The International Journal of Psychosocial Rehabilitation

Acknowledgement
The authors would like to acknowledge and thank research assistants Constanza Bade, Ann J. Galinanes and Danielle Vandenbent for contributing to data entry and data collection, and the Florida International University Graduate Student Association for contributing funding.

Contact:
W. J. Casstevens
Department of Social Work
Campus Box 7639
North Carolina State University
Raleigh, NC 27695-7639, USA

Abstract
This pilot study employs a quasi-experimental pre-post design (n = 27) to evaluate the impact of a mentored self-help workbook (Coleman & Smith, 1997) intervention.  Participants are diagnosed with severe and persistent mental disorders and experience medication-resistant psychotic symptoms.  The cognitive-behaviorally based workbook is used to target improved self-management of affective and psychotic symptoms.  The intervention can be implemented in community mental health settings by staff with less training than specialized or licensed clinicians.  Results show statistically significant improvement on the Brief Psychiatric Rating Scale factor for Anxious Depression.  This is particularly relevant given the high levels of depression found among individuals diagnosed with schizophrenia.

Keywords: cognitive-behavioral, hallucinations, schizophrenia, self-help

Introduction
This pilot study explores a low-cost, mentored self-help intervention for auditory hallucinations in a community mental health setting.  The intervention involves a mentor’s supportive assistance with written assignments exploring individual voice-hearers’ experiences of auditory hallucinations (Coleman & Smith, 1997; Hustig & Hafner, 1990).  It focuses on assignments operationalized in a published workbook, co-authored by a former psychiatric patient and a psychiatric nurse (Coleman & Smith, 1997).  Study participants completed the workbook, rather than attending a specific number and duration of treatment sessions.  Participants were adults diagnosed with a severe and persistent mood or psychotic disorder experiencing medication-resistant psychotic symptoms.  Results show statistically significant improvement in the Brief Psychiatric Rating Scale (BPRS) factor Anxious Depression for Intervention group participants, over those in the Comparison group.
The “hearing voices movement” that began in Europe following a 1987 conference in Utrecht (Romme & Escher, 1996) inspired Coleman and Smith (1997) to challenge the view of “voices” as symptoms of an illness unrelated to a person’s history.  In their workbook, Coleman and Smith also challenged the corollary that  “voice hearers” are powerless with regards to the voices.  These authors noted that hearing voices is “not the exclusive prerogative of saints and psychotics” (Coleman & Smith, p. 8), but rather part of the human condition.  Coleman and Smith provided no specific goals for their workbook, but rather suggested that any action plan a voice hearer develops should “be focused around your experiences and how you understand them, and should work to your goals and nobody else’s [sic]” (emphases in the original, p. 9). 

Despite departures from mainstream mental health/psychiatric thinking, seventeen of the twenty workbook exercises share similarities with various techniques found in the cognitive behavioral treatment (CBT) of psychosis.  An established adjunctive treatment approach in Europe and particularly the United Kingdom, CBT of psychosis is increasingly recognized in North America (Dickerson, 2000; Kinderman & Cooke, 2000).  Overall, both Coleman and Smith’s (1997) workbook and CBT of psychosis: (1) attempt to normalize the voice-hearing experience, and (2) view hallucinations as on a continuum with normalcy.  Following Romme and Escher’s (1989, 1996) normalizing rationale, workbook exercises begin with an exploration of the onset of voice hearing, and responses to the voice hearing experience, then continue with the voice hearer’s written “Life History” (Coleman & Smith, 1997, pp. 15-18).

