€¦ · Web viewAbstract word count: 248 Introduction Therapeutic alliance is a predictor of...

Therapeutic alliance in psychological therapy for people with schizophreniaand related psychoses: a systematic review

L. Shattockᵃ, K. Berryᵃ*, A. Degnanᵇ, D. Edgeᵇ

ᵃDivision of Psychology and Mental Health; School of Health Sciences, University of Manchester,

2nd Floor, Zochonis Building, Brunswick Street, Manchester, M13 9PL, United Kingdom

ᵇDivision of Psychology and Mental Health; School of Health Sciences; University of Manchester, Room 3.306, Jean McFarlane Building, Oxford Road, Manchester, M13 9PL, United Kingdom

For publication in Clinical Psychology & Psychotherapy

* Corresponding author: School of Health Sciences, University of Manchester, 2nd Floor,

Zochonis Building, Brunswick Street, Manchester, M13 9PL, United Kingdom (Email:

[email protected])

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mailto:[email protected]

AbstractTherapeutic alliance is a key predictor of therapy outcomes. Alliance may be particularly

pertinent for people with schizophrenia as this group often have a history of interpersonal

trauma and relationship difficulties including difficult relationships with mental health staff.

This review aimed to determine: 1) the quality of therapeutic alliance between people with

schizophrenia and their therapists; 2) whether alliance predicts therapeutic outcomes; and

3) variables associated with alliance. Databases were searched from inception up to April

2015. The search yielded 4,586 articles, resulting in 26 eligible studies, involving 18

independent samples. Weighted average client and therapist Working Alliance Inventory-

Short Form (WAI-SF) total scores were 64.51 and 61.26, respectively. There was evidence

that alliance predicts overall psychotic symptomatic outcomes and preliminary evidence for

alliance predicting rehospitalisation, medication use, and self-esteem outcomes. There was

evidence for specific client-related factors being linked to different perspectives of alliance.

For example, poorer insight and previous sexual abuse were associated with worse client-

rated alliance, whereas baseline negative symptoms were associated with worse therapist-

rated alliance. Therapist and therapy-related factors, including therapists’ genuineness,

trustworthiness and empathy were associated with better client-rated alliance, whereas

suitability for therapy, homework compliance and attendance were associated with better

therapist-rated alliance. Key clinical implications include the need to consider alliance from

both client and therapist perspectives during therapy; and training and supervision to

enhance therapist qualities that foster good alliance. Future research requires longitudinal

studies with larger samples that include pan-theoretical, well-validated alliance measures to

determine causal predictor variables.

Abstract word count: 248

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Introduction

Therapeutic alliance is a predictor of therapy outcomes (Horvath et al. 2011; Martin et

al. 2000) and is commonly conceptualised according to goal agreement, task agreement and

therapeutic bond (Bordin, 1979). Alliance may be particularly relevant to people with

schizophrenia and related psychoses as this group are likely to have early traumatic

experiences impacting on adult relationships and difficulties with service engagement

(Kreyenbuhl, Nossel, & Dixon, 2009; Varese et al., 2012).

Hewitt and Coffrey (2005) reviewed studies investigating alliance within nursing

relationships for people with schizophrenia and report a definitive role of alliance in

recovery from schizophrenia. However, this review did not provide detailed inclusion and

exclusion criteria, nor did it systematically evaluate included studies using a quality appraisal

tool. A second review that investigated alliance and outcomes in this client-group found

some evidence for alliance predicting fewer hospitalisations, symptom reduction and

improved functioning (Priebe, Richardson, Cooney, Adedeji, & McCabe, 2010). However,

only one of the studies included in this review considered alliance in psychological therapy,

with the remaining studies reporting on alliance within psychiatric or health settings.

There is evidence that psychological therapies are effective treatments for

schizophrenia (e.g. Pharoah, Mari, Rathbone & Wong, 2010; Wykes, Steek, Everitt & Tarrier,

2008). Nevertheless, the size of the effect of therapy on outcomes are moderate, suggesting

that further work is needed to understand predictors of better outcomes to enhance

effectiveness (Turner, van der Gaag, Karyotaki, & Cuijpers, 2014). A growing number of

studies have reported alliance as an important therapeutic variable for people with

schizophrenia diagnoses due to its role in predicting outcome. Studies have also reported

variables affecting the quality of the alliance that develops during therapy. It is important to

understand what factors predict alliance so that these can be more closely targeted. For

example, public-stigma and self-stigma (the internalisation of negative societal messages

and stereotypes about mental health problems) are significant barriers to engagement in

therapeutic interventions for people diagnosed with schizophrenia and may be key factors

in determining the quality of therapeutic alliance (Vogel, Wade & Hackler, 2007; Wood,

Burke, Byrne, Pyle, Chapman & Morrison, 2015; Pyle & Morrison, 2014).

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Despite the growing number of studies that evaluate alliance in therapy for psychosis,

the developing literature has not yet been synthesised. The aim of this paper is to

systematically review studies investigating alliance in people with schizophrenia and related

psychoses. Key objectives are to: (i) summarise average alliance ratings across studies,

thereby providing a point of comparison for future alliance studies; (ii) examine whether

alliance predicts therapy outcomes; and (iii) identify variables associated with the

development of good quality alliance. The review also assesses the methodological quality

of included studies and provides recommendations for future research.

