Journal of Clinical Nursing 1992; 1: 283-288

The use of cognitive behavioural therapy with people withschizophrenia

BOB GARDNER

Community Psychiatric Nurse, 42 St Mary's Gate, Chesterfield, Derbyshire S4l 7TH, UK

STEVE THOMPSONCommunity Psychiatric Nurse, 113 Dale Road, Matlock, Derbyshire DEL 3LU, UK

Accepted for publication 14 May 1992

lo

Summary

• The role of cognition as one aspect of the stress-vulnerability model ofschizophrenia is discussed, and the use of cognitive therapy reviewed.

• A holistic approach to the development of schizophrenia is explored.

• The stress vulnerability model is explained and the way in which individualssuffering from schizophrenia are vulnerable to attentional, perceptual andcognitive difficulties, are discussed.

• Using case examples, it is demonstrated that the use of cognitive behaviouraltechniques can be used by nurses to effectively reduce client problems associatedwith schizophrenia.

Keywords: cognitive therapy, schizophrenia, community psychiatric nursing,stress-vulnerability model.

Introduction

AETIOLOGY OF SCHIZOPHRENIA

Zubin et al. (1985) proposed seven possible models of theaetiology of schizophrenia:• ecological; .••• ,',\:-\vj \::.: cue'^rv f-

• developmental;• learning theory;• genetic;• internal environment;• neuro-physiological;• neuro-anatomical. 'i>tThese can be divided into two major classifications:• biological;• environmental.It is considered unlikely that any one of these alone, can

claim to be a sufficient cause in the aetiology of schizo-phrenia. The 'stress-vulnerability model' is a super-ordi-nate model that integrates the above factors and suggeststheir interrelationships (Zubin & Steinhaur, 1981).

Ciompi (1987), in describing the stress-vulnerabilitymodel, postulated that certain people have genetic predispo-sitions and also possible acquired impairments, that makethem vulnerable to the development of psychotic behaviourwhen under stress, especially stress of a psychosocial nature.This is supported by the research on life events (Brown &Birley, 1970) and the effects of psychosocial overstimulationon disposed individuals (Wing & Brown, 1970).J Difficulties in information processing are the cause of in-creased susceptibility to stress (Brenner, 1987; Neuchterlein& Dawson, 1984). Bleuler's (1911), affirmed view, over 50years ago, was that the primary disorders of elementarycognitive processes contribute to the so-called thought

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284 B. Gardner and S. Thompson

disorder of schizophrenia. Falloon (1987) and Libermanet al. (1987) both stated that impairment in cognitivefunctions contributes to difficulties in social functioning.

Birchwood et al. (1988) also viewed individuals as havingan intrinsic vulnerability and that episodes of schizophreniaare prompted by psychosocial stressors. Therefore, theysuggested that interventions which improve social, interper-sonal and vocational functioning, and strengthen individualclient's ability to deal with psychosocial stressors, are useful.Ciompi (1987), believed that there are two ways in whichinformation processing can be improved.

• 'Extrinsically' by simplifying the incoming information,for example, reducing the quantity of information andmaking it clear and unambiguous.

• By assisting individual's ability to strengthen their infor-mation processing systems. (This is discussed further inthe section labelled 'Outcome studies'.)There is an increasing interest in the potential for self-

help amongst people suffering from schizophrenia (Boker,1987). The self-help process has been described in threestages by Breier & Strauss (1983).• Self-monitoring—the person notices there is something

wrong.• Self-evaluation—it is identified as a 'problem' by the

person.• Defence efforts—for example, self-treatment with drugs

or alcohol, self-instruction, withdrawal and avoidance.Clearly, the aetiology of schizophrenia is complex and

the knowledge concerning cause and treatment still in itsinfancy. The aim of this paper is to focus specifically on theuse of cognitive therapy with people suffering from schizo-phrenia. While this paper does not discuss social-skillstraining, it is recognized that cognitions must be con-sidered when conducting social-skills training (Shepperd,1984; Fallon et al., 1984; Perris, 1988).

Outcome studies

THOUGHT PROCESSING

It is argued that there is a clinical value, in terms of clientoutcome, in identifying and treating the cognitive abnor-malities associated with schizophrenia. In the last decade,improvements in the knowledge concerning both informa-tion processing and cognitive behaviour modification havebeen applied to the problem of treatment (Spaulding et al.,1989). Prior to this, both Beck (1952) and Ellis (1962) havereported success in treating people with schizophrenia bycognitive methods.

