Staff expectations and views of cognitive behaviour therapy (CBT) for adults with intellectual disabilities.

BACKGROUND: The role of support workers and other professionals in the psychotherapeutic process has been commented upon but not as yet been systematically investigated. METHOD: To 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. RESULTS: Thematic 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. CONCLUSIONS: The 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.

Clinical presentation and early care relationships in 'poor-me' and 'bad-me' paranoia.

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.

A consideration of developmental egocentrism in anorexia nervosa.

Recent research has suggested that normal adolescent processes are important in understanding psychosis, and that young adult individuals with psychosis are often struggling to develop an individual and autonomous self (the "fundamental task" of adolescence). The current paper explores the utility of considering normative adolescent developmental processes in understanding anorexia nervosa. Data were collected from 31 female young-adults with symptoms of anorexia nervosa, 26 female comparison young-adults and 71 female adolescents on measures of adolescent egocentrism. A one-way ANOVA indicated that individuals with symptoms of anorexia nervosa scored more highly than both their peers and the adolescents on several dimensions of egocentric developmental beliefs. Correlations also showed that egocentrism was positively associated with eating concern in participants with symptoms of anorexia. The results suggest that young-adult women with symptoms of anorexia nervosa tended to feel physically invulnerable while also feeling both psychologically vulnerable to others and special or different. Together with the finding of excessive self-consciousness, this supports a notion that they may be experiencing exaggerated versions of normal self-developmental phenomena. Clinically, offering alternative ways of feeling unique other than dieting may be important in therapeutic approaches to anorexia nervosa. Similarly, strategies aimed at normalisation, such as facilitating healthy attachment to peers, may be useful for individuals with anorexia nervosa.

The balance of power in therapeutic interactions with individuals who have intellectual disabilities.

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.

Subtypes of paranoia in a nonclinical sample.

INTRODUCTION: Previous research has proposed that there may be subtypes of paranoia with different patterns of performance on symptom and clinical measures. However, there has been little empirical examination of whether distinct subtypes actually exist. Recent research has suggested that paranoia can be found in normal individuals and exists on a continuum. Thus, it is possible that evidence for subtypes of paranoia can be derived from nonclinical samples. METHODS: From a total of 723 participants, we identified 114 college students who showed elevated levels of paranoia as determined by two measures of paranoid ideation. The remaining sample of 609 persons served as the nonparanoid control group. All participants completed measures of depression, self-esteem, and social anxiety. Scores from the high subclinical group was subjected to cluster analysis to derive homogeneous subtypes. Participants also completed a measure of attributional style, the IPSAQ, which was used to validate the subtypes and was not used in the cluster analysis. RESULTS: Based on the cluster analysis, three subtypes were derived. Each subtype showed a different pattern of scores on measures of depression, self-esteem, and anxiety. There were also additional differences on the externalising and personalising bias scores from the IPSAQ between the subtypes. CONCLUSIONS: We conclude that there is preliminary evidence for the presence of subtypes among nonclinical samples and discuss the patterns of performance in relation to previous research on subtypes of paranoia. The implications of these subtypes for the study of paranoia are discussed.

Social anxiety and the shame of psychosis: a study in first episode psychosis.

Social anxiety disorder (SaD) or social phobia is a co-morbid affective disorder in schizophrenia, present in up to one in three individuals. We employ 'social rank' theory to predict that one pathway to social anxiety in schizophrenia is triggered by the anticipation of a catastrophic loss of social status that the stigma of schizophrenia can entail. A group of 79 people with a first episode of psychosis were assessed for social anxiety: hypotheses were tested comparing 23 socially anxious and 56 non-anxious patients on measures of cognitive appraisals of shame/stigma of psychosis and perceived social status, controlling for depression, psychotic symptoms and general psychopathology. Participants with social anxiety experienced greater shame attached to their diagnosis and felt that the diagnosis placed them apart from others, i.e., socially marginalised them and incurred low social status. We propose a stigma model of social anxiety that makes testable predictions about how the shame beliefs may contaminate social interaction and thereby exacerbate and maintain social phobia.

Socioemotional understanding and frequent aggression in people with mild to moderate intellectual disabilities.

