Predictors of the therapeutic alliance in group therapy for individuals with treatment-resistant auditory hallucinations

Predictors of therapeutic alliance, treatment feedback, and clinical outcomes among African American women in treatment for co-occurring PTSD and SUD

INTRODUCTION

Black women are at heightened risk for trauma exposure, post-traumatic stress disorder (PTSD), and substance use disorders (SUDs), compared to White women and the general population. However, disparities in treatment engagement and retention persist, particularly for Black women with co-occurring PTSD+SUD. Although therapeutic alliance is an important predictor and mediator of treatment retention and outcomes, we know little about predictors of alliance and the mediating role of alliance for PTSD+SUD outcomes among Black women.

METHODS

This study utilized data previously collected for the National Drug Abuse Treatment Clinical Trials Network (CTN) Women and Trauma Study. Participants were 88 Black/African American women (Mage = 41.90, SD = 7.72) participating in a clinical trial comparing Seeking Safety (a cognitive-behavioral intervention for PTSD+SUD) to Women's Health Education (control). This study includes participants from both arms. Measures included the Helping Alliance Questionnaire, Addiction Severity Index-Lite, and Clinician Administered PTSD Scale. Women in the intervention arm also completed the Seeking Safety Feedback Questionnaire.

RESULTS

Stepwise, hierarchical linear regressions indicated that years of education and previous alcohol/drug treatment attempts significantly predicted early alliance in the second week of therapy (β = 0.411, p = .021 and β = 0.383, p = .011, respectively), but not late alliance in the last week of therapy (ps > .794). Greater education and more treatment attempts were associated with higher early alliance. Alliance did not mediate relationships between these significant predictors and treatment outcomes (e.g., attendance, post-treatment PTSD and SUD symptoms) or treatment feedback in the Seeking Safety group.

CONCLUSIONS

Education and prior treatment attempts predicted early alliance among Black/African American women in PTSD+SUD group treatment, and higher education level was associated with poorer Seeking Safety feedback topic ratings. Educational level and treatment history should be considered during alliance building in therapeutic interventions with Black women. Clinicians may consider the integration of pre-treatment alliance-building strategies with Black female patients who have lower levels of education. This study provides insight into the relative impact of several important factors that influence early alliance among Black women with co-occurring PTSD+SUD.

Cognitive behavioural therapy (group) for schizophrenia

BACKGROUND

Schizophrenia is a disabling psychotic disorder characterised by positive symptoms of delusions, hallucinations, disorganised speech and behaviour; and negative symptoms such as affective flattening and lack of motivation. Cognitive behavioural therapy (CBT) is a psychological intervention that aims to change the way in which a person interprets and evaluates their experiences, helping them to identify and link feelings and patterns of thinking that underpin distress. CBT models targeting symptoms of psychosis (CBTp) have been developed for many mental health conditions including schizophrenia. CBTp has been suggested as a useful add-on therapy to medication for people with schizophrenia. While CBT for people with schizophrenia was mainly developed as an individual treatment, it is expensive and a group approach may be more cost-effective. Group CBTp can be defined as a group intervention targeting psychotic symptoms, based on the cognitive behavioural model. In group CBTp, people work collaboratively on coping with distressing hallucinations, analysing evidence for their delusions, and developing problem-solving and social skills. However, the evidence for effectiveness is far from conclusive.

OBJECTIVES

To investigate efficacy and acceptability of group CBT applied to psychosis compared with standard care or other psychosocial interventions, for people with schizophrenia or schizoaffective disorder.

SEARCH METHODS

On 10 February 2021, we searched the Cochrane Schizophrenia Group's Study-Based Register of Trials, which is based on CENTRAL, MEDLINE, Embase, four other databases and two trials registries. We handsearched the reference lists of relevant papers and previous systematic reviews and contacted experts in the field for supplemental data.

SELECTION CRITERIA

We selected randomised controlled trials allocating adults with schizophrenia to receive either group CBT for schizophrenia, compared with standard care, or any other psychosocial intervention (group or individual).

DATA COLLECTION AND ANALYSIS

We complied with Cochrane recommended standard of conduct for data screening and collection. Where possible, we calculated risk ratio (RR) and 95% confidence interval (CI) for binary data and mean difference (MD) and 95% CI for continuous data. We used a random-effects model for analyses. We assessed risk of bias for included studies and created a summary of findings table using GRADE.