The remediation of cognitive processing disorders is theaim of treatment when dealing with information process-

ing (Adams et al., 1981). Brenner (1989) described an'integrated psychological treatment programme' that aimedto reduce attentional/perceptual problems and other cog-nitive dysfunctions. It is reported that such treatment hadpositive effects on clients' cognitive functions but that theeffects on observable behaviour were inconsistent (Brenneret al., 1990). They proposed that in the future, cognitivedisorders would have to be understood in the context ofthe patient's current social situation and environment. Onesingle case study reported by Adams et al. (1981) hada positive outcome, in that the patient demonstrated asignificant improvement in attentional and focusing skillscombined with the elimination of delusional thoughts.

Perris (1988) used cognitive behaviour therapy to cor-rect maladaptive and distorted thoughts. Therapy wasconducted on both a group and individual basis in linewith recognized cognitive therapy techniques. This wasconsidered appropriate because he suggested that most ofthe cognitive distortions which are demonstrated by peoplewith emotional disorders as described by Beck (1976) mayalso be found in people suffering from schizophrenia, atheory supported by Greenwood (1983). Kingdon & Turk-ington (unpublished data) report the use of cognitivebehavioural therapy as an adjunct to standard treatment ofschizophrenia which reduced both medication and hospi-talization of clients. A 'normalizing' rationale was used toenable a relating of culturally acceptable beliefs to psych-otic phenomena. This was to assist in destigmatizing thepsychotic experience and to lay clients open to rationalarguments. Examples of the occurrence of the signs andsymptoms, similar to those of schizophrenia, in 'normal'subjects are given —hallucinations occurring in solitaryconfinement (Grassian, 1983), and in sleep deprivation(Oswald, 1974) and in solitary deprivation experiments(Leff, 1968). Meichenbaum & Cameron (1973) employed acognitive training procedure that enhanced 'chronicallyimpaired patients' perceptual, attention and problem-solving skills. This involved the use of self-instruction toprevent the person emitting 'schizophrenic behaviour'.

DELUSION

There is some evidence that delusions can be modified bycognitive therapy. Watts et al. (1973), reported a signifi-cant change in the intensity of delusions in three 'chronicparanoid patients' treated by cognitive therapy. Theyfound that direct confrontation merely heighten thebeliefs. This was supported by Milton et al. (1978) whostudied a group that used problem-solving techniques,significantly reducing the intensity of their delusionalbeliefs. Lamantogne et al. (1981) successfully employed

Cognitive behavioural therapy and sehizophrenia 285.

'thought stopping' to reduce the intensity of delusions andChadwiek & Lowe (1990) have also reported the successfulmodification of the delusional beliefs.

Hartman & Cashman (1983) showed that it is importantto analyse the contingencies surrounding the occurrence ofdelusional thoughts and that it is unlikely any singlestrategy will prove effective in all eases. They went on todescribe how three people were helped with differentcognitive and behavioural strategies. These were, anxietymanagement, exposure to the situation where persecutionwas feared and finally the development of more adaptivecognitions and correction of a negative self-image.

HALLUCINATIONS

Falloon & Talbot (1981), reported reduction in auditoryhallucinations in two patients by the self-administration of apainful stimuli (snapping a rubber band around their wrist)when hallucinations occurred. The provision of externalauditory stimuli by means of stereo radio music (Feder,1982) and television (Magen, 1983) have also been shown toreduce auditory hallucinations. Kansas (1984) described theuse of an educational problem-solving group which helpedpeople to develop effective ways of managing their disabili-ties. Falloon (1987) stated that it is important to recognizethe contingencies surrounding the onset of hallucinationsand to devise strategies for clients to prevent their onset.

The application of cognitive behavioural therapyin a community setting

Thompson a CPN, has developed the following cognitivebehavioural approach when helping people with schizo-phrenia to cope with their problems. Theoretically, cogni-tive behavioural therapy can be described in three stages,but in practice, these stages overlap. Throughout treat-ment, clients take an active part in the management of theirproblems and the therapy is structured in a collaborativemanner between therapist and client (Beck et al., 1985).

STAGE 1

The first stage involves getting the client to recognize thatthey are having difficulties, which can be seen as either anillness or problems. To promote this recognition, thetherapist explores the symptoms the client is experiencing,by using questions to assess in detail the client's percep-tions. These questions are usually fairly direct and involvewords such as what is happening.'' when.'' where? why? andto what extent does the client know when things are notcorrect for them?

