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Until comparatively recently, the idea of using REBT or any kind of cognitive psychotherapy for schizophrenia sounded like an oxymoron. The prevailing view in psychiatry and widely in the mental health field, was—and sometimes in routine practice still is—that psychological therapy for schizophrenia was inappropriate, even iatrogenic, in that there was a risk that it might cause as much harm as benefit.

The pursuit of preferences without demands is a major pathway to mental health and happiness, according to REBT theory and research. Even when people are thwarted in the pursuit of their preferences, they will only experience healthy negative emotions, which will spur them on to construct solutions to obstacles that prevent them from reaching their goals. However, if they are thwarted when rigidly demanding their preferences, they may experience unhealthy negative emotions and act in ways that most likely will be self-defeating. We suggest that this evidence-based classic REBT framework could benefit further by clarifying whether there is a neglected distinction to be made between two types of preference. We raise the question whether there are ‘ought’ preferences as well as ‘want’ preferences, fundamentally different in purpose, which when turned into demands, can lead to distinctly different secondary irrational beliefs and unhealthy negative emotions and behaviour patterns. We explore this possible distinction as a question which has potential ramifications for theory, research and practice.

Background Clinicians working with clients who have mild intellectual disabilities (IDs) have shown growing enthusiasm for using a cognitive behavioural approach, amid increasing evidence of good treatment outcomes for this client group. However, very little is known about the views and experiences of clients with IDs who have undergone cognitive behavioural therapy. This study aims to explore the perspective of these clients. Methods Fifteen participants with borderline to mild IDs and problems of anxiety, depression and anger were interviewed regarding their experience of cognitive behavioural therapy (CBT). Two semi-structured interviews were carried out in the first phase of therapy between session four and session nine. An interpretive phenomenological approach was taken to seek out themes from participants' own personal accounts. Results Participants valued the opportunity to talk about problems with their therapist and benefitted from therapeutic relationships characterised by warmth, empathy and validation. Participants identified areas of positive change; however, many thought that this may be short lived or not maintained beyond discharge. Conclusions The supportive aspects of therapeutic relationships were particularly important to participants undergoing CBT. The clinical implications are considered.

Objective. To test the proposal that ‘poor-me’ (PM) and ‘bad-me’ (BM) paranoia can be differentiated in terms of (1) current emotional experience and presence of grandiose delusions and (2) early caregiving and threats to self-construction. Method. Participants experiencing persecutory delusions were separated into PM (N= 21) and BM (N= 15) groups on the basis of perceived deservedness of the persecution. The groups were compared on measures examining grandiose delusions, shame and depression, parental care, and threats of alienation and insecurity. Results. As predicted, BM patients scored higher on shame and depression, and lower on grandiose delusions, than PM patients. BM patients reported higher levels of parental overprotection, but PM patients were not characterized by neglect, and the groups did not differ in type of threat to self-construction. Conclusion. The two paranoia types were differentiated on symptomatic and emotional presentation, but predicted differences in early relationships and self-construction were not fully supported.

This paper presents the REBT Competency Scale which can be used in the evaluation of adherence to an REBT treatment model in clinical and research applications. The scale has been developed to map closely onto the REBT treatment protocol developed by Dryden et al. (A primer on rational emotive behaviour therapy, Research Press, Champaign, 2003). Based on this treatment protocol 21 core steps (tasks) were identified for effective REBT practice. Each step is operationally defined, the rater is reminded of how the step relates to REBT theory and practice and scoring criteria are established that enable a rating of the therapists performance of the task. The potential uses for and application of the scale in clinical and research settings are considered.

This article describes a pilot evaluation of a new day service in Solihull. The service provides individualised day care based on ordinary life principles. Activities occur both within and outside of the home and include the use of a network of community-based work, leisure and education resources. Extensive interviews with managers, direct care workers and people with mental handicaps themselves and analysis of activity data give a positive view of the service.

