Paranoia is a fascinating, yet challenging symptom. It still remains relatively unexplored. The extent to which it brings both subjective and objective distress or dysfunction influences its underreporting. Of more relevance to psychiatrists is how it is understood and managed in clinical practice.

Reference Freeman and GaretyFreeman & Garety's (2006) article is of immense help in dealing with patients' paranoid symptoms, and it provides an insight into the multiple dimensions of delusions. It must not be forgotten that intelligence is largely well preserved in people with paranoia, and often responses and behaviours are consistent with the paranoid ideas. As far back as 1962, psychological interventions were offered early in the illness for these reasons.

Cognitive–behavioural therapy (CBT) helps professionals not only to clarify clinical issues, but also to fix the focus of the therapy. It becomes a guided discovery into the relevance and the understanding of the individual's experiences. A genuine curiosity and much empathy is required in a therapist. The passivity that often develops in the patient during therapy can be a hindrance, although it can also have more constructive uses. Trials have shown that good outcome can be predicted by the degree of cognitive flexibility concerning delusions. Evidence has demonstrated enduring and significant benefits of cognitive therapy applied in the acute phase of a non-affective psychotic disorder. Patients who received CBT showed significantly improved insight and fewer negative symptoms (Reference Drury, Birchwood and CochraneDrury et al, 2000). Expert CBT also helps in engagement, including treatment adherence (Reference Turkington, Kingdon and RathodTurkington et al, 2006). Trials of brief therapy demonstrate protection against depression and relapse. Those who do relapse have a delayed time to admission and significantly reduced time spent in hospital. Turkington et al also highlight the role of mental health nurses trained in brief CBT for schizophrenia as a supplement to case management and family interventions. More detailed therapy can be focused on individuals who are treatment resistant.

The use of CBT in the treatment of psychosis remains underdeveloped compared with its use for neurotic disorders. Further complications are its restricted availability in the NHS, the paucity of trained therapists and haphazard CBT supervision for psychiatric trainees. We believe that CBT should be further emphasised during psychotherapy supervision and routine consultant supervision for psychiatric trainees.

There is also a case for longer-term individual, group and family dynamic psychotherapies within early intervention teams (Reference MartindaleMartindale, 2007). Less evident are the benefits of non-specific, supportive counselling (Reference GrichGrich, 2002).