Four of the 20 workbook exercises closely resemble “focusing” (Bentall, Haddock, & Slade 1994; Haddock, Bentall, & Slade, 1996).  Focusing is a CBT of psychosis strategy that examines the features, contents, related thoughts, and attributed meaning(s) of “voices.”  The workbook, for example, includes an “I’ve just heard voices” checklist (Coleman & Smith, 1997, pp. 19-20) to photocopy and use daily to describe the voices, voice content and surroundings, and the voice hearer’s associated feelings and thoughts.  This checklist also asks for the voice hearer’s explanation of the voices.  Subsequent workbook exercises have the voice hearer address attributed meaning(s) of the voices through identification of personal frames of reference, beliefs about the voices, and an exploration of alternative belief systems.  A difference between the workbook’s orientation and CBT of psychosis is that the latter views telepathy as a delusional or maladaptive explanation of voices that should be challenged (e.g., Chadwick, Lowe, Horne, & Higson, 1994; Nelson, 1997).  Workbook exercises, in contrast, neutrally explore alternative belief systems (i.e., the illness model, the psychological model, and telepathy).

Workbook exercises move on to emphasize coping with voices, by using focusing and coping strategy enhancement (CSE) techniques, strategies developed in CBT of psychosis (Tarrier et al., 1993; Yusupoff & Tarrier, 1996).  Coping strategy exercises begin with an explanation of what “coping strategy” means and examples of different types of coping strategies.  Exercises are meant to examine current strategies, changes desired (if any), supports, and attributed meanings.  Further exercises are meant to explore alternative strategies and trials of new strategies.  A total of thirteen of twenty workbook exercises have similarities to CSE.  The workbook frames hearing voices as a potential adaptation to, or even survival strategy for, life events.  Guidance is provided to voice hearers for working with professionals in this context.  The net result for voice hearers interested in working with their voices is an unusual combination of client driven, non-judgmental exercises roughly similar in many respects to CBT intervention strategies with psychosis.

At the time of this study’s inception, empirical results from case study, single subject design, and small group comparison study methodologies cautiously favored using CBT of psychosis with clients experiencing various psychotic symptoms.  Subsequent randomized clinical trials (RCTs) have provided further support for individual CBT of psychosis (Durham et al., 2003; Kuipers et al., 1998; NHS Centre for Reviews and Dissemination, 2000; Rector & Beck, 2001; Sensky et al., 2000; Tarrier, et al. 1999; Turkington, Kingdon & Turner, 2002).  RCTs have utilized multiple outcome measures, including measures of overall psychotic symptoms, negative psychotic symptoms, depression, anxiety, self-esteem, self-concept and other constructs.  Generally, CBT of psychosis in the United Kingdom is largely based on the work of Beck and colleagues, with overall agreement that the principal aim “for medication-resistant psychosis is to reduce the distress and interference with functioning caused by the psychotic symptoms” (Garety, Fowler & Kuipers, 2000, p. 73).  It is noteworthy that the outcome measures used in CBT of psychosis intervention research do not directly measure this intent, but rather measure symptom reduction, in addition to a plethora of other variables. 

Summarizing outcome results with psychotic symptoms and adjunctive CBT of psychosis, Boyle (2002) stated that “although some therapeutic results may be modest, most statistical comparisons with other treatments, across a range of outcome measures, favour CBT” (p. 296).  Gaudiano (2005) tabulated 19 publications on 16 RCTs of CBT for psychosis that included individual and group modalities, inpatient and outpatient samples, first episode psychosis, recurrent psychosis, and older patients with schizophrenia.  Gaudiano cautiously concluded that “whether commonly used therapies such as CBT are specifically efficacious in treating psychotic symptoms” needs to be further researched, although evidence is clear that psychosocial interventions generally can contribute “significantly to the well-being of individuals suffering from psychosis beyond the effects of routine care” (p. 46).  Mueser and Noordsy (2005), following Gaudiano’s review, nevertheless concluded that although “the mechanisms and specificity of CBT for psychosis remain unknown, the evidence amassed supports its effectiveness” (p. 68).

Coleman and Smith’s (1997) workbook is intended for use with the support of a trusted other (e.g., friend, significant other, family member, and/or mental health professional), referred to in this study as a “mentor.”  With the workbook, power and authority are to reside solely with the voice hearer, who sets the pace and may disengage with the supportive other and/or discontinue the process without negative consequences at any point.  In addition, the voice hearer “owns” the workbook in a tangible, concrete way seldom applicable to traditional therapy.  This locus of control reflects the self-help philosophy of the workbook.