There are few evaluated psychological interventions or theoretical approaches which are specifically aimed at reducing problems related to adjustment and adaptation following a first episode of psychosis. The present study tests the efficacy of a form of CBT (Cognitive Recovery Intervention; CRI) in reducing trauma, depression and low self esteem following a first episode of psychosis, in a single-blind randomised controlled trial. A total of 66 patients who had recently experienced a first episode of psychosis were randomly assigned to CRI or treatment as usual (TAU) and followed up at 6 and 12 months. People receiving CRI tended to have lower levels of post-intervention trauma symptoms and demonstrated greater improvement than those receiving TAU alone. This was especially the case at 6 months for those with high pre-treatment levels of trauma. There was, however, no advantage for the CRI group with regards to reduced depression or improved self esteem. In conclusion, CRI appears to be an effective intervention to help young people adapt to the traumatic aspects of a first episode of psychosis although further evaluation in a larger study is warranted.

Objectives. Establishing a collaborative relationship is a cornerstone of cognitive behavioural therapy (CBT). Increasingly CBT is being offered to people with intellectual disabilities who may have problems with receptive and expressive communication, and a history of disadvantage or discrimination in their relationships with those in positions of power. Consequently, they may have difficulty establishing a collaborative interaction with their therapist. This paper uses a novel method of interactional analysis to examine if collaboration increases as therapy progresses. Design and methods. Fifteen participants with borderline to mild intellectual disabilities and significant problems of depression, anxiety and anger were recruited from specialist clinical services to participate in this study. Verbatim transcripts of therapy sessions 4 and 9 were coded using an initiative-response method of analysing power distribution in dialogue, to investigate collaboration at the level of therapeutic interaction. Results. The initiative-response scores indicated that power was relatively equally distributed between clients and therapists. On this measure there was no significant increase in collaboration as therapy progressed, as the dialogues were relatively equal from session 4. Analyses of the pattern of interaction showed that whilst the therapists asked most questions, the clients contributed to the flow of the analysis and played an active part in dialogues. Conclusions. The implications of these findings are discussed, along with the possible uses of such interactional analyses in identifying barriers to communication and ways of establishing effective therapeutic dialogue.

This study is of a grounded theory analysis of the transcripts of young men talking about their experience of psychosis. Six young men were interviewed twice during the critical period of 3-5 years following their first psychotic episode. The young men were asked to reflect on themselves and their lives before, during, and after having psychotic experiences. The transcripts were considered to have a phenomenological status, in that they represented the participants' perspectives on their experiences. Four themes emerged that were common to all the accounts: experience of psychosis, immediate expression of psychotic experiences, personal and interpersonal changes, and personal explanations. These themes are explored in detail, and their links with existing research and clinical implications are considered.

Objective: Two types of paranoia have been identified, namely persecution (or ‘Poor Me’) paranoia, and punishment (or ‘Bad Me’) paranoia. This research tests predicted differences in phenomenology – specifically, in person evaluative beliefs, self-esteem, depression, anxiety, and anger. Method: Fifty-three people with current paranoid beliefs were classified as Poor Me, Bad Me, or neither (classification was reliable). Key dependent variables were measured. Results: All predictions were supported, except the one relating to anger, where the two groups did not differ. The Bad Me group had lower self-esteem, more negative self-evaluative thinking, lower negative evaluations about others, higher depression and anxiety. Importantly, the differences in self-esteem and self-evaluations were not fully accounted for by differences in depression. Conclusion: Data support the presence of two distinct topographies of paranoia. Future research is needed to explore the theory further and examine clinical implications.