Method

Search Strategy

The databases Medline, Web of Science and PsycINFO were searched from inception to

April 2015 using the following terms:

1. (psychotic OR schizo*OR psychos*s) OR (chronic* OR serious* OR sever*) NEAR/3

(mental*) NEAR/3 (ill* OR disorder*)

AND

2. (therap* OR working* OR helping*) NEAR/2 (alliance* OR relation* OR process*) OR

(staff* OR professional*) NEAR/2 (client* OR patient) NEAR/3 (alliance* OR relation*

OR process*)

This search resulted in 6,980 citations leaving 4,586 citations when duplicates were

removed. One-third (n=1,520) were independently screened at title level by the lead author

and a postgraduate student. Following high levels of agreement (98% of cases; k=.77),

remaining citations were screened by the lead author leaving 160 that were all screened at

abstract level by the lead author and a postgraduate student (91% of cases; k=.79). The lead

author screened the remaining 55 citations at a full-text level against specified inclusion

criteria. Inclusivity was discussed with the research team, resulting in 26 included articles

(see Figure 1).

Inclusion Criteria

The inclusion criteria were:

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(i) sample with non-affective psychosis

(ii) a validated measure of alliance between client and therapist

(iii) clients receiving psychological therapy

(iv) English language

(v) peer-reviewed.

Criterion (i) included samples with severe mental illness (SMI) where >60% had non-

affective psychosis. Preliminary searches revealed that studies with SMI samples generally

included a proportion of people with non-affective psychosis, thus excluding these studies

would limit the evidence available to review. One study (Moran et al., 2014). was excluded

as diagnostic information could not be provided by the authors.

For criterion (iii) ‘psychological therapy’ was defined as “…meeting with a therapist

(a healthcare professional competent in giving psychological therapy to people with

psychosis or schizophrenia) to talk about your feelings and thoughts and how these affect

your behaviour and wellbeing” (NICE, 2014). When it was unclear if this criterion was met,

the authors were contacted. Four out of six authors responded with information that

informed the exclusion criteria - samples included assertive outreach (e.g. Cunningham,

Calsyn, Burger, Morse, & Klinkenberg, 2007) and vocational rehabilitation (e.g. Catty et al.,

2011).

Data Synthesis

Marked heterogeneity in the methodology of studies and types of relationships

measured meant that a meta-analysis was not appropriate. Instead, a narrative synthesis of

the literature (Mays, Roberts, & Popay, 2001) was conducted, reporting effect sizes of

individual studies where available. The effect size of studies that investigated whether

alliance predicted therapeutic outcomes (both symptomatic and other outcomes) are

documented in Table 3. If the effect size was not reported, but the β statistic was, the

authors adopted Peterson and Brown’s (2005) formula: r = β + .5ƛ, where ƛ=1 on occasions

when β is a positive value, in cases where β value was ±0.5 to calculate the effect size. In

cases where it was not possible to report the effect size, the results of other relevant

statistical tests were reported in Table 3.

Quality Assessment

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Methodological quality of studies was assessed using the Effective Public Health

Practice Project (EPHPP) Quality Assessment Tool for Quantitative Studies (Thomas, 2003).

The tool has good reliability and validity (Armijo-Olivo et al., 2012; Thomas et al., 2004).

Consistent with other systematic reviews involving predominantly non-randomised studies

(e.g. Safavi, Berry, & Wearden, 2015), the tool was amended to include five relevant rating

domains: (i) Selection Bias; (ii) Confounders; (iii) Data Collection Methods; (iv) Withdrawals

and Drop-outs; and (v) Analysis (two of the four items). The original version of EPHPP does

not include the Analysis domain in final ratings and for consistency this was also excluded

from the adapted version. The lead author and a postgraduate student independently rated

all papers, with substantial agreement found for overall ratings (92% level of agreement; k

=.781).

INSERT FIGURE 1

Results

Study Characteristics

Table 1 presents study characteristics and key findings. Five studies were purely

cross-sectional. There were two types of longitudinal designs which were termed ‘alliance

baseline’ and ‘alliance outcome’ to differentiate between them. There were eight ‘alliance

baseline’ studies which measured variables prior to therapy and measured alliance early

(e.g. session 3) in therapy. These studies are discussed alongside the cross-sectional studies

as they focus on factors affecting the development of alliance. There were thirteen ‘alliance

outcome’ studies which measured alliance and/or other variables at multiple time points

over the course of therapy. These latter studies are discussed in a separate section (titled

‘Relationship between Alliance and Outcome’) to described role of alliance in predicting

therapy outcomes.

Alliance was most frequently assessed (n=11) using the Working Alliance Inventory-

Short Form (WAI-SF; Tracey & Kokotovic, 1989). It was assessed from different perspectives

including: client and therapist-rated (n=21), client-rated (n=3), therapist-rated (n=1) and

observer-rated (n=1). Therapy was delivered in individual (n=23), group (n=2) and family

(n=1) settings. Eight pairs of studies used participants drawn from the same sample (i.e. full

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dataset or subsample from a larger trial), resulting in 18 independent samples across 26

studies.