There is no attempt at this stage to challenge the client'sviews about their symptoms, the aim is to get them to

recognize that the symptoms they are experiencing arecausing problems and that they can do something aboutthem. If the client is unable to recognize any of thesymptoms that they are experiencing, then the aim is to getthe client to give permission to the family or friends to helpthem to recognize these. 'Homework' can be set whichpromotes the client to monitor and write about thesymptoms they experience and again, if they are unable todo this, to verbally report to their family or friends. Theuse of the technique, 'reversal', where the client is askedhow they would view such behaviour and cognitions inothers can sometimes be useful to enable the client torecognize their own symptoms. The therapist must explainthe symptoms so they are understandable and meaningfulto the client, and thought processes explored: fast, slow,blocking, passivity—and these ean be matched to theclient's own thought processes. The therapist must con-tinually check to ensure the client is understanding what isbeing debated and is beginning to accept that at least thereis an alternative to how they view their symptoms. Asrecognition develops, full discussion around their symp-toms ean occur: what are your feelings about these? arethere any experiences you find hard to put into words?

STAGE 2

The second stage involves getting the client to developstrategies to deal with their problems. This involves theclient and therapist in exploring and understanding theeffects of stress on the elient. Through such exploration,the client may begin to understand and accept theirlimitations in terms of coping with stress and identify self-help strategies, for example, withdrawal from a situation,decreasing activities planned, structured day, to enablethem to cope more successfully. The need for some struc-ture to minimize potential stressors can be explained by thetherapist and ways of doing this explored. The method ofself-help that the client thinks they will find helpful can betested using 'homework' to find out how useful the clientfound the self-help strategy in a planned situation. A fullexplanation is given to family or friends so that they can notonly encourage the elient to use these self-help strategies butwill also have understanding of them when they do.

When the client has learnt to recognize their symptomsand use self-help strategies to reduce/eliminate the prob-lems eaused by these symptoms, the third stage can beimplemented.

STAGE 3

The third stage involves a more in-depth cognitive discus-sion about the client's symptoms, problems, illness. The

.286 B. Gardner and S. Thompson

client is encouraged not only to recognize his symptomsbut also to challenge them. An example of this is given in ashort case study at the end of this paper.

CLIENT CONTROL

One of the main goals of the cognitive behavioural ap-proach, is to give control to the client with help of families,friends, etc. Medication is reduced to the smallest dosethat is effective. The use of extra medication, if needed, isself-administered. The CPN's role here is to monitor thatthe client uses the extra medication effectively and does nottake too much extra medication, rather than the traditionalrole of ensuring that the clients take their medication. It isworth pointing out that the use of medication is explainedfully in the second stage of this approach and that the useof extra medication as required is explored in terms ofbeing a self-help strategy.

i Another important aspect of this approach is the use oflocal community resources to promote self-help strategies.This includes the use of self-help groups specifically forpeople with mental-health problems and also 'ordinary'groups that are run in the community. Paid support workersare used, to encourage the use of these resources and localfacilities, with clients who need extra help in this area.

V- -^ l i l t - . x - i - - , ? . ! ; . . • . • : . - t . • , , . , , ^ •

CLIENT BENEFITS

Clients who have benefited from this type of intervention(which is ongoing and not time-limited) have shown aswell as symptom control, a generalized improvement inother aspects of their lives.

One example of this is a 36-year-old woman, who, afternumerous psychotic breakdowns, had two children andcoped effectively. She has part-time work at the local puband has developed a more equal relationship with herpartner. Occasional experiences of psychotic ideas arecopied with effectively by cognitive strategies.

Another example is a 32-year-old woman who hadexperienced psychotic episodes and had numerous admis-sions since the age of 18. This led to conflict and loss of herrole with her two children. She is now running the familybusiness in France effectively and the relationship with herchildren has improved. She has had no admission since 1988.

•' Admissions from a group of six clients have reducedfrom 18 (during the period 1985-1988) to three (1988-1991).A reduction of approximately 50% in the use of medica-tion has also been achieved in this population.

JANE

This short case study, illustrates in the first person, the' way in which Thompson worked as a CPN using cognitive

behavioural therapy to enhance the life-style of a clientcalled Jane.

Jane is a 24-year-old woman who has been receivingpsychiatric help over the past 6 years (she also had themisfortune to develop Hodgkin's disease, which is now inremission). Her initial contact began when she startedcollege with her suffering a psychotic episode within a fewdays of starting there. The symptoms she presented withwere described as irritability, aggression, passivity feelings,and she was experiencing auditory hallucinations of apersecutory nature. She also believed she had been throwninto what she described as a 'storyline', as a character andthat she was controlled by the author.