The role of 3 personality dimensions (i.e., dependency, self-criticism, and efficacy) in recovery from an acute and severe psychosis was examined. Conceptualizing psychosis as involving difficulties in establishing psychological boundaries, the authors hypothesized that dependency has a greater disruptive effect on recovery than self-criticism. Results of a reanalysis of longitudinal data (N = 76) of people with schizophrenia spectrum disorders during recovery from acute psychosis were consistent with this hypothesis: Dependency predicted depressive and negative symptoms, and, under low efficacy, perceived loss of independence and insight into the presence of the illness. These findings elucidate the central role of interpersonal relatedness as a foundation for self-definition in recovery from psychosis.

Command hallucinations (CH) have recently become the focus of research into positive symptoms of schizophrenia. The importance of CH has become clear for theoretical and practical reasons, because CH are regarded as potentially the most dangerous symptoms of schizophrenia. The aim is to critically review research that has attempted to better understand CH and develop theories that may predict behavior and shape psychological treatments. This review draws together, presents, and critically discusses the current disparate body of literature produced (1990-2000) considering compliance with CH. The literature can be grouped broadly into three overlapping classes. (1) Studies testing for a relationship between CH and compliance. (2) Studies considering factors associated with acting on CH (mediating variables). (3) Studies that look for a relationship between CH and dangerous behavior. The body of literature is in its infancy and marred by methodological difficulties. Researchers have asked differing questions about different samples while hoping to provide similar answers. While acknowledging difficulties in interpreting the literature, themes do emerge. The weight of the evidence is that some individuals who hear commands will act on them. However, some studies show no link or only a weak link and although methodological errors account for some of the inconsistent results, there are also clearly individual differences. The relationship between command and action is more complex than many researchers have assumed. One conjecture is that the relationship is established via psychological processes or mediating variables which include beliefs about the voice and content of instruction. Prediction of compliance with commands is of further interest when dangerous behavior results. It is postulated that the issue of dangerousness is subject to the same mediating variables as other commands. It is clear however, that CH are not sufficient to produce action in isolation and that psychological processes mediate the process.

BackgroundCommand hallucinations are a distressing and high-risk group of symptoms that have long been recognised but little understood, with few effective treatments. In line with our recent research, we propose that the development of an effective cognitive therapy for command hallucinations (CTCH) would be enhanced by applying insights from social rank theory.AimsWe tested the efficacy of CTCH in reducing beliefs about the power of voices and thereby compliance, in a single-blind, randomised controlled trial.MethodA total of 38 patients with command hallucinations, with which they had recently complied with serious consequences, were allocated randomly to CTCH or treatment as usual and followed up at 6 months and 12 months.ResultsLarge and significant reductions in compliance behaviour were obtained favouring the cognitive therapy group (effect size=1.1). Improvements were also observed in the CTCH but not the control group in degree of conviction in the power and superiority of the voices and the need to comply, and in levels of distress and depression. No change in voice topography (frequency, loudness, content) was observed. The differences were maintained at 12 months' follow-up.ConclusionsThe results support the efficacy of cognitive therapy for CTCH.

Evaluative beliefs have long been regarded as “hot” cognitions fundamental to the arousal of emotion. Previous research on anger has predominantly focused on inferential beliefs, with explorations of evaluative beliefs largely ignored. Therefore, this paper presents an investigation of the nature of evaluative beliefs in individuals with anger disorders. To investigate the experimental hypotheses that individuals with anger disorders will report high levels of hostile related evaluative beliefs, two methodologies were applied to a clinical sample of individuals with anger disorders. Individuals with anger disorders reported hostile evaluative beliefs, but interestingly it was evident that such individuals endorsed high levels of negative self-evaluation. The implications of these findings for future research and clinical work are discussed.

Command hallucinations (CH) are a distressing and high-risk group of symptoms that have long been recognized but little understood, with few effective treatments. Research shows that cognitive behavior therapy (CBT) is a promising treatment for hallucinations in general and therefore has a potential role in the treatment of CH. We propose that the development of an effective CBT for CH would be enhanced by a theory specific to this uniquely problematic symptom. In this article we describe and apply such a theory from evolutionary psychology, namely social rank theory, and review recent evidence for its application to hallucinations in general. Second, we present a treatment protocol developed in accordance with the principles of the theory specifically for CH, and describe an illustrative case. Finally, we outline the design and methodology of a new, randomized, controlled trial currently being undertaken to test the efficacy of the treatment. Further developments both in the protocol and in its evaluation are discussed.

