The self, attributional processes and abnormal beliefs: Towards a model of persecutory delusions

Behao. Res. Thu. Vol. 32, No. 3, pp. 331-341, 1994 Cmvrieht %I 1994 Elsevier Science Ltd Printed in Great Britain. All rights reserved

Pergamon 00057967(93)EOOlO-3

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THE SELF, ATTRIBUTIONAL PROCESSES AND ABNORMAL BELIEFS: TOWARDS A MODEL OF PERSECUTORY DELUSIONS RICHARD Department

of Clinical

P. BENTALL,

PETER KINDERMAN

and SUE KANEY

Psychology, Whelan Building, University Liverpool L69 3BX, England

of Liverpool.

P.O. Box 147,

(Received 6 April 1993; in revised form September 1993) Summary-In this paper we review a series of recent investigations into cognitive abnormalities associated with persecutory delusions. Studies indicate that persecutory delusions are associated with abnormal attention to threat-related stimuli, an explanatory bias towards attributing negative outcomes to external causes and biases in information processing relating to the self-concept. We propose an integrative model to account for these findings in which it is hypothesized that, in deluded patients, activation of self/ideal discrepancies by threat-related information triggers defensive explanatory biases, which have the function of reducing the self/ideal discrepancies but result in persecutory ideation. We conclude by discussing the implications of this model for the cognitive-behavioural treatment of paranoid delusions.

INTRODUCTION

Despite the existence of a rich literature on social and cognitive mechanisms responsible for normal beliefs and attitudes, delusional beliefs have received surprisingly little attention from experimental psychopathologists (Winters & Neale, 1983; Oltmanns & Maher, 1988). The failure to apply models from normal psychology to the abnormal beliefs observed in the psychiatric clinic reflects psychopathologists’ long-held preference for investigating broadly defined syndromes, such as ‘schizophrenia’, encompassing many symptoms. In recent years, however, a number of authors have pointed to the advantages of studying particular psychopathological phenomena such as ‘delusions’, either because they are interesting in their own right (Persons, 1986) or because the broadly defined syndromes have little demonstrated scientific validity (Bentall, Jackson & Pilgrim, 1988). A further reason why relatively little has been done to apply the lessons of normal psychology to the understanding of delusional beliefs is the widely held conviction that the delusions of psychotic patients are determined by qualitatively different processes from those responsible for the kinds of beliefs held by ordinary people. Jaspers (1963) argued that abnormal beliefs, in general, are held with extraordinary conviction, have bizarre or impossible content and are impervious to counter-argument or the impact of experience. He distinguished between over-valued or delusionlike ideas, which arise from the individual’s personality, mood or circumstances, and primary delusions, which are ‘ununderstandable’ and which were said to arise from fundamental changes in personality and the perception of meaning (see Walker, 1991). A more extreme distinction between normal beliefs and delusions has recently been proposed by Berrios (1991), who suggests that delusions are not beliefs at all but, “Empty speech acts, whose informational content refers to neither world or self. They are not the symbolic expression of anything” (p. 12). On this view, which is consistent with a preference for studying cognitive dejicits in psychotic patients, the beliefs of psychiatric patients entirely lack the property of ‘intentionality’. This property, which might be thought of as ‘aboutness’ in ordinary language (Tallis, 1991) links normal mental processes to the world and since the time of Brentano (1874/1973) has been regarded as one of the defining attributes of normal beliefs and attitudes. In contrast to the view that delusions are qualitatively distinct from normal beliefs, a number of authors have argued that the delusions of psychiatric patients can be regarded as existing on a continuum which runs from the ordinary beliefs of daily living through to the bizarre and 331