It occurred to the present authors that Coleman and Smith’s (1997) written guidelines might constitute an additional repertoire of teachable coping strategies for psychotic symptoms in typical mental health settings.  Despite workbook similarities to strategies found in formal individual CBT of psychosis, mentoring the workbook requires less training and experience than is needed for CBT.  Could an intervention built around the workbook produce measurable positive changes in self-esteem, social functioning, depressive and psychotic symptomatology, the very areas that formal CBT of psychosis has explored?  The present study addressed this question.

Methods
This study utilized a non-equivalent comparison group design with non-random assignment to evaluate pre-post intervention change in scores on standardized measures (see below).  The study was conducted in a south Florida community mental health agency that serves adults diagnosed with severe and persistent mental disorders.  At the start of the study, the host agency served 480 “members.”  Approximately 61% of agency members were male and 39% female, 51% Anglo and 49% Minority, with an age range from 18 to over 65.  Agency members had to report experiencing and/or display psychotic symptoms to meet inclusion criteria (see below). 

The sample was one of convenience, based on staff referrals from the host agency.  The Comparison group (n = 13) consisted of participants not scheduled to intervention protocol (n = 17) after signing informed consent paperwork and completing pre-test packets.  Randomization was not possible, as participants were assigned to intervention protocol based on their ability to meet initial scheduling windows available.  Over the course of the study, one participant suffered a stroke and left the Intervention group and two Comparison group participants discontinued services at the agency.  Pre-test data from these three non-completers are not included in the data set, since no corresponding post-test data was obtained.  Thus, data from the total of 27 participants who completed the study are included in the analysis (Comparison group n =11, Intervention group n = 16). 

The sponsoring university’s Internal Review Board and the host agency’s administration approved the study.  The primary researcher met individually with each person referred to the study in order to explain the project and answer any questions about informed consent documentation.  Once informed consent was given, participants could withdraw from the study at any time without penalty or reduction of agency services.

Measures
The current study elected to measure change in overall symptomatology, symptoms of depression and anxiety, and self-esteem, using standardized instruments.  These instruments have been used in CBT of psychosis outcome studies in the United Kingdom (e.g., Haddock, Bentall, & Slade, 1996; Kuipers et al., 1998; Tarrier et al., 1999), or in community mental health research in the United States of America (Newman, DeLiberty, McGrew, & Tejeda, 2005).  Measures are discussed below. 

The Rosenberg Self-Esteem Scale (RSE, Fischer & Corcoran, 1994; Rosenberg, 1989) is a self-report instrument used to measure self-esteem.  The RSE specifies a four-point scale used to self-rate ten statements and was scored as a Likert scale.  Possible scores range from a low of 0 to a high of 30 (highest self-esteem).  The instrument’s short length and ease of administration made it suitable for inclusion in a pre and post-intervention packet of multiple measures. 

The Hoosier Assurance Plan Inventory – Adult (HAPI-A) is a standardized, clinician-rated psychosocial assessment instrument utilized by the state of Indiana with adults diagnosed with severe and persistent mental disorders.  The HAPI-A includes the factor Symptoms of Distress and Mood (Factor 1, based upon three items, A – Consumer’s Rating of Symptom Distress, B – Anxiety-Worrying, and C – Depression-Sad, Blue, or Suicidal Thoughts/Actions), and the item Thought Disorder, Item H.  Item H reads:  “Have you had any unusual experiences (e.g., are there times you hear, see, or smell things other would claim are not there)?”  Two other HAPI-A factors can be used to measure disruption in life (Factor 3 – Community Functioning, and Factor 4 – Social Support-Skills & Housing).  In the state of Indiana, the HAPI-A demonstrated sensitivity to change for clients with psychiatric diagnoses, or psychiatric diagnoses and chronic addiction, over a 90-day period HAPI-A (Newman, DeLiberty, McGrew, & Tejeda, 2005). 