MAIN RESULTS

The review includes 24 studies (1900 participants). All studies compared group CBTp with treatments that a person with schizophrenia would normally receive in a standard mental health service (standard care) or any other psychosocial intervention (group or individual). None of the studies compared group CBTp with individual CBTp. Overall risk of bias within the trials was moderate to low. We found no studies reporting data for our primary outcome of clinically important change. With regard to numbers of participants leaving the study early, group CBTp has little or no effect compared to standard care or other psychosocial interventions (RR 1.22, 95% CI 0.94 to 1.59; studies = 13, participants = 1267; I2 = 9%; low-certainty evidence). Group CBTp may have some advantage over standard care or other psychosocial interventions for overall mental state at the end of treatment for endpoint scores on the Positive and Negative Syndrome Scale (PANSS) total (MD -3.73, 95% CI -4.63 to -2.83; studies = 12, participants = 1036; I2 = 5%; low-certainty evidence). Group CBTp seems to have little or no effect on PANSS positive symptoms (MD -0.45, 95% CI -1.30 to 0.40; studies =8, participants = 539; I2 = 0%) and on PANSS negative symptoms scores at the end of treatment (MD -0.73, 95% CI -1.68 to 0.21; studies = 9, participants = 768; I2 = 65%). Group CBTp seems to have an advantage over standard care or other psychosocial interventions on global functioning measured by Global Assessment of Functioning (GAF; MD -3.61, 95% CI -6.37 to -0.84; studies = 5, participants = 254; I2 = 0%; moderate-certainty evidence), Personal and Social Performance Scale (PSP; MD 3.30, 95% CI 2.00 to 4.60; studies = 1, participants = 100), and Social Disability Screening Schedule (SDSS; MD -1.27, 95% CI -2.46 to -0.08; studies = 1, participants = 116). Service use data were equivocal with no real differences between treatment groups for number of participants hospitalised (RR 0.78, 95% CI 0.38 to 1.60; studies = 3, participants = 235; I2 = 34%). There was no clear difference between group CBTp and standard care or other psychosocial interventions endpoint scores on depression and quality of life outcomes, except for quality of life measured by World Health Organization Quality of Life Assessment Instrument (WHOQOL-BREF) Psychological domain subscale (MD -4.64, 95% CI -9.04 to -0.24; studies = 2, participants = 132; I2 = 77%). The studies did not report relapse or adverse effects.

AUTHORS' CONCLUSIONS

Group CBTp appears to be no better or worse than standard care or other psychosocial interventions for people with schizophrenia in terms of leaving the study early, service use and general quality of life. Group CBTp seems to be more effective than standard care or other psychosocial interventions on overall mental state and global functioning scores. These results may not be widely applicable as each study had a low sample size. Therefore, no firm conclusions concerning the efficacy of group CBTp for people with schizophrenia can currently be made. More high-quality research, reporting useable and relevant data is needed.

Systematic review and meta-analysis of therapeutic alliance, engagement, and outcome in psychological therapies for psychosis

AIM

The moderate association between therapeutic alliance (TA) and psychological therapy outcome is well established. Historically, the field has not focused on people with a severe mental illness. This is the first review to conduct a meta-analysis of associations between TA and therapeutic engagement as well as outcome in psychological therapy for psychosis.

ELIGIBILITY CRITERIA

Eligible studies conducted a quantitative investigation of the relationship between TA during a psychological therapy and outcome at a subsequent time-point.

METHOD

A systematic review examined the relationship between TA and engagement as well as outcome measures within psychological therapy for psychosis. Correlational meta-analyses using an aggregate random effects model were conducted.

RESULTS

Twenty-four studies were eligible for inclusion (n = 1,656) of which 13 were included in the meta-analyses. Client- and therapist-rated TA were associated with engagement in therapy (r_{client (c)}  = 0.36, p = .003; r_{therapist (t)}  = 0.40, p = .0053). TA was also associated with reduction in global (r_c  = 0.29, p = .0005; r_t  = 0.24, p = .0015) and psychotic symptoms (r_c  = 0.17, p = .0115; r_t  = 0.30, p = .0003). The systematic review identified no evidence or limited evidence for a relationship between TA during therapy and depression, substance use, physical health behaviours, global as well as social functioning, overall mental health recovery, and self-esteem at follow-up. Although number of studies was small, TA was related to a reduced risk of subsequent hospitalization in 40% of analyses (across two studies) and improved cognitive outcome in 50% of analyses (across three studies).

CONCLUSIONS

The observed TA-therapy engagement and TA-outcome associations were broadly consistent with those identified across non-psychotic diagnostic groups. Well-powered studies are needed to investigate the relationship between TA and process as well as outcome in psychological therapy for psychosis specifically.

PRACTITIONER POINTS

This is the first review to conduct a meta-analytic synthesis of the association between therapeutic alliance (TA) and both engagement and change in outcome in psychological therapies for psychosis. TA (as rated by therapist and client) was associated with the extent of therapeutic engagement as well as reduction in global mental health symptoms and psychotic symptoms. The significant associations between TA and engagement as well as change in outcome identified in the current review are broadly consistent with those observed across non-psychotic diagnostic groups. We consider factors that could impact upon the dynamic and potentially interdependent relationships between TA and therapeutic techniques, including attachment security and severity of paranoid ideation.