Aggression in a proportion of people with intellectual disabilities is often assumed to be due to social-cognitive deficits. We reported on two studies in which we compared the emotion recognition and perspective-taking abilities of 43 frequently aggressive individuals and 46 nonaggressive peers. No difference was found between the groups' ability to label facial affect. The perspective-taking task required participants to distinguish between reactions of angry versus calm characters. Although both groups had similar success with elements of the task, the aggressive group proved better at predicting characters' attributions. Results suggest that deficits in emotion recognition and perspective-taking cannot be assumed to be causal or maintaining factors of frequent aggression. This has implications for assessment and treatment.

Frequent aggression and attribution of hostile intent in people with mild to moderate intellectual disabilities: an empirical investigation.

We investigated whether aggressive individuals have an attributional bias of hostile intent compared to nonaggressive peers. We compared 43 frequently aggressive individuals who had mild to moderate intellectual disabilities with 46 nonaggressive controls on an attributional task. The aggressive participants attributed significantly more hostile intent to protagonists and indicated that they would respond more aggressively than did the controls to provocative scenes, but only when the threat was to themselves. Results suggest that differences in attribution of threat to self play a role in frequent aggression. These differences appear to be due, in part, to a positive bias of the nonaggressive participants on the self-referent scenes. Clinically, results highlight the importance of assessing and addressing aggressive individuals' interpersonal perceptions.

The future of cognitive-behavioural therapy for psychosis: not a quasi-neuroleptic.

Some 20 trials of cognitive - behavioural therapy (CBT) for psychosis have re-established psychotherapy as a credible treatment for psychosis. However, it is not without its detractors and problems, including uncertainty about the nature of its active ingredients. We believe that the way forward is to abandon the neuroleptic metaphor of CBT for psychosis and to develop targeted interventions that are informed by the growing understanding of the interface between emotion and psychosis.

The person in recovery from acute and severe psychosis: the role of dependency, self-criticism, and efficacy.

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.

Adapting to the challenge of psychosis: personal resilience and the use of sealing-over (avoidant) coping strategies.

BACKGROUND: Avoidance coping (e.g. sealing over) is common in people recovering from psychosis, but it is not understood why some individuals 'seal over'. AIMS: We examined the hypothesis that individuals who 'seal over' do not have the personal resilience to withstand this major life event. METHOD: Fifty participants were interviewed during an acute episode of psychosis and reassessed at 3-month and 6-month follow-up. Measures included psychotic symptoms, recovery style, service engagement, parental and adult attachment and self-evaluative beliefs. RESULTS: Sealing-over recovery styles are associated with negative early childhood experience, insecure adult attachment, negative self-evaluative beliefs and insecure identity. Insecure adult attachment was associated with less engagement with services. CONCLUSIONS: Sealing over was associated with multiple signs of low personal resilience in adapting to psychosis.

Acting on command hallucinations and dangerous behavior: a critique of the major findings in the last decade.

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.

Cognitive therapy for command hallucinations: randomised controlled trial.

BACKGROUND: Command 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. AIMS: We tested the efficacy of CTCH in reducing beliefs about the power of voices and thereby compliance, in a single-blind, randomised controlled trial. METHOD: A 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. RESULTS: Large 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. CONCLUSIONS: The results support the efficacy of cognitive therapy for CTCH.

Interpersonal and role-related schema influence the relationship with the dominant 'voice' in schizophrenia: a comparison of three models.

BACKGROUND: Auditory hallucinations in psychosis often contain critical evaluations of the voice-hearer (for example, attacks on self-worth). A voice-hearer's experience with their dominant voice is a mirror of their social relationships in general, with experiences of feeling low in rank to both voices and others being associated with depression. However, the direction of the relationship between psychosis, depression and feeling subordinate is unclear. METHOD: Covariance structural equation modelling was used with data from 125 participants diagnosed with schizophrenia to compare three 'causal' models: (1) that depression leads to the appraisal of low social rank, voice power and distress; (2) that psychotic illness leads to voice activity (frequency, audibility), which in turn leads to depression and the appraisal of voices' power; (3) our hypothesized model, that perceptions of social rank and social power lead to the appraisal of voice power, distress and depression. RESULTS: Findings supported model 3, suggesting that the appraisal of social power and rank are primary organizing schema underlying the appraisal of voice power, and the distress of voices. CONCLUSIONS: Voices can be seen to operate like external social relationships. Voice content and experience can mirror a person's social sense of being powerless and controlled by others. These findings suggest important new targets for intervention with cognitive and social therapy.

