Objectives. It is unclear whether and to what extent purportedly empowering practices in mental health care, like rehabilitation programs, recovery-supporting mental health care environments and peer-run services, contribute to the process of empowerment. Several American empowerment questionnaires have been developed in recent years, facilitating the measurement of empowerment outcomes. Given likely major transatlantic cultural differences in a value-sensitive concept such as empowerment, this article describes the development of the Netherlands Empowerment List (NEL) and its psychometric properties. Methods. Patients in Dutch mental health services provided meaning to the empowerment concept from which the NEL was derived. Based on 531 completed questionnaires, analyses in agreement with COSMIN criteria examined aspects of internal consistency, content validity, structural validity, convergent validity, discriminant validity, reproducibility and responsiveness of the NEL. Results. The NEL is a 40-item self-report questionnaire with six subscales: Social support, Professional help, Connectedness, Confidence and purpose, Self-management and Caring community. Internal consistency (Cronbach's alpha = 0.94), aspects of validity, reproducibility (intraclass correlation = 0.79) and responsiveness were good. Correlation with existing scales was the highest for the Mental Health Confidence Scale (r = 0.78) and the lowest for the Boston Empowerment Scale (r = 0.61). Conclusion. The NEL appears to be a suitable instrument to capture the dimension of empowerment in European mental health settings.

We examined, over a two-year period, the impact of a user-developed and userrun recovery programme (Toward Recovery, Empowerment and Experiential Expertise-TREE) on outcomes in individuals with severe mental illness, as add-on to care as usual. A randomised wait-list controlled design of TREE added to care as usual (CAU) (n = 80), versus CAU only (n = 83), was implemented in patients with severe mental illness. Follow-up was at 12 and at 24 months after inclusion. Primary outcome measures were empowerment, mental health confidence and loneliness. Secondary outcomes were quality of life, self-reported symptoms, care needs, service use and community outcomes (likelihood institutional residence and paid employment). TREE was associated with more mental health confidence (effect size for each year in TREE: 0.058, p = 0.043), less care needs (effect size for each year in TREE:-0.088, p = 0.002), less self-reported symptoms (effect size for each year in TREE:-0.054, p = 0.040) and less likelihood of institutional residence (risk ratio with each year in TREE: 0.79, p = 0.027). User-developed and user-run recovery programmes may bring about small but reliable changes in recovery and community outcome after two years. More research is required to examine how such programmes can become more successful within the context of disability-focused mental health services.

A second possibility is that antipsychotics have a normalizing effect on reward processing. Studies examining the neural response to rewarding stimuli in schizophrenia suggest that second generation antipsychotics are associated with intact response to reward outcomes in the ventral striatum 7 . Since individuals with schizotypy and youth at clinical high risk for psychosis are much less likely to be prescribed antipsychotics, the apparent paradox may reflect medication effects that become evident with more severe pathology.Third, schizophrenia is associated with more severe cognitive impairment and poorer insight into clinical symptomatology than schizotypy or clinical high risk states. It is possible that impaired cognition and insight are paradoxically protective, causing schizophrenia patients to have less awareness of hedonic deficits that may actually exist. Those with schizotypy and clinical high risk youth may be better able to accurately report their hedonic state because of higher cognitive function and insight.Fourth, environmental and stress effects may have a greater impact on youth at clinical high risk for psychosis and those with schizotypy. Schizophrenia is associated with impoverished quality of life, which for many patients reflects an environment and daily routine with restricted social, cognitive and affective demands. For individuals with schizotypy and clinical high risk youth, environments and daily routines are generally more complex and stressful. It is possible that this stress attenuates reward system responsivity. Supporting this, individuals with schizotypy seem to enjoy solitary activities, yet report activities with others as being taxing, stressful and unenjoyable 8 . Animal models and studies on humans support the notion of a "stress-induced anhedonia" 9 ; however, thisphenomenon has yet to be directly investigated in the schizophrenia spectrum. The schizophrenia spectrum anhedonia paradox harkens back to the seminal writings of P. Meehl 10 , who proposed that anhedonia is one of several polygenic potentiators that comprise the endophenotype for schizotaxia. Meehl distinguished between primary and secondary anhedonia. Primary anhedonia refers to one's hedonic capacity. This capacity is polygenically determined and dependent on neurotransmitter function and neural circuitry responsible for reward responsivity. Capacity varies on a continuous dimension, but may be taxonic at the extreme end. It seems that only a small proportion of schizophrenia patients would fall at the extreme end of the continuum, whereas substantially more individuals with schizotypy and clinical high risk youth would display primary anhedonia. Primary anhedonia may be a risk factor for the development of many forms of psychopathology, with schizophrenia being a less common outcome than others. Meehl also proposed the existence of "secondary anhedonia", which is measured via verbal report (through clinical interview or questionnaire) of one's hedonic response. He proposed that such reports are influenced b...