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impossible beliefs of the most disturbed patients (Strauss, 1969). There have been several different suggestions for the properties of this continuum (e.g. Kendler, Glazer & Morgenstern, 1983; Harrow, Rattenbury & Stoll, 1988). Delusions tend to concern certain themes (particularly themes of persecution or grandiosity, which pertain to the patient’s position in the social universe), which suggests that, contrary to Berrios (1991), these kinds of beliefs are not completely meaningless at all. Thus, the social and cognitive processes involved in normal belief acquisition and maintenance might be fruitfully investigated in psychotic patients. In particular, the apparent intentionality (meaningfulness) of delusional beliefs suggests that it might be profitable to investigate contentspecific information processing biases in deluded patients. In this paper, we review the literature on the cognitive biases of deluded patients, focusing particularly on our own series of investigations into delusions of persecution. We propose a cognitive formulation of persecutory delusions, which describes these phenomena in terms of abnormalities of well-understood psychological mechanisms, and indicate possible aetiological pathways. COGNITIVE

PROCESSES

IN DELUDED

PATIENTS

Beliefs, in general, can be construed as products of an interaction between cognitive processes and the environment. Little is understood about environmental contributions to the apparently abnormal beliefs of psychiatric patients. However, it is clear that, in some cases at least, the contents of delusions reflect worries that pre-date the onset of a disorder (Harrow et al., 1988) making it conceivable that these beliefs, in part, reflect unusual circumstances or life events. Lemert (1962), on the basis of detailed interviews with paranoid patients, argued that most if not all had been victims of genuine conspiracies. However, in the absence of objective criteria for conspiracy it is difficult to know how to evaluate this claim (Lidz, 1975). Some observers (e.g. Heilbrun & Norbert, 1972; Kaffman, 1983) suggested that paranoid constructions emerge in the context of family atmospheres characterized by aversive control, inflexible rules, irrational beliefs, distrust and apprehensiveness. Other researchers, noting that paranoid ideation tends to be particularly evident in social and economic circumstances characterized by powerlessness, have looked to the broader environment for social determinants of delusional beliefs (Mirowsky & Ross, 1983). It is possible that some delusions reflect the way that the environment is perceived rather than objective circumstances. Maher (1974; Maher & Ross, 1984) in particular, argued that the abnormal beliefs of psychiatric patients reflect rational attempts to make sense of anomalous experiences, and that the reasoning processes of deluded patients are normal. In support of his hypothesis, Maher cited research by Williams (1964) who found normal syllogistic reasoning in DSM-II diagnosed schizophrenic patients. However, it is difficult to know what to make of this evidence as many of the patients included in Williams’ study were probably not deluded, and syllogistic reasoning is a poor indicator of cognitive functioning (Gilhooly, 1983). Although anomalous perceptions do seem to play a role in some delusional states, particularly delusional misidentifications (Ellis & Young, 1990) it is clear that delusions can occur in the absence of perceptual abnormalities and that perceptual abnormalities do not necessarily lead to delusional beliefs (Chapman & Chapman, 1988). When studying cognitive abnormalities in deluded subjects (Ss), it is clearly important to focus on cognitive domains relevant to the kinds of beliefs observed in psychiatric clinics. In particular, for the reasons outlined above, it makes sense to study content-specific information processing biases, rather than gross cognitive dysfunction. As long ago as 1969, Ullman and Krasner suggested that attentional biases might serve to maintain abnormal beliefs. In a study which directly addressed this issue, Bentall and Kaney (1989) gave deluded, depressed and normal Ss an emotional Stroop task in which they were required to name the ink colours of threat-related, depression-related and neutral words. As expected, the deluded Ss were specifically slowed at colour-naming the threat-related words, showing that they were unable to avoid attending to those words. In a second study, Kaney, Wolfenden, Dewey and Bentall (1991) asked deluded, depressed and normal Ss to recall stories which either did or did not have threatening themes. The deluded Ss recalled less of the stories overall but recalled more of the specifically threatening propositions than did the psychiatric controls. More recently, Bentall, Kaney and Bowen-Jones (in press) asked deluded, depressed and normal Ss to recall items from a list of threat-related, depression-related