A Dialectical Behavior Therapy Skills Group in a Psychoanalytic Community Service: A Pilot Study

This exploratory study reports on the implementation and effectiveness of a 20-week Dialectical Behavior Therapy (DBT) skills group provided to 8 outpatients (7 women, average age 33 years old) within a psychoanalytic community clinic. We report on the practical implementation of this DBT skills group, and describe how the theoretical/technical differences between DBT and psychoanalysis were negotiated by the two co-therapists. The effectiveness of the skills group was evaluated on standardized measures of borderline personality symptoms, depression, anxiety, interpersonal problems, quality of life, and mindfulness skills that patients completed before and after treatment. At post-treatment, patients evaluated the DBT skills group on a satisfaction questionnaire and therapists completed a countertransference measure. Pre-post outcome data indicated reduced symptom levels of anxiety, depression, and improved quality of life. Both therapists reported moderate therapist responses typically associated with borderline personality disorder psychopathology. Their therapist responses were not associated with symptom levels or change but were related to patient satisfaction. Accumulative pilot studies like these add to the practice-based evidence of DBT components offered within psychoanalytically-oriented community clinics. However, given the exploratory nature of this study, strong conclusions are precluded until further effectiveness research is conducted.

Relationships Between Working Alliance and Outcomes in Group Therapy for People Diagnosed with Schizophrenia

Working alliance (WA) is an important predictor of treatment outcomes in therapy. Forming a strong WA can be challenging with people diagnosed with schizophrenia, and differences between client-rated and clinician-rated WA have been found in this population. This project examined WA in people diagnosed with schizophrenia who completed a skills training and attention shaping group intervention. Paired samples t-tests revealed differences between client and clinician ratings on the Working Alliance Inventory Short Form (WAI-S). Clinician-rated WAI-S scores were related to symptom severity, cognitive functioning, and attention during group sessions. Yet, the primary hypothesis was not supported as WAI-S scores were unrelated to clients' treatment response. Clinician-rated WAI-S was found to partially mediate the relationship between negative symptoms and overall attention. Client-rated WAI-S scores were associated with client measures of self-efficacy and mastery. Results reinforce the importance of working alliance in the treatment of those diagnosed with schizophrenia and indicate clinical and functional factors that may influence the quality of WA.

Stepped Care as an Implementation and Service Delivery Model for Cognitive Behavioral Therapy for Psychosis

Cognitive behavioral therapy for schizophrenia spectrum disorders is an evidence-based treatment that is recommended by United States schizophrenia treatment guidelines. Based on recent estimates, only 0.3% of individuals with a primary psychotic disorder are able to access this treatment in the United States. Stepped care interventions have shown promise as an applied treatment delivery model in other settings and for other psychotherapeutic interventions. The current paper describes how the stepped care model can be applied to CBT for psychosis in the US to increase access to the intervention in community mental health settings by leveraging the multidisciplinary team.

Treatment-Resistant to Antipsychotics: A Resistance to Everything? Psychotherapy in Treatment-Resistant Schizophrenia and Nonaffective Psychosis: A 25-Year Systematic Review and Exploratory Meta-Analysis

Background: Roughly 30% of schizophrenia patients fail to respond to at least two antipsychotic trials. Psychosis has been traditionally considered to be poorly sensitive to psychotherapy. Nevertheless, there is increasing evidence that psychological interventions could be considered in treatment-resistant psychosis (TRP). Despite the relevance of the issue and the emerging neurobiological underpinnings, no systematic reviews have been published. Here, we show a systematic review of psychotherapy interventions in TRP patients of the last 25 years. Methods: The MEDLINE/PubMed, ISI WEB of Knowledge, and Scopus databases were inquired from January 1, 1993, to August 1, 2018, for reports documenting augmentation or substitution with psychotherapy for treatment-resistant schizophrenia (TRS) and TRP patients. Quantitative data fetched by Randomized Controlled Trials (RCTs) were pooled for explorative meta-analysis. Results: Forty-two articles have been found. Cognitive behavioral therapy (CBT) was the most frequently recommended psychotherapy intervention for TRS (studies, n = 32, 76.2%), showing efficacy for general psychopathology and positive symptoms as documented by most of the studies, but with uncertain efficacy on negative symptoms. Other interventions showed similar results. The usefulness of group therapy was supported by the obtained evidence. Few studies focused on negative symptoms. Promising results were also reported for resistant early psychosis. Limitations: Measurement and publication bias due to the intrinsic limitations of the appraised original studies. Conclusions: CBT, psychosocial intervention, supportive counseling, psychodynamic psychotherapy, and other psychological interventions can be recommended for clinical practice. More studies are needed, especially for non-CBT interventions and for all psychotherapies on negative symptoms.

Cognitive behavioural therapy plus standard care versus standard care for people with schizophrenia

BACKGROUND

Cognitive behavioural therapy (CBT) is a psychosocial treatment that aims to re-mediate distressing emotional experiences or dysfunctional behaviour by changing the way in which a person interprets and evaluates the experience or cognates on its consequence and meaning. This approach helps to link the person's feelings and patterns of thinking which underpin distress. CBT is now recommended by the National Institute for Health and Care Excellence (NICE) as an add-on treatment for people with a diagnosis of schizophrenia. This review is also part of a family of Cochrane CBT reviews for people with schizophrenia.