Following a constructivist approach, we propose two dimensions or styles of self-construction that are related to different types of vulnerability to psychopathology. We have called these an 'insecure self' style associated with fear of exclusion, indifference, and rejection by significant others, and an 'engulfed self' style associated with fear of intrusion, control, and possession by significant others. In this paper, we report the psychometric properties of a new 14-item questionnaire, the Self and Other Scale (SOS), which is designed to measure the two types of threat vulnerability. We have produced two forms of the scale, one measuring frequency of beliefs, which was completed by 198 undergraduate psychologists, and one measuring endorsement of beliefs, which was completed by 179 undergraduate psychologists. The SOS has a 2-factor structure, as predicted from the theoretical model, and good internal reliability. We discuss the future development and use of the scale in research and clinical practice.

The present research consisted of two studies. A total of 44 participants were involved in the first study: 22 individuals with problems of aggression (Ag) and 22 non-aggressive (NAg) individuals. A sentence completion test was used to explore whether there were differences between the two groups' predicted coping responses in stressful situations. While the Ag group provided most aggressive responses, the NAg participants were more assertive. However, gender differences also emerged, with women proving to be less aggressive. A high number of passive answers were given across all the groups, suggesting that background experience could have influenced the participants' sense of efficacy in stressful situations. In the second study, a subsample of the participants were interviewed. The aim was to explore whether particular background experience coloured their perceptions of self and others, in situations of conflict. While nine out of the 10 Ag participants described incidents where they felt treated in a derogatory manner which could be linked to their disability, only two out of the nine NAg participants felt slighted in this fashion. Hence, a vulnerable sense of self could contribute to greater sensitivity in interpersonal situations, increasing the likelihood of an aggressive response. The clinical relevance of this work is discussed, alongside the possibilities for future research in this area.

The need for a measure of engagement with Community Mental Health Services has been identified. This article reports on the development and preliminary psychometric evaluation of a scale, Service Engagement Scale (SES), to measure engagement with community mental health services. Five Community Psychiatric Nurses completed the SES for 66 clients receiving Assertive Outreach services with an ICD-10 diagnosis of schizophrenia. Test-retest reliability of the subscale items and scale total is in the good to excellent range. Validity is supported by good internal consistency and by the criterion group method. Although preliminary psychometric results are promising, further psychometric study is necessary to evaluate the scale's factor structure. The SES appears to evaluate engagement with services, and may therefore be a useful tool to identify areas of concern with clients experiencing engagement difficulties.

Schizophrenia is one of the most researched, yet still one of the least understood, of the mental disorders. One key area that remains comparatively neglected is the fact that schizophrenia typically develops at late adolescence. In common with people with psychotic disorders, around 25% of normal teenagers also report finding adolescence very distressing, and a substantial empirical literature shows that certain characteristics typical of adolescence such as conflicted family relationships, grandiosity, egocentrism, and magical ideation bear a distinct resemblance to phenomena seen in psychotic disorders. Indeed, such phenomena, as might be judged prodromal or symptomatic in first-onset schizophrenia, have been shown to be remarkably common in normal adolescents, generally in about 50% of samples. Furthermore, prodromal-like signs in normal adolescents appear to be functionally linked to psychological development. For most adolescents, such phenomena pass with successful psychological development. It is proposed that psychosis in late adolescence is a consequence of severe disruption in this normally difficult psychological maturational process in vulnerable individuals, and explanations are offered as to why and how this comes about. It is suggested that problems either in reaching psychological maturity with regard to parents or in bonding to peers or both, may lead to crucial self-construction difficulties, and that psychosis emerges out of such "blocked adolescence." This approach proposes therapeutic interventions that enable professional services to side with both parents and clients simultaneously, and is normalizing and stigma-free.

