A cognitive approach to understanding mood swings and bipolar disorders is provided, with the interpretation of changes in internal state as a central explanatory factor. The model explains how attempts at affect regulation are disturbed through the multiple and conflicting extreme personal meanings that are given to internal states. They prompt exaggerated efforts to enhance or exert control over internal states, which paradoxically provoke further internal state changes, thereby feeding into a vicious cycle that can maintain or exacerbate symptoms. Counterproductive attempts at control are classified as either ascent behaviours (increasing activation), or descent behaviours (decreasing activation). It is suggested that appraisals of extreme personal meaning are influenced by specific sets of beliefs about affect and its regulation, and about the self and relations with others, leading to an interaction that raises vulnerability to relapse. Pertinent literature is reviewed and found to be compatible with such a model. The clinical implications are discussed and compared to existing interventions.

The treatment programme was superior to routine care on outcomes relating to illness and service use, and the cost was comparable to the control treatment.

This is an exploratory study that sought to investigate a number of measures of staff-patient relationships on a continuing care, low security inpatient facility for patients with severe mental illness. Twenty staff members were assessed for expressed emotion (EE) using the Camberwell Family Interview (CFI) in regard to a client for whom they were a designated key worker. Their spontaneous attributions for the patient's problems were also assessed, along with self-report staff and patient ratings of their expressed and perceived feelings and thoughts about their staff or patient counterpart. The study found that although none of the staff were rated as fulfilling criteria for high EE, there was evidence of some variability in the quality of staff-patient relationships as assessed from the subjective self-report scales of staff and patients. Patients seemed to be sensitive to staff feelings for them: patient ratings of perceived feelings and thoughts from staff were significantly correlated with staff expressed feelings both from the CFI EE ratings and the direct self-report staff measures. Staff tended to view the behaviors of patients they felt less positively disposed toward as more controllable, and this association between less benign explanations of behavior and a more critical attitude is consistent with the attribution research for familial caregivers. The more negatively perceived patient group was found to be more likely to have behavioral disturbances in the 7 months after the relationship ratings were made. This article discusses measurement issues in the assessment of formal caregiver-patient relationships in the light of this and previous studies.

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