INSERT TABLE 1 HERE

Quality Assessment

The results of the quality assessment are summarised in Table 2. Most studies

applied additional selection criteria to secondary data (e.g. only including participants who

had at least three measures of alliance) and were therefore rated ‘moderate’ for selection

bias. Ten studies received a ‘weak’ rating of selection bias due to lack of recruitment and

selection detail (n=4), no details of trial given (n=2), participants self-referred (n=1) or less

than 60% of selected individuals consented to participate (n=3). Most studies (n=19)

considered confounders either in the design and/or analyses, so were given ‘moderate’ or

‘strong’ ratings for this criterion. Seven studies received a ‘weak’ rating for confounders as

they did not report controlling for confounders in their design or analyses. ‘Strong’ ratings

were given to 22 studies for data collection methods, as they used reliable and valid

measures. Withdrawal and drop-outs was not applicable to the cross-sectional studies, but

eight longitudinal studies received a ‘weak’ rating on withdrawal and drop-outs due to lack

of detail (n=7) or because <60% of participants completed measures at the last time point

(n=1). Nineteen studies were rated ‘moderate’ for analysis. Although in general analyses

seemed appropriate to the research aims, there was a tendency for authors not to discuss

the management of missing data.

INSERT TABLE 2 HERE

Average Ratings of Alliance

Average alliance ratings were reported in 22 studies, with two studies reporting

ratings for identical samples at the same point in time (Johansen, Melle, Iversen, & Hestad,

2013a; 2013b). The weighted average alliance ratings were calculated across studies for

alliance measures comparable in at least two studies. Average ratings were weighted by

sample size to provide a more representative estimate of the mean. In studies drawn from

the same sample, the alliance ratings from the earlier dated study were used. The weighted

average of WAI-SF ratings across cross-sectional studies for clients (n=5) and therapists

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(n=4) was 64.51 (average ratings ranged from 63.70 to 70.8) and 61.26 (average ratings

ranged from 60.75 to 64.2), respectively. The weighted average California Psychotherapy

Alliance Scale (CALPAS) rating (n=2) for initial client-rated alliance was 5.32 (SD=1.01,

average ratings were 5.27 and 5.50). For both measures, higher ratings represent better

therapeutic alliance. Neither of the scales have norms or classification systems although

CALPAS ratings above four are considered indicative of ‘good’ quality alliance (Delsignore et

al., 2013).

Alliance remained stable (Dunn, Morrison, & Bentall, 2006; Jung, Wiesjahn, &

Lincoln, 2014; Lysaker, Davis, Outcalt, Gelkopf, & Roe, 2010) or improved (Chadwick,

Williams, & Mackenzie, 2003; Frank & Gunderson, 1990; Lecomte, Leclerc, Wykes, Nicole, &

Abedel Baki, 2014; Svensson & Hansson, 1999b; Wittorf et al., 2010) during therapy. Nine

studies reported significant associations (correlation ranged from .28 to .56) between

therapist and client rated-alliance (Barrowclough, Meier, Beardmore, & Emsley, 2010; Davis

& Lysaker, 2004; Dunn et al., 2006; Johansen et al., 2013b; Jung et al., 2014; Lecomte,

Laferrière-Simard, & Leclerc, 2012; Svensson & Hansson, 1999b; Wittorf et al., 2010). Clients

consistently rated significantly better alliance than therapists (Barrowclough et al., 2010;

Evans-Jones, Peters, & Barker, 2009; Jung et al., 2014; Jung, Wiesjahn, Rief, & Lincoln, 2015;

Lysaker et al., 2010; Lysaker, Davis, Buck, Outcalt, & Ringer, 2011; Mulligan et al., 2014;

Wittorf et al., 2009; 2010).

Relationship between Alliance and Outcome

Eight studies investigated alliance and symptomatic outcomes. Two group therapy

studies involving clients who had experienced a first psychotic episode found that client and

therapist-rated alliance measured at the end of therapy predicted overall symptoms with a

moderate effect size, but not positive or negative symptoms (Lecomte et al., 2012; 2014). In

Frank and Gunderson’s (1990) study, change in psychopathology for clients receiving

exploratory-insight-orientated or reality-adaptive-supportive therapy was predicted by

better therapist-rated alliance and levels of psychopathology measured at six months into

therapy. However, neither variable independently predicted change post-treatment (Frank

& Gunderson, 1990). Goldsmith et al. (2015) used structural equation modelling (SEM) and

controlled for randomisation and baseline covariates in a sample of first or second episode

psychosis patients who received either CBT or supportive counselling. The authors found

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that good initial client-rated alliance resulted in better overall symptoms at 18-months and

poorer alliance predicted poorer outcomes. The authors conclude that their SEM analysis

provides evidence that alliance has a causal effect on outcome (Goldsmith et al., 2015); that

is, good alliance leads to favourable outcomes in therapy, and poorer alliance is detrimental

to therapeutic outcomes. By considering the confidence intervals of these estimates,

Goldsmith et al. (2015) conclude that there is “a high level of certainty that these effects

exist” (Goldsmith et al., 2015, pp. 2370).

Alliance did not predict symptomatic outcomes in four studies (Berry et al., 2015;

Dunn et al., 2006; Jung et al., 2014; Svensson & Hansson, 1999b). Three of these studies,

which may be underpowered, investigated positive and/or negative symptoms as an

outcome, but did not consider overall psychotic symptoms (Dunn et al., 2006; Jung et al.,

2014; Svensson & Hansson, 1999b). The other study (Berry et al., 2015) used a co-morbid

substance misuse sample and alliance and outcome findings are mixed in the substance

misuse literature compared to the mental health literature (Meier, Barrowclough, &

Donmall, 2005).

