my peersas a result I tried to establish social independence by reinforcing differences between myself and my peer group. This turned out to be counter-productive and I was pretty much just isolating myself further and therefore heightening my social anxiety. (P25) There has definitely been a change. This could be due to a variety of factors -I rarely drink alcohol, I have become more confident, in my field I have seen lots of anxiety-prone individuals and developed ways of dealing with anxiety for myself. (P21) I learnt there are no wrong or right answers and no one will judge you… I have also learnt that I need to express my own opinions or say what I know to be able to learn and any contribution is useful. (P12)

Change factors in social anxiety
Autonomy participants identified four factors that contributed to a reduction in their social anxiety: increased social familiarity; experience of university; understanding triggers for social anxiety; and increased self-acceptance.

Increased social familiarity
Over time, familiarity with their student peers led to increased comfort and reduced anxiety: The more you get to know people (for example in seminar groups) the more comfortable you get talking in front of them. Experience of university Autonomy participants were the only group who identified positive change factors arising from the experience of attending university: these included living independently; having to form new social groups; realising that other students feel the same; improved study habits; and being encouraged to engage in group discussions: My social anxiety has been reduced by having to make presentations and having no choice over the matter as it is what my course involves. Other factors in general university life have also reduced my levels of anxiety in learning situations, for example just moving to university in the first place and not knowing anyone, therefore having to make friends by interacting with people. Interaction to make friends has increased my confidence in interaction in learning situations such as in seminars or workshops. Also the confidence of others within my seminar groups has encouraged me to display confidence and not to just sit back and avoid making any contribution within sessions.
Understanding triggers for social anxiety Participants had come to understand that their social anxiety was triggered by personal beliefs and behaviours as much as by features of the external situation: I think one reason for feeling anxious was because I had not prepared at all for it. (P24) But when I do know the topic well and know the material taught, I don't experience any social anxiety. I suppose this is because I don't fear being wrong. (P14) I found the seminars uncomfortable last year as I was anxious about expressing my views in front of people I did not know in case they thought my views were wrong as I did not want to feel embarrassed and stupid. (P26)

Increased self-acceptance
The fourth change factor identified by Autonomy participants was increased self-acceptance. They realised that anxiety was universal, that they would not always be able to avoid it, but that it could be tolerated. They were less fearful and could consider feedback as useful rather than judgemental: I know now that a lot of the other students in the tutor group were as unprepared and uncomfortable with their presentations as we were. I do wish that I was a lot more comfortable with making presentations and things like that, but I think it's just one of those things; some people are awful at it and some are quite good. Although you do get better with practice of course! (P24) I think this is due to becoming more mature and comfortable with who I am -I am now less preoccupied and worried about what people think of me, perhaps because I have become more tolerant and accepting of people myself, so I am not projecting any judgemental or intolerant attitudes onto others, and as a result I feel less social anxiety. (P25)

Discussion
Experience of social anxiety Participants agreed that standard features of university life, such as being required to speak in seminars, ask questions of academic staff and give presentations, were commonly associated with social anxiety. Their experiences were markedly similar to other accounts of social anxiety (e.g. Elliot et al. 2007;Veale 2003). The impact of social anxiety in learning was also consistent with the literature (e.g. Russell and Shaw 2006), with participants noting its personal, academic and financial consequences.

