The case of Sam is conceptualized using a normalizing cognitive approach, which assumes that the cultural acceptability of his appraisals distinguishes them as psychotic. The treatment approach that is based upon such a case formulation involves the evaluation of such distressing appraisals and the generation of alternative explanations. Intervention also involves the identification and manipulation of maintenance factors such as selective attention, thought-control strategies and safety behaviors, as well as beliefs about self, world, and others and metacognitive beliefs. The desired goals that may be collaboratively generated are considered, and potential problems in therapy are discussed.