OBJECTIVES

To assess the effects of cognitive behavioural therapy added to standard care compared with standard care alone for people with schizophrenia.

SEARCH METHODS

We searched the Cochrane Schizophrenia Group's Trials Register (up to March 6, 2017). This register is compiled by systematic searches of major resources (including AMED, BIOSIS CINAHL, Embase, MEDLINE, PsycINFO, PubMed, and registries of clinical trials) and their monthly updates, handsearches, grey literature, and conference proceedings, with no language, date, document type, or publication status limitations for inclusion of records into the register.

SELECTION CRITERIA

We selected all randomised controlled clinical trials (RCTs) involving people diagnosed with schizophrenia or related disorders, which compared adding CBT to standard care with standard care given alone. Outcomes of interest included relapse, rehospitalisation, mental state, adverse events, social functioning, quality of life, and satisfaction with treatment.We included studies fulfilling the predefined inclusion criteria and reporting useable data.

DATA COLLECTION AND ANALYSIS

We complied with the Cochrane recommended standard of conduct for data screening and collection. Where possible, we calculated relative risk (RR) and its 95% confidence interval (CI) for binary data and mean difference (MD) and its 95% confidence interval for continuous data. We assessed risk of bias for included studies and created a 'Summary of findings' table using GRADE.

MAIN RESULTS

This review now includes 60 trials with 5,992 participants, all comparing CBT added to standard care with standard care alone. Results for the main outcomes of interest (all long term) showed no clear difference between CBT and standard care for relapse (RR 0.78, 95% CI 0.61 to 1.00; participants = 1538; studies = 13, low-quality evidence). Two trials reported global state improvement. More participants in the CBT groups showed clinically important improvement in global state (RR 0.57, 95% CI 0.39 to 0.84; participants = 82; studies = 2 , very low-quality evidence). Five trials reported mental state improvement. No differences in mental state improvement were observed (RR 0.81, 95% CI 0.65 to 1.02; participants = 501; studies = 5, very low-quality evidence). In terms of safety, adding CBT to standard care may reduce the risk of having an adverse event (RR 0.44, 95% CI 0.27 to 0.72; participants = 146; studies = 2, very low-quality evidence) but appears to have no effect on long-term social functioning (MD 0.56, 95% CI -2.64 to 3.76; participants = 295; studies = 2, very low-quality evidence, nor on long-term quality of life (MD -3.60, 95% CI -11.32 to 4.12; participants = 71; study = 1, very low-quality evidence). It also has no effect on long-term satisfaction with treatment (measured as 'leaving the study early') (RR 0.93, 95% CI 0.77 to 1.12; participants = 1945; studies = 19, moderate-quality evidence).

AUTHORS' CONCLUSIONS

Relative to standard care alone, adding CBT to standard care appears to have no effect on long-term risk of relapse. A very small proportion of the available evidence indicated CBT plus standard care may improve long term global state and may reduce the risk of adverse events. Whether adding CBT to standard care leads to clinically important improvement in patients' long-term mental state, quality of life, and social function remains unclear. Satisfaction with care (measured as number of people leaving the study early) was no higher for participants receiving CBT compared to participants receiving standard care. It should be noted that although much research has been carried out in this area, the quality of evidence available is poor - mostly low or very low quality and we still cannot make firm conclusions until more high quality data are available.

Process analysis of trauma-focused cognitive behavioural therapy for individuals with schizophrenia

OBJECTIVE

Therapeutic alliance, modality, and ability to engage with the process of therapy have been the main focus of research into what makes psychotherapy successful. Individuals with complex trauma histories or schizophrenia are suggested to be more difficult to engage and may be less likely to benefit from therapy. This study aimed to track the in-session 'process' of working alliance and emotional processing of trauma memories for individuals with schizophrenia.

DESIGN

The study utilized session recordings from the treatment arm of an open randomized clinical trial investigating trauma-focused cognitive behavioural therapy (TF-CBT) for individuals with schizophrenia (N = 26).

METHOD

Observer measures of working alliance, emotional processing, and affect arousal were rated at early and late phases of therapy. Correlation analysis was undertaken for process measures. Temporal analysis of expressed emotions was also reported.

RESULTS

Working alliance was established and maintained throughout the therapy; however, agreement on goals reduced at the late phase. The participants appeared to be able to engage in emotional processing, but not to the required level for successful cognitive restructuring.

CONCLUSION

This study undertook novel exploration of process variables not usually explored in CBT. It is also the first study of process for TF-CBT with individuals with schizophrenia. This complex clinical sample showed no difficulty in engagement; however, they may not be able to fully undertake the cognitive-emotional demands of this type of therapy. Clinical and research implications and potential limitations of these methods are considered.