The effects of the psychiatric label 'borderline personality disorder' on nursing staff's perceptions and causal attributions for challenging behaviours.

OBJECTIVES: The aim of the study was to investigate how the psychiatric label 'borderline personality disorder' (BPD) affected staff's perceptions and causal attributions about patients' behaviour. METHODS AND DESIGN: The study utilized a within-participants questionnaire methodology and participants comprised qualified mental health nursing staff. The questionnaire contained descriptions of challenging behaviour in which the patient was described with a diagnosis of depression, schizophrenia or BPD. Participants were asked to identify a likely cause of the behaviour and then on a Likert-type scale rate attributions of internality, stability, globality and controllability. In addition they recorded their level of sympathy with the patient and their optimism for change. RESULTS: Patients with a label of BPD attracted more negative responses from staff than those with a label of schizophrenia or depression. Causes of their negative behaviour were rated as more stable and they were thought to be more in control of the causes of the behaviour and the behaviour itself. Staff reported less sympathy and optimism towards patients with a diagnosis of BPD and rated their personal experiences as more negative than their experiences of working with patients with a diagnosis of depression or schizophrenia. CONCLUSIONS: Staff regard patients with a BPD label to be more in control of negative behaviour than patients with a label of schizophrenia or depression. In accord with Weiner's (1985) model, attributions of control were inversely related to staff sympathy. Addressing attributions of control may provide a means to modify staff sympathy towards patients with a diagnosis of BPD and counteract their negative experiences.

Predicting engagement with services for psychosis: insight, symptoms and recovery style.

BACKGROUND: Treatment non-adherence and service disengagement are commonly attributed to impaired insight. There is evidence that recovery style (i.e. psychological adjustment) may underlie service engagement. AIMS: We examined whether insight, psychotic symptoms or individuals' recovery style ('integration' v. 'sealing-over') predicts service engagement. METHOD: Fifty patients with schizophrenia were assessed during acute psychosis and at 3-month and 6-month follow-ups. Measures included recovery style, psychosis symptoms, insight and service engagement. RESULTS: Sealing-over at 3 months following onset of an episode of psychosis predicted low service engagement at 6 months. Neither insight nor symptoms predicted engagement. The clear shift from integration to sealing-over within the first 3 months was independent of changes in symptoms or insight. Sealing-over between 3 and 6 months was associated with improvement in psychosis symptoms. CONCLUSIONS: Recovery style contributed more to engagement than did insight, appears to be dynamic in the short term and is orthogonal to insight. Overall, this study demonstrated the importance of addressing psychological adjustment to psychosis as well as illness status when investigating treatment engagement in people with psychosis.

Measuring vulnerability to threats to self-construction: the self and other scale.

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.

A new scale (SES) to measure engagement with community mental health services.

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.

Contingent reinforcement or defending the self? A review of evolving models of aggression in people with mild learning disabilities.

This paper examines the changing approaches to working with people with a moderate to mild learning disability, who are frequently aggressive. Long-held assumptions about the lack of inter-personal understanding and impulsiveness continue to play a central role in clinical assessment and intervention for this group. Yet, there is a lack of controlled studies indicating the influence of such factors in frequent aggression. The dominant behavioural tradition has long encouraged such assumptions, but has focused on people with more severe disabilities where such assumptions are arguably more appropriate. The current review of the literature shows a clear evolution away from a strict behavioural approach towards cognitive-behavioural therapy (CBT) approaches that take account of the heterogeneous psychosocial causes of aggression. We find support for CBT in the child-development literature, which examines inter-personal difficulties from an information-processing perspective. Finally, we argue that much of the literature implicitly utilizes the concept of self, and we suggest that this should be made explicit in a reformulated theory of the 'person', incorporating the self concept and embedding individual cognitive processes and behaviour in a social context.