For the HAPI-A, a lower score indicates a more severe problem or symptom.  Score range per item on the HAPI-A is from seven to one.  Since Factor 1 – Symptoms of Distress and Mood is made up of three items, its score ranges from 21 to three.  Factor 3 – Community Functioning, and Factor 4 – Social Support-Skills & Housing, are each comprised of four items, hence these scores range from 28 to four.  Item H (Thought Disorder) ranges from seven to one and is reported separately.

The BPRS is a clinician-rated global instrument for measuring symptoms of psychopathology that includes items related to depression and anxiety (Faustman & Overall, 1999; Overall & Gorham, 1962).  Overall and Klett (1972) identified four general factors within the BPRS, including the factor Anxious Depression.  This factor is based upon three subscales, i.e., Anxiety, Guilt Feelings, and Depressed Mood.  The BPRS measures clinical symptoms across a range of mental diagnoses, such as those present in the clinical sample studied.  Possible BPRS global scores for overall symptomatology range from 18 to 126, where 18 indicates no symptoms and 126 indicates all symptoms rate as extremely severe.  The higher the BPRS global or factor score, the more severe is the symptom rating.

Inclusion Criteria
Study data collection began in the fall of 2001 and extended into the winter of 2004.  Given a sample of convenience, non-random assignment to group, and non-equivalent groups, results should not be generalized to the larger population of Americans diagnosed with major mental disorders and experiencing psychotic symptoms who reside in the community.  Study inclusion criteria included agency membership; this excluded developmentally delayed or mentally retarded individuals, as well as individuals using alcohol or illicit substances.  
Additional inclusion criteria were as follows:  (1) 21 to 65 years of age; (2) no legal guardian; (3) English literacy/fluency; (4) agency record of a DSM-IV (American Psychiatric Association, 1994) diagnosis of Schizophrenia, Schizoaffective Disorder, or Mood Disorder with psychotic features; if the disorder on record was none of these and criterion six (below) was met, intervention protocol was deemed potentially appropriate and the agency member was permitted to enroll in the study (n = 1); (5) agency record of a DSM-IV Global Assessment of Functioning (Axis V) score in the range of 35 to 60; (6) reports by agency staff of observable symptoms such as delusional verbalization or aberrant behavior, and/or verbalization of a problem related to auditory hallucinations, “voices,” intrusive thoughts, or excessive doubts or worries, despite reported adherence to prescribed psychotropic medication; (7) community residence (defined to include residential treatment facilities, assisted living facilities, and group homes); and (8) either no alcohol or illegal substance use diagnoses, or no current alcohol or illegal substance use per staff and self-report, if such diagnoses were on record at the agency.

The first author extracted data on participant demographic and clinical characteristics from agency case files.  MSW-level social workers not affiliated with the host agency and blind to intervention/comparison group status administered pre and post-test instruments.  Weekly intervention sessions with each participant began after completion of the pre-test packet, with the host agency requirement that the first author act as mentor.  Broad variation in both number of sessions and duration of the intervention was expected and, indeed, occurred (range from 12 to 42 weeks, with one outlier at 57 weeks; details below).
A mentored session with an Intervention group participant began with the Topography of Voices Rating Scale (TVRS).  The TVRS is a one-page, unstandardized self-report instrument (Chadwick, Birchwood & Trower, 1996; Hustig & Hafner, 1990) used as an “ice-breaker” to support open discussion of symptoms.  Sessions were one-on-one and followed a semi-structured format of 15 to 45 minute duration.  (The mentor documented details of each session on the Mentor Report Form.)  After completing the TVRS and responding to initial inquiries on medication and current status, the participant was handed the workbook.  Each workbook exercise was read aloud and any confusion clarified prior to the participant completing it.  Verbal responses were redirected with a gentle “write it down.”  Once the workbook was completed, the mentor facilitated contact between participant and assessor to schedule the post-test.  As a participant completed intervention protocol, the mentor referred both that participant and a Comparison group participant to an assessor for post-testing (this was not possible for five Intervention group participants, because of differing group sizes).