PRACTITIONER POINTS

This sample showed no difficulties engaging with TF-CBT and forming a working alliance. However, the participants may not have achieved a level of active involvement required for successful cognitive restructuring of trauma memories. This discrepancy may relate to the mediating role of both working alliance and cognitive-emotional processing. The results underscore the importance of therapists understanding the relationship between alliance and other process factors which may be implicit in facilitating change.

Therapeutic alliance in psychological therapy for people with recent onset psychosis who use cannabis

BACKGROUND

This paper examines the role of therapeutic alliance in predicting outcomes in a Randomized Controlled Trial of Motivational Interviewing and Cognitive Behavioral Therapy (MICBT) for problematic cannabis use in recent onset psychosis.

METHODS

All clients were participating in a three arm pragmatic rater-blind randomized controlled trial of brief MICBT plus standard care compared with longer term MICBT plus standard care and standard care alone. Participants completed measures to assess clinical symptoms, global functioning and substance misuse at baseline, 4.5months, 9months and 18months. Clients and therapists completed the Working Alliance Inventory approximately one month into therapy. Client alliance data was available for 35 participants randomized to therapy and therapist alliance data was available for 52 participants randomized to therapy.

RESULTS

At baseline, poorer client-rated alliance was associated with more negative symptoms, poorer insight and greater cannabis use, whereas poorer therapist-rated alliance was only associated with amount of cannabis used per cannabis using day. Alliance ratings were also positively associated with amount of therapy: client-rated alliance was higher in the longer compared to the briefer therapy; therapist-rated alliance was associated with greater number of sessions attended (controlling for type of therapy) and therapy completion. In predicting outcome, client-rated alliance predicted total symptom scores and global functioning scores at follow-up. Neither client nor therapist alliance predicted changes in substance misuse at any time point.

CONCLUSIONS

Findings demonstrate that individuals with psychosis and substance misuse who form better alliances with their therapists gain greater benefits from therapy, at least in terms of improvements in global functioning.

Psychodynamically Oriented Supportive Group Therapy With Psychotic Patients

This pilot study investigates the contribution of supportive psychodynamically oriented group psychotherapy to the clinical characteristics and functioning of psychotic patients. After a year of group psychotherapy using an intermediary object, the drawings of a number of psychotic patients were inspected separately so as to ascertain the improvement of psychopathological elements depicted. Two groups of 38 patients each, with similar psychopathology, clinical and demographic data were assessed before and after 1 year. One group participated in group psychotherapy, with or without an intermediary object; the other group received standard care. The study demonstrated improvement in functioning, quality of life, positive/negative symptoms, and relapses of hospitalizations for patients participating in group psychotherapy. Moreover, elements that indicate psychopathology declined in the drawings of the group in therapy with an intermediary object. Psychodynamically oriented group psychotherapy, with or without an intermediary object, could be an additional treatment option for psychotic patients.

Are Group Psychotherapeutic Treatments Effective for Patients with Schizophrenia? A Systematic Review and Meta-Analysis

BACKGROUND

Different psychotherapeutic treatments for schizophrenia are delivered in groups. However, little is known about the effectiveness of these group therapies for people with schizophrenia across different treatments with varying therapeutic orientations. This review aimed to (1) estimate the effect of different group psychotherapeutic treatments for schizophrenia and (2) explore whether any overall 'group effect' is moderated by treatment intensity, diagnostic homogeneity and therapeutic orientation.

METHODS

A systematic search of randomised controlled trials exploring the effectiveness of group psychotherapeutic treatments for people with schizophrenia was conducted. Random-effect meta-analyses on endpoint symptom scores compared group psychotherapeutic treatments with treatment as usual and active sham groups. Findings on social functioning were described narratively, and meta-regression analyses on group characteristics were carried out.

RESULTS

Thirty-four eligible trials were included. A weak-to-moderate significant between-group difference in favour of group psychotherapeutic treatments was found for negative symptom scores (standard mean difference = -0.37, 95% confidence interval -0.60, -0.14; p < 0.01, I(2) = 59.8%) only when compared to treatment as usual and not to active sham groups. Improved social functioning was reported as a treatment outcome in the majority of studies compared to treatment as usual. The 'group effect' on negative symptoms was positively related to 'treatment intensity' (β = 0.32, standard error = 0.121; p < 0.05).

CONCLUSION

Group psychotherapeutic treatments can improve negative symptoms and social functioning deficits in the treatment of schizophrenia. The effect occurs across different treatments and appears to be non-specific. Future research should identify the underlying mechanisms for the positive effect of participating in groups and explore how they can be maximised to increase the therapeutic benefit.

The alliance in psychiatric rehabilitation: Client characteristics associated with the initial alliance in a supported employment program

BACKGROUND

The therapeutic alliance is associated with outcomes for individuals in psychiatric rehabilitation programs. However, there are no known studies examining factors associated with the alliance in these programs.

OBJECTIVE

To determine whether client characteristics associated with the alliance across multiple populations and program types were associated with the alliance for individuals enrolling in a supported employment program.