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and emotionally neutral words. The deluded Ss showed a recall bias towards both threat-related and depression-related words. Depressed Ss showed a recall bias only towards depression-related words. Taken as a whole, these findings suggest a pattern of information processing biases similar to those observed in depressed patients. However, whereas the schemas underlying the biases in depressed patients concern negatively toned material (Williams, Watts, MacLeod & Mathews, 1988) those underlying the biases of deluded patients also concern material relating to personal threat. Given that delusional beliefs usually concern the patient’s position in the social universe, attribution theory provides a further, compatible theoretical framework for considering cognitive biases in deluded patients. In a preliminary study of attributional processes in patients with persecutory delusions, Kaney and Bentall (1989) gave deluded Ss, depressed controls and normal controls the Attributional Style Questionnaire (ASQ; Peterson, Semmel, von Bayer, Abramson, Metalsky & Seligman, 1982). This questionnaire asks Ss to generate likely causes for hypothetical positive and negative events. Having generated causal statements, the Ss are then asked to self-rate these statements on scales of internality (i.e. the degree to which the events are attributed to the self or external causes such as circumstances or other people), stability (i.e. the degree to which the causes are likely to be present in the future) and globalness (i.e. the degree to which the causes are likely to influence a wide range of events in addition to the specific events mentioned in the questionnaire). When the ratings of deluded Ss were examined it was found that, like the depressed Ss, they made excessively global and stable attributions for negative events. However, unlike the depressed Ss, who made excessively internal attributions for negative events and excessively external attributions for positive events, the deluded Ss made excessively external attributions for negative events and excessively internal attributions for positive events (see Fig. 1). This result was substantially replicated by Candid0 and Romney (1990) who studied groups of depressed paranoid patients and non-depressed paranoid patients. Depressed paranoids did not differ from nondepressed paranoids on attributions for negative events, although they were less inclined to make extreme internal attributions for positive events. These results have been extended in various ways. First, Bentall, Kaney and Dewey (1991) studied deluded Ss’ reasoning about observed positive social interaction (e.g. “Sally said that she likes Kim”) and negative social interactions (e.g. “Colin talks about Andrew behind his back”) using the attributional framework suggested by Kelley (1967). Deluded Ss made normal use of contextual information when determining whether these events were caused by the actor (“Cohn is responsible for talking about Andrew behind his back”) or the target (“Andrew is the cause of Colin saying bad things about him”) but, nonetheless, they had a relative bias towards attributing negatively-valued actions to the actor rather than circumstances. In this study, it was also found that the deluded Ss tended to be excessively confident about their social judgements when

ASQ

“7

--t-

Deluded

--t-

Depressed

--f-

Normal

10

0’

1 Posltlve

Negative

Fig. 1. Deluded, depressed and normal Ss’ internality ratings for hypothetical positive and negative events (ASQ items) from the study of Kaney and Bentall (1989). Higher scores indicate an increasing tendency to attribute events to external causes. [Figure from Bentall (1994). Copyright 0 Lawrence Erlbaum Associates 1993. Reprinted by permission.]

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compared with normal controls. In comparison, depressed Ss tended to be relatively lacking in confidence. In a further study, Kaney and Bentall (1992) investigated contingency judgements in deluded Ss using a technique devised by Alloy and Abramson (1979). Ss were exposed to two computer games which were pre-programmed so that, irrespective of the Ss’ responses, they tended to win points on one game and lose points on the other. After each game the Ss were asked to rate their degree of control over the outcome. Consistent with the findings of Alloy and Abramson (1979) depressed Ss were sadder but wiser, claiming little control in either condition. The normal Ss, on the other hand, showed a self-serving bias, claiming little control in the lose condition but substantial control in the win condition. The self-serving bias was significantly more evident in the deluded Ss in comparison with the normals. On the basis of the kind of data reviewed above, Bentall (1994) suggested that persecutory delusions reflect an exaggeration of cognitive biases observed in normal individuals, particularly in response to threat. It is believed that, in normal individuals, the tendency to attribute the cause of negative events to external factors maintains self-esteem through the abrogation of responsibility (Taylor, 1988). Since this tendency is significantly more marked in people with persecutory delusions, such delusions can be seen as an extreme method of maintaining self-esteem, a hypothesis which is consistent with Zigler and Glick’s (1988) suggestion that paranoia is a form of camouflaged depression. This hypothesis in turn raises the possibility that persecutory delusions may be associated with a fundamental disorder of the self-concept. THE

