Longitudinal changes in therapeutic alliance with people with psychosis: Relationship between client and therapist assessments

Working alliance in treating staff and patients with Schizophrenia Spectrum Disorder living in Residential Facilities

OBJECTIVES

Working Alliance (WA) is important in the care of patients with Schizophrenia Spectrum Disorders (SSD). This study aims to determine which sociodemographic and clinical factors are associated with WA, as assessed by patients and staff members in Residential Facilities (RFs), and may predict WA dyads' discrepancies.

METHODS

Three hundred and three SSD patients and 165 healthcare workers were recruited from 98 RFs and characterized for sociodemographic features. WA was rated by the Working Alliance Inventory (WAI) for patients (WAI-P) and staff members (WAI-T). SSD patients were assessed for the severity of psychopathology and psychosocial functioning.

RESULTS

Pearson's correlation revealed a positive correlation (ρ = .314; p < .001) between WAI-P and WAI-T ratings. Linear regression showed that patients with higher education reported lower WAI-P ratings (β = -.50, p = .044), while not being engaged in work or study was associated with lower WAI-T scores (β = -4.17, p = .015). A shorter lifetime hospitalization was associated with higher WAI-P ratings (β = 5.90, p = .008), while higher psychopathology severity negatively predicted WAI-T (β = -.10, p = .002) and WAI-P ratings (β = -.19, p < .001). Better functioning level positively foresaw WAI-T (β = .14, p < .001) and WAI-P ratings (β = .12, p < .001). Regarding discrepancies, staff members' age was associated with higher dyads discrepancy in Total scale and Agreement subscale scores, which were also associated with more severe negative symptoms, while patients' age was negatively correlated to Relationship subscale discrepancy.

CONCLUSIONS

This study provides insight into the factors that influence WA in SSD patients and health workers in RFs. The findings address interventions to improve WA and ultimately patient outcomes.

A dyadic session-by-session assessment of therapeutic alliance and short-term outcome among clients with schizophrenia in comparison with clients with emotional disorders

OBJECTIVE

Although the clinical significance of the therapeutic alliance (TA) is well documented, the literature regarding the establishment of TA and the relation between client-therapist agreement on it to short-term outcome among various diagnostic groups-and specifically among clients diagnosed with serious mental illness (SMI)-is sparse. The aim of the present study was to examine the effect of client diagnosis on the abovementioned TA characteristics.

METHOD

Dyadic analyses of session-by-session (SBS) data were used to compare clients diagnosed with schizophrenia and clients diagnosed with emotional disorders (based on a clinical interview) in their TA characteristics.

RESULTS

TA as initially rated by clients was stronger in the emotional disorders group than in the schizophrenia group. Higher TA ratings, regardless of whether these were provided by the therapist or the client, predicted better subsequent functioning in the emotional disorders group, whereas in the schizophrenia group, this association was observed only among good-outcome cases.

CONCLUSIONS

Establishing TA, having client-therapist agreement on it, and having clients derive therapeutic benefit from it might be more challenging with clients with schizophrenia than with clients with emotional disorders. Special attention should be given to specific challenges and needs regarding clients' diagnosis in order to enhance favourable therapy outcomes.

The effect of Oxytocin administration on patient-therapist alliance congruence: Results from a randomized controlled trial

OBJECTIVES

The effects of oxytocin (OT) administration on psychotherapeutic processes have thus far been elusive. This study explored the effect of OT administration on patient-therapist congruence of the working alliance.

METHOD

Inpatients with mental disorders (N = 87) participating in a randomized controlled trial received OT (n = 44) or placebo (n = 43) intranasally twice a day, for four weeks. Patients and therapists rated the alliance after each session.

RESULTS

Oxytocin significantly moderated the level of agreement (b = -0.56, SE = 0.25, t = -2.30, p = 0.02), such that patients receiving OT demonstrated lower discrepancy (b = -0.73, p < 0.001) than did those receiving placebo (b = -1.30, p < 0.001). On the other hand, the mutual covariance of patient-therapist ratings across sessions was positive and significant for patients receiving placebo (b = 0.26, p = 0.01) but not for patients in the OT group (b = -0.06, p = .56).

CONCLUSION

Oxytocin can reduce discrepancies of patient-therapist perceptions of the alliance, although additional studies are needed to explore OT's effect on alliance development over time. As alliance congruence is associated with therapy outcomes, such intervention may lead to enhancement of therapeutic gains.