She was admitted for psychiatric care as an in-patientwhich lasted 6 months and was treated mainly withneuroleptic medication and lithium. Whilst in hospital, shewas at times extremely difficult to manage, and on occa-sions, when her mood became euphoric, her behaviour wasunpredictable, for example, setting fire to her bedding.

During the next 4 years, she had numerous admissionsto her local psychiatric hospital where medication becamethe central aspect of her care. In 1989, she came to livewith her father and stepmother in the locality where Iworked and was admitted almost immediately to our localMental Health Unit under section 2 of the 1983 MentalHealth Act, with a similar presentation to the past.

On her discharge, she was referred to me for communitysupport and monitoring of her medication. Her medicationon discharge was chlorpromazine 600 mg daily, lithiumcarbonate 1000 mg daily, thyroxin 30 mg daily and imipra-mine 200 mg daily. On return to her father's house, shewas spending long periods of time in bed, she wasemotionally flat and lacked the motivation or confidence toleave the house. There was also evidence that she remainedauditory hallucinated and that the 'voices' were reinforcingher idea that she was being persecuted.

Despite her history and obvious psychiatric condition,on assessment, it became clear in a very short time that shehad some insight into her experiences and saw them asabnormal. After discussion, I felt that she may benefitfrom cognitive behavioural interventions that would helpher cope with her distressing symptoms.Three major problems identified and are listed below.• Her inability to separate 'reality' from any 'unreal'

experiences she was encountering. An example of thiswas her concern about her auditory hallucinations—shebelieved that her 'voices' were received from a transmit-ter in the garden and that she was under surveillancefrom some agency.

• She became anxious in numerous situations which led toan increase in her auditory hallucinations and if left to

Cognitive behavioural therapy and schizophrenia 287

develop, would become a full-blown psychotic ex-perience.There was family conflict relating mainly to their diffi-culties in understanding Jane's problems and ways ofdealing with her behaviour. ••, H v ; - - , - . - e r i '•

The therapeutic approach

The first part of my approach, as for others, was toestablish a relationship that enabled therapeutic work totake place. Jane and her family were educated about hercondition in a language that made sense to them. Possibleways of dealing with distressing symptoms were exploredand the family, with Jane's permission, were to take a partin helping her to deal with them.

After this, the next step was to get her to identify, indetail, her problems. Reality testing was used where shewould check out her experiences with me (later on, herfamily and a nominated friend) and we would use apredetermined criterion by which to judge these ex-periences.

From this analysis, a chain of events were shown to leadto her experiencing psychotic behaviour whilst in town.There was a connection between her anxiety feelings andher auditory hallucinations in this situation. The chain wasas follows:• action—going into town alone;• feeling—physiological signs and symptoms of anxiety,

for example, palpitations, tremor, 'butterflies' in stomach;• belief—everyone in town knows me and can read my

mind;• reaction—'voices' run a commentary of her experiences;• formulation — I know everyone, as well as them knowing

me;• enters into a 'storyline' as a character controlled by the

author.This simple chain method was also used to explore morecomplex psychotic experiences she was having. In theabove example, Jane's self-monitoring enabled her torecognize that her increased anxiety led to an increase inher auditory hallucinations. By the use of exposure andanxiety management, she was able to reduce her anxietyand correspondingly her idea that people were monitoringher thoughts. One of the main goals was to extend thecontrol Jane had over her distressing symptoms. It alsohelped her to recognize that this belief was irrational andrelated to her experiencing anxiety.

I made myself available to Jane and she was advised tocontact me to check out any experiences between sessionsthat were causing her concern.

Jane's progress to date

Jane has been admitted to hospital only once since 1989and this was planned and was due to a bereavement in thefamily. It lasted only 3 weeks and she was able to use self-help strategies to prevent a serious deterioration in hermental health. Her medication now is lithium 800 mgdaily, thyroxine 30 mg daily and pimozide 2 mg daily.

Jane is at present looking for her own flat and is seekingemployment. She still on occasions, when under increasedstress, has a return of her psychotic experiences, but is ableto use the self-help strategies to control these.

Conclusions

The use of cognitive therapy for schizophrenia has steadilygrown over the- last decade. Some of the results suggesteflicacy, but controlled evaluation is needed. Tyrer et al.(1988), stated that cognitive behavioural techniques lendthemselves readily to controlled evaluation while Kingdon& Turkington (1991) state that the planning of suchtreatment trials are proceeding.