In terms of other outcomes, alliance did not predict general functioning in two

studies with aforementioned problems relating to the sample size (Jung et al., 2014) and

comorbid substance misuse (Berry et al., 2015) that may account for lack of significant

findings. In contrast, one study (Svennson & Hansson, 1999b) reported that client-rated

alliance predicted improvements in general functioning (moderate effect size). Although

comprised of a relatively small sample, it was considered methodologically robust due to

the use of well-validated measures and good levels of retention in therapy.

There was no support that alliance predicted social functioning (Frank & Gunderson,

1990; Jung et al., 2014). As highlighted previously, Jung et al.’s (2014) study may be

underpowered. Frank and Gunderson’s (1990) study had a considerable sample size with

acceptable withdrawal and drop-out rates, suggesting that this finding may be robust.

However, Frank and Gunderson (1990) only considered alliance from the therapists’

perspective, meaning that no firm conclusions can be made with regards to client-rated

alliance and social functioning.

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Frank and Gunderson (1990) found better initial therapist-rated alliance was

significantly related to fewer rehospitalisations over a two-year period. In a study where 28

clients received behavioural family management, observer ratings of better therapeutic

alliance, but not client or therapist-rated alliance significantly predicted days until first

rehospitalisation and first use of rescue medication (Smeurd & Rosenfarb, 2011). Despite

being small (n=28), the sample was considered moderately representative and the measures

used had demonstrable reliability. Self-esteem was significantly predicted by client-rated

alliance in a therapeutic group for clients with first episode psychosis (Lecomte et al., 2012).

In the quality assessment, this study was considered to have a moderately representative

sample, used validated measures, and conducted appropriate analyses.

In summary, preliminary evidence exists for both therapist-rated, and to a greater

degree, client-rated alliance, predicting overall symptomatic improvement across early

psychosis samples measured at different time points across studies. There is also evidence

that good quality therapist-rated and observer-rated alliance predicts fewer

rehospitalisations and reduced medication use and that client-rated alliance predicts self-

reported self-esteem. Social functioning does not appear to be predicted by therapist-rated

alliance, but findings are inconclusive with regards to client-rated alliance. See Table 3 for

effect size statistics for the relationship between alliance and outcome across all

longitudinal studies.

INSERT TABLE 3 HERE

Variables Associated with Alliance

Client demographic variables

Eleven studies examined alliance and demographics, most of which found non-

significant associations. Ethnicity and therapist alliance were considered in three studies.

One study found better observer-rated alliance was associated with working with Black

families (Smerud & Rosenfarb, 2011), whereas another study found better therapist-rated

alliance was related to working with White clients (Barrowclough et al., 2010). These two

studies did not report therapists’ ethnicity, so no conclusions can be drawn regarding ethnic

matching between client and therapist. Evans-Jones et al. (2009) found no significant

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relationship between therapeutic alliance and ethnicity from either perspective, even when

ethnicity was matched.

Client psychopathology variables

Fifteen studies investigated alliance and psychopathology assessed at baseline. One

study (Svensson & Hansson, 1999b) found better client-rated alliance was associated with

higher ratings on the Symptom Check-List-90 (Derogatis & Fasth, 1977). Another study

showed that psychotic symptoms assessed at the time of the session using the Brief

Psychiatric Rating Scale (Woerner, Mannuza & Kane, 1988) were significantly negatively

associated with observer-rated alliance (Smerud & Rosenfarb, 2011).

Seven studies reported no significant relationships between client-rated alliance and

positive or negative symptoms at baseline (Barrowclough et al., 2010; Couture et al., 2006;

Evans-Jones et al., 2009; Johansen et al., 2013a; Jung et al., 2015; Lysaker et al., 2011;

Mulligan et al., 2014). Only two studies reported a significant relationship between negative

symptoms at baseline and client-rated alliance assessed early in therapy (Jung et al., 2014;

Lysaker et al., 2011). These contrasting findings may reflect differences in the

conceptualisation of alliance. For example, Jung et al. (2014) used a three-item alliance

measure that did not measure agreement on the ‘goals’ or ‘tasks’ of therapy, which is often

assessed in other measures such as the WAI or CALPAS (Jung et al., 2014). The other study

that reported significant findings used the WAI-SF (Lysaker et al., 2011) and investigated the

association between negative symptoms and alliance subscales (‘bond’, ‘goal’, and ‘task’) in

addition to overall alliance. The authors found that baseline negative symptoms were

significantly correlated with the ‘bond’ and ‘goal’ subscales, but not the ‘task’ subscale.

Minimal selection bias and controlling for confounders in the study design suggested that

Lysaker et al.’s (2011) study was of good quality. Two studies reported significant

associations between positive symptoms at baseline and client-rated alliance assessed

relatively early on in therapy (Lysaker et al., 2011; Wittorf et al., 2010). As in the case of

negative symptoms, Lysaker et al. (2011) found that higher ratings of positive symptoms

were significantly related to poorer overall client-rated alliance. When the authors

considered specific subscales of the WAI, greater positive symptoms were only significantly

associated with poorer ratings on the ‘goal’ subscale (not ‘task’ or ‘bond’ subscales). Wittorf

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et al.’s (2010) study found that clients in the ‘low’ alliance cluster had significantly higher

scores on positive symptoms compared with those in the ‘high’ alliance cluster. The sample

involved clients with persistent positive symptoms who received either CBT or supportive

therapy. Two studies (Johansen et al., 2013a; 2013b) using the same sample reported a

significant relationship between poorer client-rated alliance and higher ratings of excitative

symptoms (using the five-factor model of PANSS), with excitative symptoms being a key

predictor variable in multivariate analysis (Johansen et al., 2013b).