We asked British cognitive behaviour therapists and researchers for their views on the current status of Rational Emotive Behaviour Therapy in Britain. All agreed that REBT had lost influence in comparison with Cognitive Therapy since the “cognitive revolution” 20 years ago. The main reasons given were that REBT, particularly in comparison with CT, was under-researched, was too rationalist in its approach and too active/directive in its style. One responder thought REBT was remarkably atheoretical. Overall there was a surprising degree of ignorance and misinformation. On the positive side, REBT was felt to be focused on the person rather than the symptom, and oriented more to the client than the professional or academic in its publication output than CT. We consider each issue and make recommendations for change.

In the 10 years or so prior to original publication in 1978 new theories and discoveries in the social sciences had given a scientific basis and new impetus to the development of social skills training as a form of therapy. This book explores the progress made with this idea and gives practical guidance for therapists based on several years’ experience with the technique. The book provides an account of the latest ideas at the time, about the analysis of social behaviour – non-verbal communication, social skill, rules, analysis of situations, etc. The different techniques for training and modifying social behaviour – some old, some very new – are described and compared, with detailed accounts. There is a careful critical review of follow-up studies of social skills training and other forms of social therapy on in-patients, out-patients and volunteer subjects. The second part of the book consists of a manual for assessing deficits and difficulties, and for training in ten main areas of social deficiency such as observation, listening, speaking, asserting and planning. A rating scale, questionnaire and user’s booklet of training exercises is included. The book should be of interest, not only to psychiatric professionals – psychiatrists, clinical psychologists, psychiatric nurses, occupational therapists – but to many others, such as social and community workers, teachers, prison officers, and lay people who may be interested in forming self-help groups, either on their own or with professional guidance.

Originally published in 1984, one of the few facts that emerged clearly in the beleaguered field of psychology and mental health at the time was the extent of poor social skills in psychiatric patients, the mentally handicapped and problem adolescents. As a result, during the 1970s, social skills training – espoused as a form of behaviour therapy – seemed to offer great promise, based on the notion that social skills, like any other skills, are learnt and can be taught if lacking. However, in evaluating social skills training, many investigators found that skills did not endure and generalise. This book attempts a major re-assessment of social skills training. It examines the underlying paradigms, which are shown to be fundamentally behaviourist. Such paradigms, it is argued, severely constrain the aims and method of current types of training. Thus the book develops what is termed an ‘agency’ approach, based on man as a social agent who actively constructs his own experiences and generates his own goal-directed behaviour on the basis of those constructs. This new model is developed in both theoretical and practical ways in the main body of the book and should, even today, be of great interest to all those involved with social skills training.

BackgroundIn paper I we reported that depression in the acute stage remitted in line with the psychosis and that 36% of patients developed post-psychotic depression (PPD).AimsWe apply our cognitive framework to PPD and chart the appraisal of self and psychosis and their link with the later emergence of PPD.MethodPatients with ICD–10 schizophrenia (n=105) were followed up over 12 months following the acute episode, taking measures of depression, working self-concept, cognitive vulnerability, insight and appraisals of psychosis.ResultsBefore developing PPD, these patients felt greater loss, humiliation and entrapment by their illness than those who relapsed or did not become depressed, and were more likely to see their future selves in ‘lower status’ roles. Upon becoming depressed, participants developed greater insight, lower self-esteem and a worsening of their appraisals of psychosis.ConclusionsDepression in psychosis arises from the individual's appraisal of psychosis and its implications for his/her perceived social identity, position and ‘group fit’. Patients developing PPD feel forced to accept a subordinate role without opportunity for escape. Implications for treatment are discussed.