Research Questions and Data Analysis
This study aims to determine if a low cost mentored intervention that uses Coleman and Smith’s (1997) workbook provides benefits to clients experiencing psychotic symptoms beyond what treatment as usual provides.  This aim is reflected in the following four research questions:  (1) does self-esteem increase post-intervention, relative to self-esteem of a comparison group not receiving the intervention?; (2) does depression-anxiety decrease post-intervention, relative to a comparison group?; (3) does overall psychotic symptomatology decrease post-intervention, relative to a comparison group?; and (4) does disruption in life lessen post-intervention, relative to a comparison group?. 

Repeated measures analysis of variance (Repeated measures ANOVA, or RMANOVA) assessed whether positive change occurred over: (1) self-esteem, (2) depression-anxiety, (3) overall psychotic symptomatology, and (4) disruption in life.  Two measures were used for the latter three of the four constructs, and Bonferroni corrections set Type I (p) error at .025 (i.e., .05/2) for these analyses.  The general linear model (GLM) approach within the Statistical Package for Social Sciences (SPSS) Version 11.0 was used to conduct the analysis.

ANOVA is relatively robust regarding failures to meet assumptions of homogeneity and normality (Garson, 2005).  The F-test (or F-ratio) is the key statistic for ANOVA and its formula reflects whether the variance among the group means (for given sample size and within group variances) is significantly larger than the error variance within the groups.  With smaller variances and smaller samples, F is conservative, i.e., it is more difficult to detect statistical significance (Garson, 2005).  When using the GLM model within SPSS, the F-test is unaffected by unequal group sizes.  In studies evaluating cognitive-behavioral or other individual psychotherapy approaches, large samples of individuals diagnosed with serious mental disorders are seldom available (Gottdiener & Haslam, 2002).  Researchers have used any one of several effect size statistics to describe the magnitude of any significant differences observed between intervention conditions.  In this study, effect size was estimated using the “partial eta square” statistic, which reflects the proportion of variance associated with a given variable.

Results
Specific demographic and clinical characteristics of Intervention and Comparison group participants are shown in Table 1.  Overall, Intervention group participants tended to be: (1) an average of seven years older, (2) more likely to have more debilitating psychiatric disorder diagnoses, and (3) more likely to be of non-Hispanic White ethnicity/race, than Comparison group members. 

<>Table 1 Intervention and Comparison Group Demographics (n = 27)

	Intervention Group (n = 16)	Comparison Group (n = 11)
Characteristic	n (%)	n (%)
Gender
Female	4 (25)	3 (27)
Male	12 (75)	8 (73)
Race/Ethnicity
White	13 (81)	7 (64)
Minority	3 (19)	4 (36)
Marital Status
Single/Divorced	15 (94)	10 (91)
Married	1 (6)	1 (9)
Education
High School or below	7 (44)	6 (55)
Post High School/GED	9 (56)	5 (45)
Residence
Independent	11 (69)	7 (64)
Group home Diagnostic Category	5 (31)	4 (36)
Psychotic Disorder	15(94)	7(64)
Mood Disorder	1(6)	3(27)
Other Disorder	0(0)	1(9)

Table 2 shows that at pre-test, the Intervention group had significantly higher BPRS global scores.  However, the difference on the BPRS Anxious Depression factor was not statistically significant and other differences appeared trivial and were not statistically significant.

This pilot study employs a quasi-experimental pre-post design (n = 27) to evaluate the impact of a mentored self-help workbook (Coleman & Smith, 1997) intervention.