Seven studies found no significant relationship between therapist-rated alliance and

negative symptoms (Barrowclough et al., 2010, Couture et al., 2006; Evans-Jones et al.,

2009, Johansen et al., 2013a, Jung et al., 2015, Mulligan et al., 2014; Lysaker et al., 2011),

whereas four studies reported a significant relationship between poorer therapist-rated

alliance and greater negative symptoms (Johansen et al., 2013b; Jung et al., 2014, Wittorf et

al., 2009; 2010). Three of the four studies reporting significant findings conducted

multivariate analysis and negative symptoms were retained as a significant predictor of

therapist-rated alliance in one study (Jung et al., 2014). This study minimised selection bias,

controlled for most potential confounds and used validated measures and robust analyses,

which resulted in the quality assessment being rated as ‘strong’. One study by Couture et al.

(2006) conceptualised psychotic symptoms using a five-factor solution of the PANSS (White,

Harvey, Opler, & Lindenmayer, 1997). The authors reported that better therapist-rated

alliance was significantly associated with lower ratings on the activation and autistic

preoccupation factors, but no significant relationship was found between negative

symptoms and alliance. Interestingly, the preoccupation factor includes PANSS items that

are widely considered as negative symptoms in other PANSS factor analyses. Differences in

findings may be partly explained by differences in the methods of categorising symptoms.

Arguably, the activation and autistic subscales include PANSS items that are likely to have

the biggest impact on social functioning and therefore most likely to be related to

therapeutic alliance.

Nine studies investigated therapist-rated alliance and baseline positive symptoms

(Barrowclough et al., 2010; Couture et al., 2006; Evans-Jones et al., 2009; Johansen et al.,

2013a; Jung et al., 2014, 2015; Lysaker et al., 2011; Mulligan et al., 2014; Wittorf et al.,

2009; 2010). All studies except for Wittorf et al.’s (2009) study found no significant

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relationship. This discrepancy may be due to Wittorf et al. (2009) using a three-item

unpublished measure of alliance that narrowly conceptualises therapeutic alliance as

therapists’ perceived emotional bond with their clients.

Four studies examined the relationship between baseline, client-reported depression

and alliance. All four studies examined the relationship between client-rated alliance and

depression, two of which found no significant association (Barrowclough et al., 2010; Kvrgic

et al., 2013). Jung et al. (2014) reported better client-rated alliance was associated with

lower depression ratings, whereas Mulligan et al. (2014) found that better client-rated

alliance was associated with higher ratings of depression. These differences may be

attributable to distinct differences across the samples, including severity of symptoms and

comorbid substance misuse. Three studies investigated therapist-rated alliance and

depression, two of which found no significant association (Jung et al., 2014; Mulligan et al.,

2014). Barrowclough et al. (2010) reported that better therapist-rated alliance was

associated with high ratings of depression. Barrowclough et al. (2010) had a substantially

bigger sample size (n = 116) compared to the other samples investigating therapist-rated

alliance and depression which may suggest other studies were underpowered to detect an

effect.

In summary, there were mixed findings for the relationship between therapist-rated

alliance and baseline negative symptoms and no consistent relationship was found between

alliance and positive symptoms, nor between alliance and depression.

Client insight and cognitive variables

Ten studies reported associations between insight and alliance. Six of the ten studies

investigating insight and client-rated alliance found a significant, positive association

(Barrowclough et al., 2010; Dunn et al., 2006; Kvrgic et al., 2013; Lysaker et al., 2011; Wittorf

et al., 2009; 2010). Non-significant associations in the remaining studies may be due to

some studies using recent-onset psychosis samples and those with SMI (Johansen et al.,

2013a; Lecomte et al., 2012) or having restricted variance across insight scores (Jung et al.,

2014; 2015). Two (Barrowclough et al., 2010; Johansen et al., 2013a) of the eight studies

(Barrowclough et al., 2010; Johansen et al., 2013a; Jung et al., 2014; 2015; Lecomte et al.,

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2012; Lysaker et al., 2011; Wittorf et al., 2009; 2010) investigating therapist-rated alliance

and insight found a significant relationship.

Three studies considered different cognitive and personality factors, such as

mastery, verbal memory, and personality traits (Davis & Lysaker, 2004; Davis et al., 2011;

Johansen et al., 2013b). Clients in ‘high’ and ‘intermediate’ mastery groups rated alliance

with their therapists as significantly better than those with poorer mastery (‘low’ group)

(Davis et al., 2011). Lower client-rated alliance was associated with poorer ratings on a

verbal memory test (Davis & Lysaker, 2004). Higher scores on the submissive-hostile

interpersonal personality dimension were associated with poorer client-rated alliance,

whereas therapist-rated alliance was associated with ‘agreeable’ personality traits

(Johansen et al., 2013b).