METHODS

Previously collected data were available for 70 individuals served by the single employment specialist in the program. Potential independent variables and the strength of their relationship to the alliance were identified, then further explored using a forward stepwise logistic regression model.

RESULTS

Seventy-three percent of the sample had the highest possible alliance rating. Being older and having a smaller social network size were significantly correlated with a high alliance, but neither remained a predictor of the alliance, controlling for the effects of the other.

CONCLUSIONS

Client age and social network size were associated with the initial alliance, though not in a model containing both variables. Low power may have hindered the ability to show additional relationships, and the uniqueness of the program structure limits the generalizability to other programs. Future research should investigate the variables examined further.

Understanding process in group cognitive behaviour therapy for psychosis

BACKGROUND

Group cognitive behaviour therapy for psychosis (GCBTp) has shown to be effective in diminishing symptoms, as well as in improving other psychosocial dimensions such as self-esteem. But little is known regarding the processes that generate these therapeutic improvements and might be harnessed to further improve its effectiveness.

OBJECTIVES

The current study aimed at investigating these processes, particularly those linked to interpersonal relationships.

DESIGN

The participants were all assessed at baseline, were given 24 sessions of GCBTp over the course of 3 months and were assessed again at post-treatment as well as 6 months later (9 months from baseline).

METHOD

Sixty-six individuals with early psychosis took part in a study of GCBTp where therapist alliance and group cohesion were assessed at three time points during the therapy, and punctual (each session) self-perceptions on symptoms and optimism were collected.

RESULTS

Improvements in symptoms (BPRS), self-esteem (SERS-SF) and in self-perceived therapeutic improvements (CHOICE) were linked to specific aspects of the alliance, group cohesion, as well as optimism. The variables retained were not always overall scores, suggesting the importance of the variables at key moments during the therapy.

CONCLUSIONS

The results clearly demonstrate the importance of the alliance and group cohesion, together significantly explaining improvements measured at post-therapy or follow-up.

PRACTITIONER POINTS

This study has attempted to focus mostly on relational aspects, as well as on self-perceptions, in the context of a GCBTp for individuals with early psychosis. This study also showed that these therapeutic relationships are especially useful when they are more stable and at specific moments during the therapy, namely when more difficult psychological work is done.

An investigation of the relationship between therapist characteristics and alliance in group therapy for individuals with treatment-resistant auditory hallucinations

BACKGROUND

Alliance is a well-studied construct; however, little research has investigated predictors of alliance in a group context.

AIMS

This study investigates the relationship between therapist characteristics and group alliance in 65 individuals with schizophrenia receiving outpatient group therapy for treatment-resistant auditory hallucinations.

METHODS

Raters coded 120 sessions of cognitive behavioral therapy or supportive therapy for therapist warmth and friendliness, therapist exploration and negative therapist attitude. Alliance was assessed at week six.

RESULTS

Higher average levels of therapist warmth and friendliness and lower average levels of negative therapist attitude in sessions one to five were associated with stronger alliance at week six at the trend level (p < 0.10). Therapist exploration did not predict alliance at week six. Higher negative therapist attitude at treatment engagement was associated with higher post-treatment symptom scores.

CONCLUSIONS

Our results suggest that therapist attributes but not therapist techniques are associated with client's perceptions of alliance and that negative therapist behaviors are associated with higher symptom levels at post-treatment. Implications for clinical practice are discussed.

An exploration of the therapeutic alliance within a telephone-based cognitive behaviour therapy for individuals with experience of psychosis

OBJECTIVES

This study investigated the therapeutic alliance (TA) between clients and therapists involved in a telephone-based cognitive behaviour therapy (CBT) oriented psychological intervention for individuals experiencing psychosis.

DESIGN

The telephone intervention involved recovery-focused CBT with use of a self-help guide and group intervention co-facilitated by colleagues with personal experience of psychosis. It was delivered as part of a Participant Preference Trial.

METHODS

Twenty-one client/therapist dyads were examined within this study. In addition to a measure of TA, clients completed measures of depression, social functioning, symptom severity, and strength of treatment preference, while therapists completed measures related to the level of shared formulation, therapist confidence, and therapeutic change estimates.

RESULTS

Therapeutic alliance levels were comparable to previously reported face-to-face psychosis intervention studies. Clients consistently reported significantly higher TA ratings compared to therapists. Depression scores and the strength of preference for treatment were significantly associated with client TA. Greater therapist perceived change was associated with higher therapist rated TA, while higher numbers of missed therapy sessions associated with lower therapist ratings.

CONCLUSIONS

Telephone-based psychosis interventions may support the formation of positive relationships that are comparable to the quality of relationships developed between therapists and clients during face-to-face CBT therapy. Methodological limitations including low participant numbers and heightened risk of a Type I error necessitate caution when interpreting findings. Further research into therapist and client variables associated with TA is required.