<>Table 2 Between Group Differences at Pre-test

Measure	Group (I = 16, C = 11)	Mean + SD	Range	F (dF: 1, 25)	p	Partial Eta Squared
RSE	Inter.	19.31 + 6.26	8-30	0.613	.441	.024
	Comp.	21.09 + 5.03	14-30
BPRS Anx.Dep.	Inter.	8.06 + 3.13	3-13	3.428 (1,24)	.076	.125
	Comp. (10)	5.80 + 2.86	2-13
HAPI-A Mood	Inter.	15.94 + 4.19	9-21	.146	.706	.006
	Comp.	16.55 + 3.82	6-21
BPRS Global	Inter.	37.56 + 7.79	25-50	5.729 (1,24)	.025	.193
	Comp. (10)	29.60 + 8.97	19-43
HAPI-A Tht.Dis.	Inter.	4.88 + 2.03	1-7	1.552	.224	.058
	Comp.	5.82 + 1.78	1-7
HAPI-A Comm.	Inter.	20.56 + 5.14	11-28	.439	.514	.017
	Comp.	21.82 + 4.35	14-28
HAPI-A Soc.Supp.	Inter.	23.69 + 4.01	11-28	.001	.982	<.001
	Comp.	23.73 + 5.02	14-28

The number of mentored self-help sessions for 15 Intervention group participants ranged from eight to 18 (mean = 12.6) with a duration range of 12 to 42 weeks (mean = 28.3), excluding the one participant with 25 sessions over 57 weeks.  In sum, there was a pronounced central tendency of 13 sessions over a 29-week period, despite differing levels of education/literacy and scheduling idiosyncracies.  As noted above, the intervention aimed only for workbook completion (a behavioral criteria) rather than for a specific “dosage” of intervention, thus neither the duration of the intervention nor the number of sessions should be taken as an indicator of quantity or intensity:  Longer duration indicated slower progress in completing workbook exercises.

Pre-post differences analyzed using RMANOVA are shown in Table 3.  Using RMANOVA and appropriate Bonferroni corrections, no significant differences were found for self-esteem, overall psychotic symptoms, or disruption in life.  For depression and anxiety, the two measures used were the BPRS Anxious Depression and HAPI-A Distress-Mood factors.  Because the statistical test required two separate analyses, a Bonferroni correction set Type I error (p) at .025 (i.e., .05/2).  No significant difference was found between groups for the HAPI-A factor, however, a significant difference was found between groups for the BPRS factor, with a strong effect size, η2 = .218.  Further, the correlation between the change in scores for the BPRS factor Anxious Depression and the change in scores for the HAPI-A Factor Symptoms of Distress and Mood was significant at the .05 level (r = -.341).  In sum, one of two measures of depression-anxiety symptoms suggested that these symptoms showed significantly greater reduction for the Intervention group and the two measures were significantly correlated with each other.

<>Table 3 Pre-post Test Differences:  ANOVA Results

Measure	Group (I = 16, C = 11)	Mean + SD	Range	F (dF: 1, 25)	p	Partial Eta Squared
RSE	Inter.	18.81 + 4.17	10-26	0.006	.940	<.001
	Comp.	20.73 + 4.27	16-30
BPRS Anx.Dep.	Inter.	6.69 + 3.24	3-13	6.985 (1, 24)	.014	.218
	Comp. (10)	7.70 + 3.89	1-15
HAPI-A Mood	Inter.	15.31 + 4.50	8-21	.193	.664	.008
	Comp.	16.73 + 3.04	11-21
BPRS Global	Inter.	37.94 + 12.0	18-65	.577 (1, 24)	.455	.023
	Comp. (10)	34.70 + 10.8	23-51
HAPI-A Tht.Dis.	Inter.	5.25 + 1.77	2-7	.016	.902	.001
	Comp.	6.09 + 1.14	3-7
HAPI-A Comm.	Inter.	22.19 + 3.60	14-27	.067	.797	.003
	Comp.	23.82 + 3.09	16-28
HAPI-A Soc.Supp.	Inter.	23.13 + 4.84 24.64 + 3.07	14-28 17-28	.707	.408	.028
	Comp.