BackgroundDepression in schizophrenia is a rather neglected field of study, perhaps because of its confused nosological status. Three course patterns of depression in schizophrenia, including post-psychotic depression (PPD), are proposed.AimsWe chart the ontogeny of depression and psychotic symptoms from the acute psychotic episode over a 12-month period and test the validity of the proposed course patterns.MethodOne hundred and five patients with ICD–10 schizophrenia were followed up on five occasions over 12 months following the acute episode, taking measures of depression, positive symptoms, negative symptoms, neuroleptic exposure and side-effects.ResultsDepression accompanied acute psychosis in 70% of cases and remitted in line with the psychosis; 36% developed PPD without a concomitant increase in psychotic symptoms.ConclusionsThe results provided support for the validity of two of the three course patterns of depression in schizophrenia, including PPD. Post-psychotic depression occurs de novo without concomitant change in positive or negative symptoms.

This paper reports the psychometric properties of the Hospital Anxiety and Depression Scale when used with 341 members of a self-help group for people with depression. We report internal reliability and factor structure for the complete data set and factor structure for groups split by gender, previous hospitalization for depression and current use of medication for depression. In each instance the factor structure reflects the intended depression and anxiety subscales. We comment on the usefulness of the HADS in studies of cognitive processes in depression and anxiety.

We report the development and a preliminaryanalysis of the Evaluative Beliefs Scale (EBS). The EBSmeasures negative person evaluations, a key class ofbeliefs within cognitive psychotherapy and thought to be closely linked to emotional disturbance.Three hundred ninety-four members of a UK-basedself-help group called Depressives Anonymous completedthe EBS and the Hospital Anxiety and Depression Scale (HADS). The EBS was found to have good internalreliability, a clear factor structure and concurrentvalidity when compared with the HADS. We believe the EBSmight have utility for clinical research and practice, not only as an assessment and outcomemeasure but also for testing hypotheses aboutconnections between cognitions and emotions.

We argue that social psychological and evolution theories can be combined to produce an adequate theory of social anxiety. From this combination we predict that the socially anxious utilize competitive schemata in social interaction whereas non-anxious people utilize cooperative schemata, with consequent differential effects on cognitions and emotions. These predictions were evaluated in an experiment in which two groups of studentsÐ12 high and 12 low scorers on the Fear of Negative Evaluation ScaleÐengaged in a semi-naturalistic, mildly stressful interaction, after which they were asked to reconstruct their thoughts and feelings at points of `discomfort' using video-aided recall. Anxious students evaluated themselves as subordinate, the confederate as dominant, thought he should take the lead, and blamed themselves for disruption in the conversation and experienced embarrassment. Non-anxious students in contrast evaluated themselves as more dominant than the confederate, thought the conversation should have been more reciprocal, and tended to blame the confederate for disruptions. The results were interpreted as providing qualified and preliminary support for the theory. # 1998 John Wiley & Sons, Ltd.