Client psychosocial variables

Six studies that investigated alliance and baseline social functioning found no

significant relationship between client-rated alliance and social functioning or social contact

across a variety of measures. Three of the six studies reported significant associations with

therapist-rated alliance (Couture et al., 2006; Jung et al., 2014; Svennson & Hansson,

1999b). These studies all used different, but well validated measures of social functioning

with sufficiently representative samples. Of the three studies reporting no association, two

(Evans-Jones et al., 2009; Mulligan et al., 2014) had limited statistical power and one

included a sample of comorbid substance misuse (Barrowclough et al., 2010).

Two studies investigated alliance and general functioning on the General Functioning

Scale (GAF) at baseline. While therapist-rated alliance was not associated with general

functioning, client-rated alliance was in one study (Jung et al., 2014), but not in another

(Barrowclough et al., 2010). However, general functioning may share variance with negative

symptoms, as Jung et al. (2014) found it did not predict alliance in multivariate analysis.

Adverse experiences (n=1) and attachment style (n=2) were investigated in relatively

few studies. Clients with sexual assault histories rated poorer alliance compared to those

with no such histories, with significant effects remaining after controlling for positive

symptoms (Lysaker et al., 2010). Therapist-rated alliance did not differ between client

groups who had and had not experience assault. Two studies found non-significant

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associations between client reports of attachment style and alliance (Berry et al., 2015;

Kvrgic et al., 2013).

Therapist-related variables

Two studies investigating client-reported therapist characteristics found significant,

strong associations with client-rated alliance. Better client-rated alliance was related to

more perceived genuineness, competence, and convincingness, and moderately correlated

with positive regard (Jung et al., 2015). Similarly, Evans-Jones et al. (2009) found better

client-rated alliance was associated with perceived empathy, expertness, attractiveness and

trustworthiness. There was a trend towards higher therapist-rated alliance being associated

with higher self-ratings of empathy (Evans-Jones et al., 2009). Clients in both studies

received CBT for psychosis. Therapists’ confidence in their own abilities to carry out therapy

(Evans-Jones et al., 2009) and in supporting clients achieving their goals (Mulligan et al.,

2014) was not associated with client or therapist-rated alliance, neither was number of

years qualified (Evans-Jones et al., 2009).

Therapy-related variables

Four studies considered variables relating to the therapeutic process. Three studies

examined alliance and the role of formulation. Client-rated alliance was not significantly

associated with presentation of a formulation in CBT (Evans-Jones et al., 2009). Neither

client nor therapist-rated alliance were associated with therapists’ perception of

collaboration and complexity of formulations (Mulligan et al., 2014). Chadwick et al. (2003)

included 13 clients who received CBT and found there were significant improvements in

therapist-rated alliance before and after a formulation was presented but not for client-

rated alliance. All three studies had small samples, suggesting that they may be

underpowered.

Three studies investigated alliance and clients’ therapy attendance (Evans-Jones et

al., 2009; Lecomte et al., 2012; Mulligan et al., 2014). Client and therapist-rated alliance

predicted attendance and level of participation during group therapy sessions (Lecomte et

al., 2012). Lower therapist but not client-rated alliance was associated with greater non-

attendance (Mulligan et al., 2014). At a trend level, better therapist-rated alliance was

associated with clients attending more sessions, and better client-rated alliance was

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associated with receiving more types of cognitive behavioural interventions (Evans-Jones et

al., 2009). The small sample size may have contributed to findings not reaching significance

in this study.

In one study, lower levels of therapist-rated suitability for therapy and lower levels of

homework compliance were both significantly related to poorer therapist-rated alliance in

CBTp (Dunn et al., 2006). Another study showed that higher therapists rating of perceived

change due to therapy was associated with better therapist, but not client-rated alliance

(Mulligan et al., 2014).

Discussion

Summary of Findings

This review consistently found that alliance was established early and either

maintained or improved during therapy with clients rating better alliance compared to

therapists (e.g. Dunn, Morrison, & Bentall, 2006; Jung, Wiesjahn, & Lincoln, 2014; Lecomte,

Leclerc, Wykes, Nicole, & Abedel Baki, 2014; Svensson & Hansson, 1999b; Wittorf et al.,

2010). There was evidence for therapist and client-rated alliance predicting overall

symptomatic outcomes (Goldsmith et al., 2015; Lecomte et al., 2012; 2014). Many client-

related factors measured at baseline were not consistently associated with alliance. There

was some evidence for better insight (e.g. Barrowclough et al., 2010; Dunn et al., 2006) and

fewer past experiences of sexual abuse being associated with better client-rated alliance

(Lysaker et al., 2010), and fewer negative symptoms at baseline being associated with better

therapist-rated alliance (e.g. Johansen et al., 2013b; Jung et al., 2014) across samples with

schizophrenia spectrum disorders. A few studies investigated therapist and therapy-related

factors and found that greater therapist genuineness, trustworthiness and empathy were

associated with better client-rated alliance (Evans-Jones et al., 2009; Jung et al., 2015), and

greater suitability for therapy, homework compliance and attendance were associated with

better therapist-rated alliance (Dunn et al., 2006).

Average Alliance Ratings

The average WAI-SF ratings of 64.51 and 61.26 for clients and therapists,

respectively, have not been provided by other systematic reviews that cite the WAI-SF (e.g.