PRACTITIONER POINTS

Telephone delivered interventions to support people with psychosis-related difficulties can result in the development of a good quality TA between therapists and clients. There is a significant difference between therapist and client ratings of TA. Clients tend to score the quality of the TA significantly more highly than therapists. Providing clients with choice when participating in therapeutic interventions could potentially contribute towards improved TA reporting by clients.

The therapeutic relationship after psychiatric admission

The therapeutic relationship is one of the most central and important factors in the treatment of mental health disorders. A better therapeutic relationship is associated with service engagement, medication adherence, and satisfaction with services. This study aimed to compare the demographic and clinical factors associated with the therapeutic relationship in voluntarily and involuntarily admitted psychiatric service users. We found that individuals who had been admitted involuntarily, who had a diagnosis of a psychotic disorder, and who reported higher levels of perceived pressures on admission were more likely to have a poorer therapeutic relationship with their consultant psychiatrist. Greater levels of insight and treatment satisfaction, together with higher levels of procedural justice experienced on admission, were associated with a better therapeutic relationship. We found that the level of perceived coercion on admission was not related to the therapeutic relationship. Targeted interventions to improve the therapeutic relationship, particularly for involuntarily admitted service users, are discussed.

A case series exploring possible predictors and mechanisms of change in hearing voices groups

OBJECTIVES

Hearing voices groups (HVGs) are increasingly common in National Health Services and are often preferred to individual therapy by both service users and providers. Whilst a range of approaches exist, mixed results have been found and only cognitive behaviour therapy (CBT) was supported by well-controlled trials. This study aimed to explore possible predictors and mechanisms of change in a seven-session CBT group for voice hearers.

DESIGN

An exploratory case series design was used. Method. Fifteen outpatients with a diagnosis of schizophrenia or schizoaffective disorder completed a HVG and carried out weekly measures of distress, negative beliefs about voices, self-esteem, effective coping strategies, and activity levels. Visual inspection and quantitative rules were used to group participants with similar results and cross-correlations and t tests were used to verify key findings.

RESULTS

Several pathways emerged across therapy. Despite measurement frequency, changes on different outcomes tended to occur simultaneously, making conclusions about mechanisms difficult. However, changes in beliefs about voice malevolence and omnipotence correlated most frequently with changes in distress. Visual analysis indicated 53% of participants improved on a measured outcome but satisfaction scores were higher, with 93% feeling the group helped them deal with their problems more effectively. Clients especially valued the chance to meet similar others.

CONCLUSIONS

The results suggest HVGs are valued by clients, regardless of their background or symptoms. HVGs should emphasize testing negative beliefs about voices and allow space for supportive discussions between clients. Recommendations for future research are discussed, including consideration of benefits not detected by outcome measures.

Therapeutic alliance in schizophrenia: the role of recovery orientation, self-stigma, and insight

The present study examined variables related to the quality of the therapeutic alliance in out-patients with schizophrenia. We expected recovery orientation and insight to be positively, and self-stigma to be negatively associated with a good therapeutic alliance. We expected these associations to be independent from age, clinical symptoms (i.e. positive and negative symptoms, depression), and more general aspects of relationship building like avoidant attachment style and the duration of treatment by the current therapist. The study included 156 participants with DSM-IV diagnoses of schizophrenia or schizoaffective disorder in the maintenance phase of treatment. Therapeutic alliance, recovery orientation, self-stigma, insight, adult attachment style, and depression were assessed by self-report. Symptoms were rated by interviewers. Hierarchical multiple regressions revealed that more recovery orientation, less self-stigma, and more insight independently were associated with a better quality of the therapeutic alliance. Clinical symptoms, adult attachment style, age, and the duration of treatment by current therapist were unrelated to the quality of the therapeutic alliance. Low recovery orientation and increased self-stigma might undermine the therapeutic alliance in schizophrenia beyond the detrimental effect of poor insight. Therefore in clinical settings, besides enhancing insight, recovery orientation, and self-stigma should be addressed.

A review of hearing voices groups: evidence and mechanisms of change

As a heavily stigmatized group, voice hearers often value the chance to meet others with similar experiences. As a result, Hearing Voices Groups (HVGs) are becoming increasingly common in both inpatient and outpatient settings. Where resources are constrained, HVGs are frequently viewed as a desirable alternative to individual therapy and are often preferred by service users themselves. HVGs often vary in their content and structure, with four common approaches: CBT, skills-training, mindfulness and unstructured support groups. This review evaluates the evidence for HVGs and the mechanisms of change for successful interventions. CBT was the only approach with evidence from well-controlled studies. However, several evidence-based treatments share 'key ingredients' which evidence suggests help reduce distress. Successful groups supply a safe context for participants to share experiences, and enable dissemination of strategies for coping with voices as well as considering alternative beliefs about voices. Future research should focus on isolating mechanisms of change and predictors of outcome in order to refine HVG approaches, rather than polarizing them and setting them against one another in efficacy trials.