SELF-CONCEPT

AND

DELUSIONAL

COGNITIVE

BIASES

Many theoreticians have considered ‘schizophrenia’ in general, and paranoia in particular, to be disorders involving the self. This was acknowledged by Bleuler (1950) who observed that “in schizophrenia the alteration of the ego and its attitude towards the world is more pronounced than in any other psychosis” (p. 143). Similarly, Schneider (1959) regarded a weakening of ego boundaries as the cause of first-rank symptoms. In the psychoanalytic view, paranoia is seen as an attempt to defend the self against threats which originate from within the sufferer’s own psyche (Hingley, 1992). For example, Freud (1915/1956) viewed paranoia as an attempt to deal with unacceptable homosexual yearnings, whereas Colby, Faught and Parkinson (1979) explained persecutory delusions as the product of a tendency to perceive threats to self-esteem coupled with a protective mechanism which attributed the source of those threats to external causes. However, studies using direct measures of self-esteem show only moderate levels of disturbance in psychotic patients who, as a whole, demonstrate significantly higher self-esteem than depressed patients (Silverstone, 1991). When compared with normal Ss, patients with a diagnosis of schizophrenia do not make more self-rejecting statements (Kaplan, 1975) and often give higher ratings of satisfaction with the self (Wylie, 1979). More sophisticated studies, which have examined the differences between patient’s self-perceptions and their ideals, have found that such differences are no greater in broadly defined groups of patients with a diagnosis of schizophrenia than in normal Ss (Ibelle, 1961; Rogers, 1958). Moreover, Havner and Izard (1962) observed that such differences are smaller in patients diagnosed as paranoid in comparison with those with a diagnosis of schizophrenia. Despite these observations, there is considerable evidence of complex disturbances of the self in psychotic patients. People with a diagnosis of schizophrenia appear to have poorly elaborated (Robey, Cohen & Gara, 1989) and contradictory (Gruba & Johnson, 1974) self-concepts with the consequence that “schizophrenic patients do not have uniformly lower self-esteem than normals, but, rather, specific domains of self-esteem are affected” (Garfield, Rogoff & Steinberg, 1987; p 225). Given the existing doubts about the scientific validity of broad psychiatric classifications such as ‘schizophrenia’ (Bentall et al., 1988) it seems likely that the role of the self-concept in psychosis will be rendered less ambiguous by focusing on specific symptoms such as delusions. Moreover, the findings referred to above indicate the potential utility of studying the self-concept as a set of inter-related mental representations of one’s self (Kihlstrom & Cantor, 1984) and one’s relationships with others (Baldwin, 1992) rather than as a unitary entity.

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335

delusions

Closure of Actual /

Fig.

2. Hypothesized

relationships

between

self-discrepancies delusions.