Horvath et al., 2011, Martin et al., 2000). These figures provide a benchmark to compare

16

alliance ratings in future studies. Although comparisons are limited, the client-rated alliance

average from this review were not dissimilar to samples with post-traumatic stress

(mean=65.37; Keller, Zoelliner, Feeny, 2010), anxiety (mean=70.52; Hayes-Skelth, Roemer,

Orgillo, 2013) and depression (mean=66.99; Missirlian, Toukmaniam, Warwar, & Greenbery,

2005) during psychological therapy.

The finding that clients rated alliance better than therapists is consistent with

previous alliance research reviewing studies involving individual psychotherapy for different

clinical samples (Tyron, Blackwell, & Hammel, 2007). Therapists’ lower alliance ratings may

relate to the notion of ‘better safe than sorry’, whereby therapists are motivated to be

vigilant to detecting alliance ruptures that may lead both to underestimating alliance and

attunement to fluctuations in the therapeutic bond (Atzil-Slonim, Bar-Kalifa, Rafaeli, Lutz,

Rubel & Schiefele, 2016; Marmarosh & Kivlighan, 2012). This hypothesis is congruent with

wider outpatient psychotherapy literature whereby therapists’ identification of potential

ruptures predicts better client-rated alliance (Chen, Atzil-Slonim, Bar-Kalifa, Hasson-Ohayon,

& Refaeli, 2016).

Alliance Predicting Outcomes of Therapy

The finding that client and therapist-rated alliance predicted overall symptomatic

outcomes, with significant results demonstrating a moderate effect size, is in keeping with

previous meta-analyses of psychological therapies (e.g. Horvath, Del Re, Flückiger, &

Symonds, 2011; Martin, Garske, & Davis, 2000). Statistically significant findings were across

samples who had experienced an acute first or second psychotic episode, including a small

proportion of participants who were diagnosed with affective psychosis.

Other outcomes aside from symptoms were considered, and consistent with Priebe

et al’s (2010) review in general psychiatric settings, better therapist-rated alliance predicted

fewer hospitalisations and reduced medication use. Preliminary evidence for client-rated

alliance predicting self-esteem and general functioning was reported in heterogenic samples

who had experienced a first psychotic episode. Although there was no evidence for

therapist-rated alliance predicting social functioning, findings were inconsistent with regards

to the relationship between client-rated alliance and social functioning, possibly reflecting

differences in how social functioning was assessed.

17

Variables Associated with Alliance

The lack of a significant relationship between positive symptoms at baseline and

alliance supports the notion that therapeutic relationships can be formed despite severity of

positive symptoms, such as paranoia or delusional beliefs. The preliminary finding that

greater negative symptoms in samples with schizophrenia spectrum disorders was

associated with poorer therapist-rated alliance may suggest that therapist find clients with

negative symptoms challenging to work with, possibly because they present as more

interpersonally detached or perhaps because certain negative symptoms, such as blunted

affect, may be interpreted as poor alliance (Wittorf et al., 2009). This latter hypothesis is

consistent with a recent study with a schizophrenia sample reporting that mental health

workers’ underestimation of clients’ social needs was related to negative symptoms (Ofir-

Eyal, Hasson-Ohayon, Bar-Kalifa, Kravetz, Lysaker, 2016). Agreement on clients’ (social)

needs and goals is often considered a key component of the therapeutic alliance (e.g. WAI-

SF subscales).

Insight was associated with client but not therapist-rated alliance across non-

affective psychosis samples. Measures of insight assessed the perceived need for psychiatric

treatment. Understandably, differences between clients’ and professionals’ explanatory

models for psychosis have implications for a collaborative engagement, especially if clients

perceive they are not in need of psychiatric treatment (Lysaker et al., 2013). Developing

mutual understanding of the nature of the clients’ problems may be a therapeutic goal for

therapists. Therefore therapists anticipating discrepancies in understanding may explain

why therapist alliance is not affected by client insight.

The finding that baseline measures of social functioning were associated with

therapist, but not client-rated alliance early in therapy was surprising given that alliance did

not predict social functioning at the end of therapy, but suggests that therapist may be able

to persist in engaging those with poorer social functioning to bring about change. Past

sexual assault was associated with poorer client-rated alliance in a sample with

schizophrenia spectrum disorders which may be due to previous adverse experiences

preventing clients from trusting those in positions of power (Lysaker et al., 2010). However,

developing good quality alliance from clients’ perspectives is integral to therapy, as it has

18

been associated with better therapeutic outcomes in non-psychosis samples with abuse

histories (e.g. Cloitre, Stovall-McClough, Miranda, & Chemtob, 2004). Surprisingly,

attachment was not significantly associated with alliance in two studies, inconsistent with

findings from general psychotherapy literature (e.g. Daniels, 2006). Lack of significant

findings in the studies in this review may be due to therapists’ abilities to develop good

alliances with clients despite attachment difficulties (Berry et al., 2015; Kvrigic et al., 2011).

The lack of studies that investigated therapist and therapy-related factors may

reflect a general assumption that client-related factors predominantly predict alliance.