Bentall (1990), in his concluding chapter, stated thatthere is evidence that psychological interventions can helppeople who are experiencing psychosis, and Chadwick &Lowe (1990) in discussing the modification of delusionalbeliefs, stated 'even on the basis of the limited work todate, it would appear that more can be done for thispopulation than is typically undertaken.'

Another psychological intervention discussed in Ben-tail's book by Tarrier (1990) is the family management ofschizophrenia. A number of studies carried out that haveused family interventions, have consistently and success-fully reduced relapse rates.

Brooker's (1990) research found that CPNs couldachieve far more with schizophrenia suiferers and theirfamilies at home than previously acknowledged, usingpsychosocial interventions. To enable this to happen,structured training programmes have been developed toteach CPNs the skills necessary to carry out familyinterventions in this way.

Bentall (1990), in his concluding chapter, says theproblem with these psychological interventions, is thathardly anyone is carrying them out. Yet, we suggest thatthese treatments are an area that CPNs should becomeincreasingly involved with, as demonstrated by this paperand Brooker's research.

References

Adams H.E., Brantley P.J., Malatesta V. & Turkat I.D. (1981)Modification of cognitive processes. A case study of schizo-

288 B. Gardner and S. Thompson

phrenia. Journal of Consulting and Clinical Psychology 49(3),

460-464.

Beck A.T. (1952) Successful outpatient psychotherapy of a chronic

schizophrenic with a delusion of borrowed guilt. Psychiatry 15,

305-312.

Beck A.T. (1976) Cognitive Therapy and The Emotional Disorders.

International Universities Press, New York.

Beck A.T., Emery G. & Greenberg R.L. (1985) Anxiety Disorders

and Phobias: a Cognitive Perspective. Basic Books, New York.

Bentall R.P. (1990) Reconstructing Schizophrenia. Routledge, Lon-

don and New York.

Birchwood M.J., Hallett S.E. & Preston M.C. (1988) Schizophrenia:

An Integrated Approach to Research and Treatment, Longman Ltd,

Harlow Essex.

Bleuler E. (1911) Dementia Praecox or the Group of Schizophrenias.

International Universities Press, New York.

Breier A. & Strauss J.S. (1983) Self control in psychotic disorders.

Archive of General Psychiatry. 40, 83, 1141-1145.

Boker W. (1987) On self help among schizophrenia: problem

analysis and empirical studies. In Psychosocial Treatment of

Schizophrenia (Strauss J., Boker W. & Brenner H., eds). Hans

Huber Publishers, Toronto, pp. 167—179.

Brenner H.D. (1987) On the importance of cognitive disorders in

treatment and rehabilitation. In Psychosocial Treatment of Schizo-

phrenia (Strauss J., Boker W. & Brenner H., eds). Hans Huber

Publishers, Toronto, pp. 136—151.

Brenner H.D. (1989) The treatment of basic psychological dysfunc-

tions from a systemic point of view. British Journal of Psychiatry.

155 (Suppl. 5), 74-83.

Brenner H.D., Kraemer S., Hermanutz M. & llode B. (1990)

Cognitive treatment in schizophrenia. In Schizophrenia: Concepts,

Vulnerability and Intervention (Straube E.R. & Hahlweg H., eds).

Springer-Verlag, Berlin.

Brooker C. (1990) All in the family? Nursing Times 86(2), 26-29.

Brown G.W. & Birley L.T. (1970) Crises and Life Changes and the

Onset of Schizophrenia. Cambridge University Press, London.

Chadwick P.D.J. & Lowe C.F. (1990) Measurement and modifica-

tion of delusional beliefs. Journal of Consulting and Clinical

Psychology 58(3), 225-232.

Ciompi L. (1987) Towards a coherent multidimensional under-

standing and therapy of schizophrenia: converging new concepts.

In Psychosocial Treatment of Schizophrenia (Strauss J., Boker W.

& Brenner H., eds). Hans Huber Publishers, Toronto, pp. 48-62.

Ellis A. (1962) Reason and Emotion in Psychiatry. Lyle Stuart, New

York.

Fallon J.L., Boyd J.L. & McGill C.W. (1984) Family Care of

Schizophrenia. Guildford Press, New York.