Research exploring inferential, especially attributional, thinking supports the theory that paranoia is a defense against low self-esteem. The present study extends this research by examining the place of evaluative beliefs in paranoia and depression. In particular, the study begins to explore the possibility that the defensive function of paranoia is to prevent perceived negative other-self evaluation becoming self-self, as happens in depression, by discrediting others through negative self-other evaluations. A paranoid group (n = 23) a depressive group (n = 22) and a normal control group of (n = 22) are compared on their responses to the Beck Depression Inventory and the Evaluative Beliefs Scale, an 18-item measure of other-self, self-self and self-other negative person evaluations. Results supported and refined this theory. As expected, subjects in both clinical groups perceive significantly more negative other-self evaluation (i.e., threat) than controls, with scores significantly higher for the depressed group. Negative self-self evaluation was highest in the depressives; the paranoid group scores were significantly higher than controls, perhaps implying that the paranoid defense is only partial. Lastly, negative self-other evaluations were significantly higher in the paranoid group; the depressives and controls did not differ. The theory that paranoia is a defense against low self-esteem has a long history. Zigler and Glick (1988) argue that it is delusions of persecution, the core feature of paranoia, which assuage a sense of personal inadequacy in two ways. First, they allow the projection of responsibility for personal inadequacy on to others, and second, they confer a personal importance. The first of these ideas has received substantial recent empirical support. In an important series of empirical studies, Bentall and colleagues (see Bentall, Kinderman, & Kaney, 1994) have shown that people with paranoid delusions show an exaggerated form of the self-serving bias (Miller & Ross, 1975)-that is, an ordinary defensive tendency to attribute responsibility for failure externally and success internally, and thereby maintain self-esteem. This is in contrast to people with depression, who show the reverse attributional pattern (Peterson & Seligman, 1984) and therefore have low self-esteem. Furthermore, when an indirect measure of attributional thinking is used, the Pragmatic Inference Test, individuals with paranoia are found to show a depressive style of thinking; this is consistent with the idea that underlying paranoia is low self-esteem (see Bentall et al., 1994). The second of Zigler and Click's observations about the defensive properties of persecutory delusions is consistent with the commonly reported finding that paranoid people, although usually depressed, have high self-esteem. Hitherto research has concentrated on drawing out the nature of the inferential, especially attributional, thinking in paranoia. The present study begins to consider the place of evaluative thinking in paranoia. One of the main tenets of cognitive psychotherapy has long been that negative evaluations are functionally associated with emotional distress (e.g., Arnold, 1960; Beck, 1976; Ellis, 1962)-a position that has both theoretical and empirical support (Lazarus, 1989; Smith, Haynes, Lazarus, & Pope, 1993). Indeed, Ellis even goes so far as to suggest that it is only evaluations, and not inferences, which provoke emotional problems. An evaluation or "hot" cognition may be defined as a good-bad judgment, or a preference as opposed to an inference (Zajonc, 1980) and aperson evaluation as an evaluation of either oneself or another person. Negative person evaluations are defined as stable, global and total condemnations of the entire person and may be attributed in three directions: "other-self where the other is making an evaluation of me, "self-self" where I evaluate myself, and "self-other" where I evaluate the other (Trower, Casey, & Dryden, 1988). …

There is growing agreement that at least certain kinds of delusions defend against negative self-evaluation, and in consequence that cognitive therapy for delusions needs to address issues of self-evaluation more explicitly. However, in practice it can be difficult to enable clients to see the connection between delusions and self-esteem. The present single-case study exemplifies the conceptual and practical application of cognitive therapy for individuals who are both paranoid and have strong negative self-evaluative beliefs. A multiple-baseline approach is used, whereby one man's negative self-evaluative belief and two paranoid delusions are challenged sequentially. Conviction in two of the three beliefs changes at the point of intervention; conviction in the third changes prior to intervention. We discuss the details of the case, as well as the wider implications for cognitive approaches to delusions.

It is often assumed that if physical differences exist between the brains of people with schizophrenia and normal people then those biological differences will have caused the psychological abnormalities to occur. In this article, we challenge this view. First, we argue that the reverse case is also plausible, namely, that it is possible for the physiological differences associated with the condition to be the result of the condition and not the cause. Less contentiously, we propose that the relationship between the psychological problems and the physiology should be viewed not as a simple billiard-ball style cause-and-effect relationship but more as a reciprocal and iterative relationship where psychological effects can affect the physiology that can in turn affect the psychology. The evidence for the various physiological differences between people with schizophrenia and normals is assessed and it is concluded that these differences exist but that there is little evidence to demonstrate that all (or indeed even any), of them precede the onset of schizophrenic symptoms. Similarly, current information-processing theories can also be considered as descriptive of a psychotic state rather than causal to it. Similarities between traumatic shock and schizophrenia are discussed and it is argued that phenomena associated with trauma might need to be considered as an integral part of the psychotic's experience. It is also concluded that no psychological theory can deny the importance of the physiological level in schizophrenia.