Changes in social anxiety
Thematic analysis focused on four clusters of social anxiety experience, provisionally labelled Stasis, Dialogue, Engagement and Autonomy. In terms of the Clark and Wells (1995) model, the Stasis group illustrated typical features of social anxiety, with participants excessively focused on their anxious feelings, physiological states and fears of negative social evaluation. Their primary coping strategy was avoidance and their social anxiety was seen as unchangeable. Their status appeared to be an example of 'subject consciousness' (Kegan 1994): they were attached to social anxiety as part of their self-concept and were unable to view it with any objectivity. In Kegan's model, development requires movement from an emotion-laden involvement with anxiety-provoking experiences to a more detached and reflective position. Applying Prochaska and DiClemente's (1984) Stages of Change model, the Stasis group appeared to be in the Pre-contemplation stage; they kept a safe distance from anxiety-provoking situations and if they considered change they did not show any desire for it. This contrasts with Gianakis and Carey's (2011) study of recovery without intervention, which suggested that a desire for change and a strong emotional experience are necessary to initiate the change process. Feelings of helplessness persisted in the Dialogue group; identification with their social anxiety was little changed, but there were signs of independence. Motivational conflict is common in younger adults (Riediger and Freund 2008) and, following Prochaska and DiClemente (1984), participants in the Dialogue group appeared to be on the cusp of Contemplation and Action stages. Participants were able to reflect on the causes of their social anxiety and to consider remedies. They were sometimes able to manage their anxiety, albeit with difficulty and discomfort, and were becoming aware that familiarity with peers may reduce its impact. In a review of the evidence for client autonomy as a key sustainable outcome of therapy, Ryan and Deci (2008) found that this is achieved through increased awareness and through exploring external conditions. For students, this would include both anxiety-provoking learning situations and potential peer support. Given their ambivalence about change, this is where student support may need to be most sensitive, yet may be most valuable in facilitating progress or preventing withdrawal.
All the participants had chosen to attend university and to subject themselves to its opportunities, challenges and constraints. That choice is consistent with the idea of an innate self-actualising tendency, of people knowing and being motivated by a drive towards a fuller and more integrated self (Rogers 1959); or, as Roberts and Caspi (2003) have argued, with the drive to identity development causing people to seek contexts which promote change, such as new roles or new relationships. Despite fears that education has become more instrumental and aimed solely at gaining employment (e.g. Atwood 2008), recent focus groups suggest that personal development is still important to students (K. Kelly, personal communication, 7 December 2011).
Consistent with this view, the Engagement group were active in the process of trying to overcome their anxiety. They appeared to be in the Action stage of change (Prochaska and DiClemente 1984): they could reflect on improvements as well as on the continuing challenges of their social anxiety. Within a therapy setting, this would be expected to involve some remoralisation of the individual student (e.g. Howard et al. 1993): an increased sense of hope about managing their concerns, which is a pre-requisite to substantive change. So, while the Engagement group still suffered from physiological symptoms and fears of social evaluation, these did not stop them engaging with anxiety-provoking situations.
Self-determination increases as people move through stages of change (Mullan and Markland 1997), and our participants may have been driven by awareness of the negative impact of social anxiety. We suggest that the tone of the Engagement accounts also indicates a shift from subjectivity to objectivity; for example, by using the third person to refer to their anxiety: 'It also had an impact on my ability to make friends within my course' (P10). In line with Kegan's (1994) model of development, participants' experience of social anxiety was becoming detached from their sense of self.
Accounting for change: the Autonomy group Universities invite their students to become autonomous learners, develop academic and vocational competencies and engage with colleagues as part of their academic and social development. The association of autonomy, competence and relatedness with positive mental health and development has been marked in psychotherapy (Ryan and Deci 2008) and in student identity development (Chickering 1969). From the Autonomy group we heard evidence of movement in those directions.
Participants attributed change to the benefits of peer relationships; to understanding the triggers for their anxiety; to the general benefits of being at university, such as increased independence; and to being more accepting of themselves. Having reached their second year, increasing academic competence had a positive impact on self-evaluative cognitions. Concurrently, through repeated exposure and growing familiarity, they had begun to shift their perception of colleagues from a threat to a source of support. These reflect findings from therapeutic trials on the value of cognitive-behavioural interventions for helping people revise their self-focused negative thinking about social situations (Hofmann et al. 2004). Repeated exposure to lectures, seminars and informal social gatherings is a regular, unavoidable and quasi-therapeutic feature of student life.
Outside therapy, factors which have been reported to help reduce social anxiety in adults are increased self-esteem, exposure to anxiety-provoking situations, determination and maturity (Chartier et al. 1998). Gianakis and Carey (2011) found that a connection with others was important in bringing about change, and that a change in thinking was associated with the resolution of psychological distress for most of their participants. Previous studies of university students have found that support from friends and family was of primary importance in helping students to manage their social anxiety (e.g. Topham 2009). Also cited were getting to know people, practice and experience and maturation. These resonate with the accounts of the Autonomy group: although not entirely free of its impact, they were more in control of their social anxiety; they were becoming more objective about it (Kegan 1994), were committed to managing it (Prochaska and DiClemente 1984) and were more socially autonomous than ashamed (Erikson 1959).