Promoting Meaning and Recovery for Psychosis: Comparison of Metacognitively-Oriented Psychotherapists and Clinicians in Psychiatric Rehabilitation

Introduction

Recovery from psychosis is an expected and desired outcome in psychiatric rehabilitation that may involve subjective outcomes related to personal recovery. While a considerable amount of qualitative research has examined patients' experience of recovery oriented approaches, there are less studies examining clinicians' perspectives. Examining the clinician point of view is important for both supporting clinicians within recovery-oriented practice, as well as for understanding underlying therapeutic processes. The aims of this study were to explore clinician experience of offering different psychiatric rehabilitation treatments for individuals with psychosis, and to understand similarities and differences of clinicians whose work differed in its recovery emphasis.

Methods

Open-ended interviews were conducted with 10 psychotherapists providing Metacognitive Reflection and Insight Therapy (MERIT), a recovery oriented form of integrative psychotherapy focused on subjective aspects of recovery, and 10 clinicians providing standard psychiatric rehabilitation services.

Results

Thematic analysis revealed important similarities and differences between these two groups of providers. There were seven themes found for MERIT therapists: Comfort with uncertainty, Emphasis on collaboration, Being part of therapeutic change, Connecting with clients, Emphasis on patient autonomy, Experiencing growth, and Therapist use of self-awareness. There were four themes found for psychiatric rehabilitation clinicians: Value of a structured approach, Focus on a strengths-based approach, Witnessing behavioral change, and Building rapport to support the work.

Discussion

As expected, both similarities and differences arose between clinician groups. Results indicated that both groups focused on the therapeutic relationship and monitoring progress and outcomes. Unexpectedly, MERIT therapists reported growth as well as comfort with uncertainty. These findings suggest that MERIT is a a psychotherapy that offers unique opportunities for creative and flexible exploration of meaning and agency that is both challenging and rewarding for clinicians. Implications for supporting healthy clinician practice and the development of services are discussed.

Show me you care: A patient- and family-reported measure of care experiences in early psychosis services

AIM

Despite their emphasis on engagement, there has been little research on patients' and families' experiences of care in early intervention services for psychosis. We sought to compare patients' and families' experiences of care in two similar early psychosis services in Montreal, Canada and Chennai, India. Because no patient- or family-reported experience measures had been used in a low- and middle-income context, we created a new measure, Show me you care. Here we present its development and psychometric properties.

METHODS

Show me you care was created based on the literature and stakeholder inputs. Its patient and family versions contain the same nine items (rated on a 7-point scale) about various supportive behaviours of treatment providers towards patients and families. Patients (N = 293) and families (N = 237) completed the measure in French/English in Montreal and Tamil/English in Chennai. Test-retest reliability, internal consistency, convergent validity, and ease of use were evaluated.

RESULTS

Test-retest reliability (intra-class correlation coefficients) ranged from excellent (0.95) to good (0.66) across the patient and family versions, in Montreal and Chennai, and in English, French, and Tamil. Internal consistency estimates (Cronbach's alphas) were excellent (≥0.87). The measure was reported to be easy to understand and complete.

CONCLUSION

Show me you care fills a gap between principles and practice by making engagement and collaboration as central to measurement in early intervention as it is to its philosophy. Having been co-designed and developed in three languages and tested in a low-and-middle-income and a high-income context, our tool has the potential for global application.

Metacognitive Reflection and Insight Therapy (MERIT) Delivered Virtually During the COVID-19 Pandemic: An Illustration of Two Cases

Alternative platform offerings for psychotherapy have become a necessity in the age of the novel coronavirus (COVID-19) pandemic. The current study describes the virtual adaptation of Metacognitive Reflection and Insight Therapy (MERIT) for people with psychosis. MERIT is a recovery-oriented psychotherapy that has shown promise in increasing metacognition and allowing individuals to make meaning of their psychiatric challenges and direct their own recovery efforts. MERIT delivery requires the assumption that metacognitive reflection is an intersubjective act where individuals make meaning with others instead of in isolation. As such, considering the current COVID-19 pandemic, research is needed to understand how intersubjectivity and the therapeutic alliance may differ in a virtual environment rather than in-person. The present study addresses this question by illustrating two case examples of MERIT's adaptation to a virtual delivery telehealth format. Moreover, this study expands on Lysaker and colleagues' (2020) investigation of virtual adaptations of MERIT by exploring how MERIT is adapted in a virtual environment, how intersubjectivity changes in a virtual environment, and, what opportunities virtual platforms allow for metacognitive reflection. Overall, we found that MERIT can be successfully delivered in a virtual telehealth platform. We discuss opportunities and considerations for MERIT and other psychotherapy virtual delivery.