Negative symptoms and poor insight as predictors of the similarity between client and therapist ratings of therapeutic alliance in cognitive behavior therapy for patients with schizophrenia

Recent studies have found that clients with schizophrenia rate therapeutic alliance more highly than therapists. Unclear is whether there are clinical characteristics which predict the degree of difference in client and therapist ratings. To explore this, we correlated client and therapist ratings of therapeutic alliance with baseline assessments of positive negative, and disorganized symptoms and awareness of need for treatment. Participants were 40 adults with schizophrenia enrolled in a 6-month program of cognitive behavior therapy. Results indicated that clients produced higher ratings of therapeutic alliance than therapists and that therapist and client general ratings were more disparate when clients had fewer negative symptoms and better insight. Higher overall client ratings of therapeutic alliance were linked to lower levels of positive, negative, and disorganized symptoms and better awareness of need for treatment. Higher overall therapist ratings were linked only to lower levels of disorganized symptoms among clients.

Does the cognitive dispute of psychotic symptoms do harm to the therapeutic alliance?

We examined whether the cognitive dispute of psychotic symptoms has a negative impact on the course of the therapeutic alliance. Sixty-seven patients with persistent psychotic symptoms received either cognitive behavioral therapy (CBT) or supportive therapy. Questionnaire-based alliance ratings were repeatedly obtained throughout the course of therapy. Patient and therapist alliance ratings were examined separately. Data analyses comprised repeated measurement analyses of variance and cluster analytic procedures. Neither patient nor therapist alliance ratings showed a differential course throughout the treatments. This was despite the implementation of disputing strategies in later stages of CBT. Irrespective of the treatment condition a cluster with a positive alliance rating and a cluster with a poorer rating were found for therapist and patient ratings, respectively. Baseline symptoms and insight differentiated between the types of clusters. In conclusion, CBT-specific interventions that challenge psychotic symptoms do not necessarily negatively influence the course of the alliance.

Predicting therapeutic alliance in clients with psychosis and substance misuse

The importance of therapeutic alliance in predicting treatment outcomes is well established, but less is known about client characteristics that predict alliance. Clients with co-occurring psychosis and substance misuse (n = 116) who received integrated motivational interviewing and cognitive behavior therapy in the context of a large randomized controlled trial completed the Working Alliance Inventory. Their trial therapists also completed Working Alliance Inventories. Rating perspectives were compared, and in a cross-sectional study, client predictors of therapeutic alliance were examined. As hypothesized, clients' negative attitudes to treatment, including lack of insight, were predictive of poorer alliance. Therapist-rated alliance was also predicted by the client's attitude to medication, self-reported depression, and living situation. Symptom severity and substance use measures were unrelated to alliance. Consistent with previous studies, rating perspectives differed, with clients rating alliance more positive than therapists.

Predictors of adherence to cognitive-behavioural therapy in first-episode psychosis

OBJECTIVE

To investigate predictors of adherence with a cognitive-behavioural intervention in first-episode psychosis (FEP) patients.

METHOD

Predictors of adherence to cognitive-behavioural therapy (CBT) were longitudinally investigated in the experimental arm of a randomized controlled trial designed to evaluate the effectiveness of a CBT intervention for relapse prevention early in the course of psychosis when compared with treatment as usual within 2 high quality, youth oriented, specialist FEP programs (the EPISODE II trial).

RESULTS

Longer duration of untreated psychosis (DUP) and poorer level of insight predicted poor adherence to CBT. This association remained significant after controlling for potential confounders.

CONCLUSIONS

Treatment delay may decrease adherence with CBT in FEP patients. Reducing DUP and promoting insight early in the course of psychosis are likely to enhance adherence with CBT.

The influence of baseline symptoms and insight on the therapeutic alliance early in the treatment of schizophrenia

BACKGROUND

The consistent association between therapeutic alliance and outcome underlines the importance of identifying factors which predict the development of a positive alliance. However, only few studies have examined the association between pretreatment characteristics and alliance formation in patients with schizophrenia.

OBJECTIVE

The study examined whether symptoms and insight would predict the therapeutic alliance in psychotherapy of schizophrenia. Further, the associations and differences between patient and therapist alliance ratings were studied.

METHODS

Eighty patients with schizophrenia spectrum disorders received manual-based psychotherapy. Assessment of symptoms and insight was conducted at baseline, and questionnaire-based alliance ratings were obtained three weeks into treatment. Patient and therapist alliance ratings were examined separately.

RESULTS

Patient and therapist alliance ratings were not significantly correlated (r=0.17). Patient ratings of the alliance were significantly higher than the ratings of their therapists (d=0.73). More insight in psychosis significantly predicted higher patient ratings of the alliance. Less positive and negative symptoms were significant predictors of higher therapist alliance ratings.

CONCLUSION

The findings indicate that symptoms and insight have an influence on the therapeutic alliance in the treatment of schizophrenia spectrum disorders. Patients' and therapists' perceptions of the alliance do not seem to demonstrate much convergence.