and

attributional

style

in persecutory

Higgins (1987) outlined a model of the self that directly addresses the interactions of different domains of the self-concept. In this framework the discrepancies between a person’s perceptions of different aspects of themselves are considered to be particularly important. For example, discrepancies may exist between the actual-self and the ideal-self or between the actual-self and the self as it ought to be. Discrepancies also may exist between different viewpoints on the self, for example between the actual-self as perceived by one’s_self and the actual-self as apparently perceived by others. Higgins (1987) investigated the relationship between particular discrepancies and specific psychological symptoms, observing for example that depression reflects discrepancies between the actual- and ideal-selves. Strauman & Higgins (1987) were able to show that specific emotions, e.g. depression and agitation, could be primed by information relating to specific kinds of self-discrepancy. More recently, Scott and O’Hara (1993) found a relationship between specific self-discrepancies and clinical depression and anxiety in student Ss: depression was associated with actual-ideal discrepancies and anxiety was associated with actual-ought discrepancies. The cognitive biases involved in persecutory ideation can be understood within this perspective. Whereas depression is characterized by a gulf between self-perceptions and self-ideals, persecutory ideation can be thought of as resulting from the struggle to reduce this gulf to a minimum. On this view, when self-ideal discrepancies are activated by negative life events or stimuli deluded patients actively minimize perceived differences between the actual-self and the ideal-self at the expense of perceiving others as having a negative view of themselves. This process can be thought of as dynamic and responding to moment-by-moment changes in circumstances. Such a model not only begins to make sense of much of the conflicting literature on self-esteem in schizophrenia, but also begins to explain the aetiology of the attributional style abnormalities found in deluded patients. Higgins (1987) noted that a person with a high actual-self/ideal-self discrepancy, with actual-self seen as inferior to ideal-self, is likely to make internal attributions for negative or ambiguous events, since the most available explanatory representation is internal (“I’m not as good as I would like to be-that is the reason for my failure”). In the account of persecutory ideation proposed here, the relationship between attributional biases and paranoid self-discrepancies is seen as self-perpetuating. Relatively small discrepancies from the view point of the self are maintained by attributional biases which inevitably lead to relatively large discrepancies between self-perceptions and how deluded individuals feel that other people perceive them. As indicated in Fig. 2, the resulting schemata about self-other differences, in turn, would make accessible to the individual explanatory representations involving other people (external attributions). Hence the deluded patient’s abnormal attention to threat-related stimuli. Although the most obvious direct tests of this account remain to be carried out, a clear implication is that self-referent information should be particularly salient for deluded people. Consistent with this prediction, Fenigstein (1984) found that self-consciousness in normal Ss was associated with the tendency to perceive ‘self-as-target’ (e.g. that one is being scrutinized by others). This association was strongest for public self-consciousness, consistent with the hypothesis that differential activation of schemata involving discrepancies in the self-other domains lead to explanatory frameworks involving other persons. More recently, Fenigstein and Vanable (1992)

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found that self-consciousness in normal Ss was associated with high scores on a questionnaire measure of paranoid thinking. A study that directly addressed the salience of self-referent information for clinically deluded patients was recently carried out by Kinderman (in press). Patients with persecutory delusions, depressed patients and normal controls were asked to rate a series of negative and positive trait adjectives as to whether or not they were self-descriptive. Ss then completed an emotional Stroop test which required them to colour-name similar words. Consistent with the prediction that they would struggle to maintain a positive self-image, even when negative self-discrepancies were activated, the Ss with persecutory delusions endorsed a high number of positive trait words (about the same as normal controls and much more than depressed Ss) but also endorsed a high number of negative trait words (about the same as depressed Ss). The deluded Ss also showed a marked degree of interference when colour-naming both positive and negative words (see Fig. 3).

THE

DEFENSIVE

FUNCTION

OF ATTRIBUTIONAL

STYLE

We have hypothesized that deluded individuals minimize perceived discrepancies between the actual-self and the ideal-self at the expense of perceiving large discrepancies between their self-perceptions and the apparent perceptions of themselves by others. The extreme self-serving attributional biases of deluded people reflect and maintain this cognitive organization. On this account, deluded Ss’ defensive biases should be absent if there is no direct activation of their self-ideal discrepancies, or if those discrepancies are activated implicitly but not explicitly. These observations suggest that deluded Ss’ responses on measures of cognitive bias are likely to vary according to whether the stimulus material is explicitly self-focused. In a study that addressed this prediction, Lyon, Kaney and Bentall (in press) gave deluded depressed and normal Ss a non-obvious attributional style measure devised by Winters and Neale (1985). In this test, known as the Pragmatic Inference Task (PIT), Ss listen to short stories describing successful or unsuccessful outcomes involving themselves (e.g. they set up a dry-cleaning business which does well). After each story Ss have to answer a number of multiple-choice questions, including one which implicitly requires them to make an attributional inference based on the ambiguously worded information in the story (e.g. they have to decide whether their dry-cleaning business succeeded because there was no competition or because they worked hard). Using a version of the ASQ, Lyon et al. (in press) replicated Kaney and Bentall’s (1988) original observation of a high self-serving bias in deluded Ss. However, on the PIT the same Ss, like the depressived controls, made more internal attributions for negative events than for positive events (see Fig. 4). Thus, when required to make implicit explanatory judgements on the PIT, deluded Ss tended to blame themselves for

Self-Ratings

0’

I

Posltlvo traits

Negatlvo Traits

fJ

d Porltlve Traits

Negatlve Traits

Fig. 3. Deluded, depressed and normal Ss’ endorsement as self-descriptive positive and negative trait words (left panel) and interference indices (time to colour-name target words minus time to colour-name neutral words) for colour-naming the same words in an emotional Stroop paradigm (right panel). [From Kinderman (in press). Copyright aBritish Psychological Society 1993. Reprinted by permission.]