Discussion

The study used three standardized instruments with an Intervention and a treatment-as-usual Comparison group, to examine pre-post differences over four constructs.  Research questions related to self-esteem, depression-anxiety, overall psychotic symptomatology, and disruption-in-life, respectively.  Interestingly, five of seven outcomes showed non-significant change scores that favored the Comparison group over the Intervention group.  These outcomes do not reach statistical significance, and whether they would sustain with a more powerful study is a question for future research.  
The study is an exploratory pilot and findings are limited.  Results cannot be generalized, given the small sample size, non-random assignment to group, non-equivalent groups, and other study limitations (see recommendations below).  Overall, a conservative interpretation of results is that the one significant difference in pre-post instrument scores occurred due to chance.  An alternative interpretation is that the mentored self-help intervention made an actual improvement in the level of depression-anxiety experienced by Intervention group participants.  This is particularly relevant, if so, given the high levels of depression and depression-associated suicide among individuals diagnosed with schizophrenia.  The alternative interpretation supports further research on the intervention.  
Recommendations for a future study address limitations of the current one and include:  (1) random assignment to group; (2) use of different mentors simultaneously, each mentor working one-on-one with individual participants, to avoid the confound of a single individual administering the intervention; (3) advance stipulation of the number of sessions to standardize “dosage;” (4) use of specific standardized instruments to assess symptoms of depression and anxiety; (5) use of a standardized measure of self-efficacy rather than self-esteem; and possibly (6) use of qualitative measures, rather than the HAPI-A, to assess disruption in life.

The statistically significant result obtained was over the construct depression-anxiety and one might cautiously conclude that the single pre-post difference was an artifact of multiple measures over multiple questions, i.e., that one of seven measures (14%) showed improvement purely due to chance, despite a priori formulation of research questions and an appropriate use of Bonferroni corrections in the analysis.  The change in the more disturbed Intervention group might also indicate regression towards a mean; if so, however, one might have expected the global score of the same scale to show a similar shift and this did not occur.  The BPRS Anxious Depression factor pre-post difference showed a strong effect size, and although the difference was only seen with one of two measures, the difference scores on both the BPRS and the HAPI-A factors correlated significantly at the .05 level.  A more positive interpretation of observed results is that the intervention served to assist individuals with severe and persistent psychotic symptoms in reducing distress associated with at least some of those symptoms.

Few CBT studies have measured secondary aspects of psychosis such as depressive symptoms or anxiety, although Sensky et al. (2000) and Turkington, Kingdon and Turner (2002) reported improvements in depressive symptoms.  Rector and Beck (2001) noted “upwards of two-thirds of patients receiving a diagnosis of schizophrenia will also experience a major depressive episode” (p. 285).  Kaplan and Sadock (1998) reported up to ten percent of people diagnosed with schizophrenia die from suicide and that an estimated 4,000 people diagnosed with schizophrenia in the United States die annually by suicide (see also World Health Report, 2001).  Further, only a small percentage of these people commit suicide because of psychotic symptoms: depressive symptoms are associated with over two-thirds of these suicides.  Beck (in Kingdon & Turkington, 1994) correctly highlighted depressive symptoms as natural sequelae of a schizophrenic diagnosis.  If the mentored self-help workbook intervention is shown in future studies to decrease levels of depression in this population, the intervention format lends itself to implementation in community mental health agency settings through supportive staff.

An excursion into speculative thought is in order, given (1) the observed reduction in BPRS Anxious Depression scores for the Intervention group, (2) the positive impact of all major forms of individual therapy for those diagnosed with schizophrenia (Gottdiener & Haslam, 2002), and (3) the prevalence of depressive symptoms and suicide in this population.  Given the demonstrated positive impact of all forms of individual therapy, depressive symptoms and associated suicides might be reduced by use of interpersonal, relational interventions.  The implication for practice with this population is that developing interpersonal practitioner-client relationships based on mutual respect, trust, and client choice is a critical foundation of treatment.  Use of a self-help workbook co-authored by a mental health consumer might assist the development of such practitioner-client relationships, whether the workbook was used one-on-one or within a group format.  Study results indicate that the workbook – despite its departures from mainstream mental health thinking – when used one-on-one with a supportive mentor, appeared to do no harm and that it may in fact be a positive process for clients experiencing medication resistant psychotic symptoms.  

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