Falloon I.R.H. (1987) Cognitive and behavioural interventions in

the self control of schizophrenia. In Psychosocial Treatment of

Schizophrenia (Strauss J., Boker W. & Brenner H., eds). Hans

Huber Publishers, Toronto, pp. 180-^190.

Falloon I.R.H. & Talbot R.E. (1981) Persistent auditory hallucina-

tions: coping mechanisms and implications for management.

Psychology Medicine 11, 329-339.

Feder R. (1982) Auditory hallucinations treated by radio head-

phones. American Journal of Psychiatry 139, 1188-1190.

Grassian G. (1983) Psyehopathology of solitary confinement. Amer-

. ican Journal of Psychiatry 140, 1450-1454. iij<vr<f

Greenwood V.B. (1983) Cognitive therapy with the young adult

chronic patient. In Cognitive Therapy with Couples and Groups

(Freeman A., ed.). Plenum Press, New York.

Hartman L.M. & Cashman F.E. (1983) Cognitive-behavioural and

psychopharmacological treatment of delusional symptoms: a pre-

liminary report. Behavioural Psychotherapy 11, 50-61.

Kansas N. (1984) Self control of psychotic prediction in schizo-

phrenia. Archives of General Psychiatry 41, 919-920.

Kingdon D.G. & Turkington D. (1991) The use of cognitive-beha-

viour therapy with a normalising rationale in schizophrenia.

Journal of Nervous and Mental Disease. 179(4), 207-211.

Lamantogne Y., Andret N. & Elie R. (1983) Thought stopping for

delusions and hallucinations: a pilot study. Behavioural Psycho-

therapy 11, 177-184.

Leff J.P. (1968) Perceptual phenomena and personality in sensory

deprivation. British Journal of Psychiatry 114, 1499-1508.

Liberman R.P., Jacobs HE. , Boone S.E., Fay D.W., Donahue C ,

Falloon I.R.H., Blackwell G. & Wallace C.J. (1987) Social skills

training for the community adaption of schizophrenics. In Psy-

chosocial Treatment of Schizophrenia. (Strauss J., Boker W. &

Brenner H., eds). Hans llubcr Publishers, Toronto, pp. 9+-109.

Magen J. (1983) Increasing external stimuli to ameliorate hallucina-

tions. American Journal of Psychiatry 40, 269-270.

Meichenbaum D. & Cameron R. (1973) Training schizophrenics to

talk to themselves: a means of developing attentional controls.

Behaviour Therapy 73(4), 515-534.

Milton F., Patwa V.K. & Hafner R.J. (1978) Confrontation versus

belief modification in persistently deluded patients. British Jour-

nal of Medical Psychology 51, 127-130.

Neuchterlein K.H. & Dawson M.E. (1984) A heuristic vulnerability/

stress model of schizophrenic episodes. Schizophrenia Bulletin 10

(2), 300-312.

Oswald I. (1974) Sleep 3rd edn. Penguin, Harmondsworth.

Perris C. (1988) Cognitive Therapy with Schizophrenics Patients. The

Guilford Press, New York. London.

Shepherd G. (1984) Assessment of cognitions in social skills train-

ing. In Radical Approaches to Social Skills Training (Trower P.,

ed). Croom Helm, London, pp. 261—283.

Spaulding W., Gabrin C.P. & Crirean W.J. (1989) The logical and

psychometric prerequisites for cognitive therapy of schizophrenia.

British Journal of Psychiatry 155 (Suppl. 5), 69-73.

Tarrier N. (1990) The family management of schizophrenia. In

Reconstructing Schizophrenia (Bentall R.P., ed.) Routledge, Lon-

don and New York, pp. 254—282.

Tyrer P., Sievewright N. & Murphy S. (1988) The Nottingham

study of neurotic disorder: comparison of drug and psychological

treatment. Lancet ii, 359—363.

Watts F.N., Powell G.E. & Austin S.V. (1973) The modification of

abnormal beliefs. British Journal of Medical Psychology, 46,

359-363. braad'Wing J. & Brown G.W. (1970) Institutional Schizophrenia Cam-

bridge University Press, London.Zubin J. & Steinhauer S.R. (1981) How to break the logjam in

schizophrenia: a look beyond ^cnctica. Journal of Neurological and

Mental Disease 169(8), 477-491.Zubin J., Steinhauer S.R., Day R. & Kaiser D.P. (1985) Schizo-

phrenia at the crossroads: a blueprint for the '80s. Comprehensive

Psychiatry 26, l\l-m). ..fi'rtV>.vi-..v:)dnuK^'-ism 'sv-,