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delusions

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PIT

ASQpf

”

”

Positive

Positive

Negative

Negative

Fig. 4. Deluded, depressed and normal Ss’ internality ratings for hypothetical positive and negative events in a modified ASQ (left panel) and in the opaque or non-obvious PIT (right panel). Higher scores on both measures indicate an increasing tendency to attribute events to internal causes. [From Lyon et al. (in press). Copyright ORoyal College of Psychiatrists. Reprinted by permission.]

negative outcomes. However, when required to make explicit attributions for blame via their responses on the ASQ, they tended to blame others and not themselves for negative outcomes. This result raises important questions about the nature of the externalizing responses made by the deluded Ss when responding on the ASQ. A recent paper by Kinderman, Kaney, Morley and Bentall (1992) directly addressed this issue. ASQ data from Kaney and Bentall’s (1989) study were combined with a further data set employing identical measures. The verbal statements of causal attribution given by this extended series of Ss as responses on the ASQ were re-analysed by independent judges, who rated the statements for internality. The judges’ ratings were then compared with the self-ratings of internality made by the Ss. Whereas the judges typically agreed with the normal Ss’ self-ratings they disagreed with many of the self-ratings made by the deluded Ss. Specifically, the deluded Ss self-rated as external many causal statements which were rated by the independent judges as being internal. This discrepancy between the location of blame implicit in the paranoids’ statements of causal attribution and in their explicit self-ratings of internality reflects the discrepancy observed by Lyon et al. (in press) between implicit attributional responses on the PIT and paranoids’ self-ratings of attribution on the ASQ. Taken together, these findings support the view that persecutory delusions are associated with cognitive biases, which serve the function of protecting the individual against feelings of low self-esteem. The more aware deluded patients are that they are being required to judge self-blame for negative outcomes, and hence the more that self-ideal discrepancies are explicitly activated, the more likely they are to make external attributions.

IMPLICATIONS

FOR

FURTHER

RESEARCH

In this paper we have presented a cognitive formulation of persecutory delusions. This model is clearly descriptive in the sense that it reformulates the key characteristics of persecutory delusions in terms of well-understood psychological mechanisms. However, the model also has explanatory power in the sense that it leads to predictions about the performance of deluded Ss on experimental tests and also because it points to possible aetiological pathways to paranoid ideation. Although the model is necessarily speculative, it offers considerable potential for further research into aetiological pathways that lead to paranoid ideation. One possible line of research would involve looking for the roots of the deluded patient’s cognitive biases in the early environment. It is almost axiomatic that the self-concept develops during childhood and that family members, especially parents, have a crucial influence over such development (Wylie, 1979). Any psychological model that implies disturbances in the self-concept inevitably leads to speculation about the role of family processes in the origins of those disturbances. That there may indeed be such a role is attested to by the observation of a significant correlation between the attributional style of children