Limitations of the study
The participant group was largely female (34/39) and ethnicity and socioeconomic data were not obtained. Future studies could pay more attention to commonalities and differences arising from these variables. The data was collected at a single point in time, seeking current and retrospective views on experience and change in social anxiety in the first two years of university life. We did not sample participants' experience over that period and it was our interpretation of the clusters that they indicated a sequence of remission or maturation in relation to social anxiety. Future research should consider cohort studies to monitor participants' experience of social anxiety before and during the first two years of university, at least. This would enable a clearer view on whether a temporal and progressive sequence of change in social anxiety is occurring. Of particular interest is prior experience, personal and academic; impacts on transition to university; the anxieties triggered during that period; and students' experience of how remission occurs over time.

Conclusions and implications
In this study, psychosocial models of change and development have been offered to explain the changes in participants' experience of social anxiety. One view is that maturational potential in the individual is met by a matching response from the social environment (peers, colleagues, tutors, university culture) that enables that potential to be realised (Erikson 1959). More recently, Hendry and Kloep (2002) suggested that development occurs as a result of an interaction between current challenges and individual resources, including those available from the social environment. The outcome of this psychosocial partnership is not guaranteed: the university can facilitate growth and it can also maintain or exacerbate existing anxieties. A psychosocial model calls for identification of the forms of support within a university community which will enable students to achieve a less fearful and more engaged relationship with their role.
Less clear are the prospects for students who would be described as being in Stasis: we had no evidence that these would embark on a process of change. Participant accounts from other groups did not make clear whether they had all begun in Stasis or whether some had started in another group. Whereas those in Autonomy demonstrated functional if not entirely experiential independence from social anxiety, the accounts of those in Stasis illuminate its persistence in adulthood where intervention is not sought or accepted.
Guidance for academic and advisory staff on working with student social anxiety has been published elsewhere (e.g. Topham and Russell 2012) and there is no shortage of online information about learning to manage social and performance anxieties. If social anxiety in early adulthood is associated with maturation, then interventions are more likely to be effective if they are matched to individual readiness. Higher education staff can benefit from increased awareness of developmental progression and appreciation of maturational stages, helping them to balance academic support and challenge for individual anxious students. However, we suggest that proposals for specific interventions based on the stages outlined here will benefit from further studies to determine their validity as an explanatory framework for developmental change in socially anxious students.
1. Mature students may also be at risk of social anxiety. While adult students who do not fall within the early adulthood period of development are more diverse with regard to, and perhaps less intensely affected by, life-stage issues (Wilson 1997), they are often resuming an education that finished in mid-adolescence and may be equally vulnerable to academic anxieties, as well as to age-related isolation (Stone 2008).

Notes on contributors
Phil Topham is Senior Researcher in Counselling Psychology in the Department of Psychology at the University of the West of England, Bristol. After a career as a practitioner, he is now developing research in counselling and psychological support for students.
Naomi Moller is Principal Lecturer in the Department of Psychology at the University of the West of England, Bristol. She trained as Counselling Psychologist in the US where she worked in student counselling services; she now teaches counselling to doctoral level.
Hannah Davies has just completed her Doctoral training in counselling psychology and is currently working as a psychological therapist in an IAPT service. She has previously worked in primary, secondary and tertiary level care within mental health services as well as a number of voluntary agencies.