BackgroundThe role of support workers and other professionals in the psychotherapeutic process has been commented upon but not as yet been systematically investigated. MethodTo explore their views and expectations of cognitive behaviour therapy (CBT) for adults with intellectual disabilities, eleven paid support workers and professionals were recruited and interviewed before the CBT sessions commenced for their service users and nine took part in the second interview that took place after nine sessions. ResultsThematic Analysis of the interview transcripts indicates that staff members do not perceive CBT as a long-term solution for psychological problems have little knowledge of CBT and do not feel included in the process. Nevertheless, after nine sessions, most participants reported improved psychological well-being for their service users and expressed a wish for longer-term involvement of the therapist. ConclusionsThe results suggest that for CBT to be effective in the longer term, the therapist is required to consider a wider systemic approach including staff training and supervision, staff and management consultancy and creating a delicate balance between confidentiality and sharing the psychological formulation with significant others' to ensure maintenance and generalisation of improved psychological well-being.

In this paper we describe an approach to training in Shared Action Planning that involves both plan coordinators and people with learning disabilities as equal participants. The training consists of five workshops which introduce Shared Action Planning and give staff and clients an opportunity to discuss preferences in home life, leisure and day activity or work. We present an evaluation of the training approach which indicates that it is well received by both staff and clients.

Developments in cognitive therapies and theories for paranoid psychosis have constituted a significant breakthrough in our understanding of this disorder, offering a valid psychological alternative to biomedical approaches, which have been criticized on scientific, pragmatic, and ethical grounds. However, we have recently found evidence for two types of paranoia which, together with other conceptual and empirical work, show these cognitive theories to be insufficient. We propose an interpersonal theory of the self, which places the cognitive, emotional, and behavioral aspects of paranoia within a broader context of the person. In this article, we (a) survey cognitive theories and the alternative Interventions they imply; (b) describe new findings on two types of paranoia, which imply the need for significant theoretical adjustments; and (c) propose and describe a modified theory of paranoid threat and defense of the self, which, we argue, more adequately explains the phenomena.

OBJECTIVE. To test the proposal that 'poor-me' (PM) and 'bad-me' (BM) paranoia can be differentiated in terms of (1) current emotional experience and presence of grandiose delusions and (2) early caregiving and threats to self-construction. METHOD. Participants experiencing persecutory delusions were separated into PM (N= 21) and BM (N= 15) groups on the basis of perceived deservedness of the persecution. The groups were compared on measures examining grandiose delusions, shame and depression, parental care, and threats of alienation and insecurity. RESULTS. As predicted, BM patients scored higher on shame and depression, and lower on grandiose delusions, than PM patients. BM patients reported higher levels of parental overprotection, but PM patients were not characterized by neglect, and the groups did not differ in type of threat to self-construction. Conclusion. The two paranoia types were differentiated on symptomatic and emotional presentation, but predicted differences in early relationships and self-construction were not fully supported.

Cognitive behavioural therapy (CBT) is increasingly used to address the emotional and interpersonal problems of people with ID. There is a limited but promising evidence base supporting this activity. However, these individuals face real and continuing challenges in their lives that have implications for their self and interpersonal perceptions. These adversities have implications for the adaptation of CBT. First, it may mean that characteristically negative perceptions may be more common and may be the result of a complex interaction with a truly aversive environment and should not simply be considered as cognitive distortions. Secondly, clients may have limited control over their everyday lives, with limited opportunity to negotiate change with their informal and formal sources of support. This review suggests that it is important to consider the interpersonal context of therapy both to ensure effective work within sessions and to enable real change in clients' everyday lives. The review draws upon Vygotsky's theory of the zone of proximal development and ecological models of change to consider the challenges of establishing collaborative relationships and the potential to use CBT within a broad psychosocial model. The aim is to offer a helpful framework for practitioners and to identify directions for future research.