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and that of their mothers (Seligman, Peterson, Kaslow, Tanenbaum, Alloy & Abramson, 1984). Research also indicates that the children of depressed adults tend to acquire the depressogenic cognitive style of their parents (Hammen, 1991). It has been found that the causal attributions typical of depressed patients occur in the children of both depressed and agoraphobic parents (Hoffart & Torgesen, 1991). It appears, therefore, that particular cognitive styles can be transmitted between generations and that these styles involve both self-perception and attributional biases. The observation that parental criticism may precipitate relapse in psychiatric patients (Brown. Birley & Wing, 1972; Leff & Vaughn, 1980) provides a second strand of evidence indicating that family functioning may play an important role in the occurrence psychotic symptoms. Although the aetiological significance of parental expressed emotion has yet to be adequately evaluated, there is at least some evidence that familial emotional climate is related to the subsequent onset of psychotic disorders in vulnerable individuals (Valone, Norton, Goldstein & Doane, 1983). The impact of a hostile and critical environment on the emergence of self-discrepancies remains a topic for future investigations. However, the account of delusional cognition outlined here may serve as a basis for developing hypotheses about deluded patients’ perceptions of parental behaviour, and for predicting the cognitive style of the parents themselves. Although the model presented here postulates biases in particular cognitive systems, some degree of neurological specificity of such systems is not impossible. By way of comparison, in the field of childhood autism it is widely accepted that there exist neurological deficits specific to the processing of information concerning the thoughts of other people (Leslie, 1991). In the case of delusions, some neuropsychological abnormalities may play a causal role because they similarly limit the kinds of information which can be processed by the individual. For example, Ellis and Young (1990) argued that delusional misidentifications, such as the Capgras syndrome, may reflect neurological deficits affecting systems involved in facial recognition, although these authors have also acknowledged that the kind of cognitive biases described above may be additionally necessary for the development of these kinds of delusions (Young, 1992). A more intriguing possibility is that particular neuropsychological deficits may facilitate the acquisition of abnormal cognitive biases. Sackheim (1986) for example, speculated that damage to the right hemisphere of the brain may result in the disinhibition of defensive cognitive biases which, he argues, are implemented by left-hemisphere structures. Finally, the model of persecutory cognition given here may have implications for the assessment and treatment of deluded patients. The further investigation of attributional and self processes in deluded patients may lead to the development of cognitive measures which have clinical utility and which are sensitive to therapeutic change. For example, measures such as Higgins’ (1987) Selves Questionnaire, which is specifically designed to assess self-discrepancies, may aid the clinician in identifying areas of therapeutic importance. The measurement of such processes may in turn facilitate cognitive-behavioural interventions with deluded patients. For example, clinicians may seek to encourage patients to reflect on evidence which either supports or refutes their understanding of what other people think about them. Patients might be encouraged to develop strategies for coping with real-life negative opinions which are expressed about them. Finally, family and ward-based interventions similar or identical to those used to address parental expressed emotion (Tarrier, 1990) might be used to reduce environmental risk factors for the activation of patients’ self-ideal discrepancies. The hypothesis that persecutory delusions have a self-perpetuating motivational basis is consistent with clinical experience with deluded patients, who vigorously resist direct challenges to their beliefs. For this reason, the most effective cognitive therapy strategies for treating delusions that have been evaluated to date seem to require the therapist to avoid directly contradicting the patients’ abnormal beliefs (Chadwick & Lowe, 1990; Hartman & Cashman, 1983; Watts, Powell & Austin, 1973). The role of the therapeutic relationship in this kind of treatment is likely to be crucial, as patients’ beliefs about their therapists’ perceptions of them are likely to become an impediment to therapeutic change. For this reason, future research into the psychological treatment of delusional beliefs might focus, not only on particular cognitive-behavioural strategies but also on variables relating to the therapeutic alliance, perhaps using established psychotherapy process measures (e.g. Marmar, Horowitz, Weiss & Marziali, 1986; Stiles, 1980). Such variables, although apparently predictive of outcome in psychotic patients (Frank & Gunderson, 1990) have been

Towards

relatively neglected symptoms.

by investigators

a

model of persecutory delusions

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339 treatment

of psychotic

SUMMARY Recent studies of cognitive processes in persons experiencing persecutory delusions appear to point to two conclusions. First, it seems clear that people with paranoid ideation make abnormal attributions and that these attributions serve the function of protecting the individual against negatively self-referent information. Second, it seems likely that these attributional biases are associated with complex abnormalities in the processing of information related to the self-concept. These observations can be accounted for by a model in which it is hypothesized that, in deluded patients, explicit activation of self-ideal discrepancies by threat-related information triggers defensive explanatory biases, which have the function of reducing the self-ideal discrepancies but result in persecutory ideation. Further tests of specific predictions generated by this model are needed, together with investigations designed to explore the aetiological implications of the model. Acknowledgement-Much the Wellcome Trust.

of the research

described

in this paper

has been supported

by a grant

to Richard

Bentall from

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