Therapeutic alliance in a cognitive rehabilitation programme for people with serious mental illness: A qualitative analysis

OBJECTIVE

Therapeutic alliance is an important element of evidence-based treatments for people diagnosed with a serious mental illness. Cognitive enhancement therapy (CET) is an efficacious cognitive rehabilitation programme that emphasizes coach-participant relationships. The purpose of this study was to examine experiences of therapeutic alliance among CET participants.

DESIGN

We used an exploratory qualitative approach.

METHODS

Semi-structured interviews were conducted with 24 participants diagnosed with a serious mental illness. Interview transcripts were analysed by three independent coders using thematic analysis.

RESULTS

Four themes related to therapeutic alliance emerged: (1) positive regard; (2) collaboration; (3) authenticity; (4) negative alliance.

CONCLUSIONS

Findings suggest that therapeutic alliance is an important component of CET that bolsters the learning environment and ensures a positive group experience. Our qualitative analyses contribute greater understanding of how strong therapeutic relationships impact people with serious mental illnesses participating in evidence-based treatments beyond psychotherapy context.

The Working Alliance Inventory's Measurement Properties: A Systematic Review

Measurement properties of the Working Alliance Inventory (WAI) and its various translations and adaptations for specific target groups have been investigated for over 30 years. No systematic review analyzing studies on measurement properties of the WAI has been conducted to date. COnsensus-based Standards for the selection of health Measurements INstruments (COSMIN) were developed for conducting high-quality systematic reviews on measurement properties in a transparent and standardized way. Aim of this study was to systematically review studies on measurement properties of the WAI, and its adapted versions, within psychotherapy, and other healthcare contexts using COSMIN criteria. PsycINFO, Medline, and EMBASE were searched (1989–2021). In all phases of the review procedure, study selection, data extraction, risk of bias assessment, rating of the quality of measurement properties, and rating of the quality of evidence for measurement properties, disagreement between reviewers was resolved by discussion. Results on validity, internal structure, reliability, construct validity, and responsiveness were analyzed. In total 66 studies were included. In most studies, evidence for measurement properties was according to COSMIN criteria, insufficient, lacking, or conflicting. Content validity was rated insufficient because neither patients nor healthcare professionals were involved in the development and validation process. Hence evidence for content validity of the WAI is unknown. Conflicting evidence was found for structural validity. Evidence for internal consistency could not be established. Limited evidence was found for inter-rater reliability and convergent validity. Conflicting evidence was also found for test-retest reliability and divergent validity. COSMIN criteria exposed persistent problems in validation studies of the WAI. These findings may indicate that measurement properties of the WAI are not up to current standards, or that COSMIN criteria may be less appropriate for assessing measurement properties of the WAI, or it could indicate both. The results of this systematic review suggest that WAI outcomes should be interpreted with caution and further research is needed regarding the content validity and hypotheses development. For the future, the theoretical framework underlying the measurement of the working alliance needs to be studied in psychotherapy and other health contexts, and tested in methodologically sound studies.

Longitudinal assessments of therapeutic alliance predict work performance in vocational rehabilitation for persons with schizophrenia

OBJECTIVES

To promote functional recovery in persons diagnosed with a psychotic disorder, vocational interventions have emerged over the last few decades which range from sheltered employment to supported employment in the community.

DESIGN

Using data from a 6-month vocational rehabilitation programme, we examined whether assessments of the therapeutic alliance were related to the quality of work performed in this work placement. Our first hypothesis was that stronger alliances would be related to better work performance. Second, we expected that client assessments of the TA would better predict outcomes than therapist assessments. Third, we expected that the discrepancy between assessment scores from the client and therapist (client rating minus therapist rating) would be a better predictor for outcome than individual assessments by the therapists or clients.

RESULTS

Clients systematically rated the alliance higher than therapists. Modelling the data longitudinally, we found both therapist and client ratings predictive of outcome, though client assessments over time were inversely related to work performance.

CONCLUSIONS

Discrepancy in scores was also shown to be predictive of work performance during the program. Clinicians are advised to routinely assess the therapeutic alliance from both client and therapist perspectives and calculate the discrepancy between them as they may indicate ruptures are occurring and thus hamper the intervention.

PRACTITIONER POINTS

Clinicians are advised to regularly assess the therapeutic alliance from both their own and the client's perspective. Growing discrepancy in scores may impede intervention effectiveness. Therapeutic alliance may help buffer against work stresses experienced by participants in a vocational programme. Be aware that therapists tend to rate the alliance lower than their clients.