Consistent with Ackerman and Hilsenroth’s (2002) review of samples in individual

psychotherapy, client-rated therapist qualities such as perceived genuineness, empathy and

trustworthiness were significantly associated with better client-rated alliance. These

characteristics may be particularly important for clients with psychosis who experience

suspiciousness or paranoia. The finding that therapists’ confidence was not significantly

associated with alliance is encouraging as it points to therapists’ confidence (often

associated with less clinical experience) as not integral to the development of the

therapeutic relationship (Johnson & Caldwell, 2011). Poorer attendance to therapy, lower

suitability and less homework compliance was associated with poorer therapist-rated

alliance which highlights the importance of therapists assessing readiness to engage,

discussing expectations of therapy, facilitating good engagement and ensuring collaboration

on therapy tasks. The latter reflects an emphasis on the ‘active ingredients’ of therapy which

may be more specific to particular therapeutic models such as CBT.

Limitations

Client-rated alliance measures used in therapy only capture the experiences of those

who are engaged in therapy, thus excluding those who have disengaged. Higher

disengagement is linked to poorer therapeutic alliance (Lecomte et al., 2008), suggesting

that alliance results may be positively skewed. A review of psychotherapy studies reported

that clients predominantly use the top 20-30% of available ratings scale points of alliance

measures, including the WAI, WAI-SF and CALPAS (Tyron, Blackwell, & Hammel, 2008).

While this could genuinely reflect how alliance is perceived, it may also suggest difficulties in

discriminating between lower ratings points and/or increased social desirability bias.

Despite clients and therapists using a restricted range of scores on alliance measures,

19

significant relationships between alliance and outcome were detected. Studies using

observer-rated alliance measures negate this problem, but rely on behavioural and/or

verbal indications of alliance quality and omit subjective experience. Another limitation of

this body of literature relates to high levels of missing alliance data common across alliance

studies resulting in biased interpretation of findings and reduced power. Many studies did

not report on the handling of missing data and had small sample sizes.

Limitations associated with the review itself include the difficulty in determining the

competency criteria included in the NICE (2014) definition of psychological therapy. While

most studies (n=18) used standardised therapies with specialist training as prerequisites,

others included trainee therapists and some did not provide this information. Studies were

only included if they were published in peer-reviewed journals, thus increasing the risk of

publication bias. Similarly studies were only from a restricted range of countries, in part

reflecting the English language inclusion criterion.

Rating the quality of studies required adaptations to the quality assessment tool

(EPHPP). This was partly because the included studies often imposed additional inclusion

criteria to secondary data (e.g. participants completed at least three therapeutic alliance

measures), which increased sample selection bias. Although the EPHPP can be applied to a

wide range of studies, it is best suited to rating Randomised Controlled Trials. Due to these

challenges, quality assessment ratings should be interpreted cautiously.

Finally, this review included four studies that had samples with SMI, as well as

studies with samples that were purely diagnosed with non-affective psychosis. This

heterogeneity may limit the generalisability of findings to psychosis. However, we had an

inclusion criterion that at least 60% of the sample had a diagnosis of non-affective psychosis

and arguably including samples with SMI may more accurately reflect clinical populations

within community or outpatient clinics.

Research and Clinical Implications

Establishing good quality alliance may prevent disengagement from services which is

a key issue for people with psychosis (O’Brien, Fahmy, & Singh, 2009). There is preliminary

evidence to suggest that there is a role of alliance in predicting outcomes in psychological

therapy, especially in recent-onset samples. This suggests that early onset is a crucial time to

engage clients in a good therapeutic relationship to promote better recovery. There was

20

preliminary evidence for poorer alliance predicting poorer overall psychotic symptoms.

Understanding and avoiding non-helpful therapeutic relationships is integral to preventing

potentially poorer therapeutic outcomes (Ljungberg, Denhov, & Topor, 2015). There was

initial evidence for therapeutic alliance predicting other outcomes, such as general

functioning, rehospitalisation and self-esteem. Understanding the impact of therapeutic

relationships on these outcomes has implications for clients’ wellbeing and service usage.

Overall, many client-related factors did not consistently predict therapeutic alliance,

which encouragingly suggests that clients with differing symptoms and characteristics can

engage in psychological therapy. Some client-related factors, such as negative symptoms,

were associated more with poorer therapist-rated alliance which highlights the need for

these client-related factors to be addressed in therapist training and supervision. Findings

that therapist-related factors predict alliance suggest we should also pay attention to

therapist characteristics that are amenable to change. Therapist qualities, such as

trustworthiness, perceived genuineness, and an empathic approach are particularly

important and can be enhanced during training by using specific feedback during

supervision (Harmon et al., 2007). Client suitability for and attendance to therapy were also

associated with therapist-rated alliance. This means therapists should carefully consider and

assess appropriateness and timing of therapy, support clients to prepare and anticipate

therapy requirements and enhance engagement, particularly with early psychosis clients

where disengagement from treatment is high (Meyers et al., 2014). Other therapist

variables, such as therapists’ attachment styles, might influence alliance development

(Degnan, Seymour-Hyde, Harris, & Berry, 2015) and further exploration of the importance of

this variable in the context of psychological interventions for psychosis samples is

warranted.

Surprisingly, no studies investigated the impact of stigma on the development of

alliance, or indeed how a good alliance may reduce feelings of self-stigma. Given evidence

that stigma has been related to decreased intentions to seek psychological therapy (Vogel et

al., 2007) and compliance with therapeutic interventions (Fung et al., 2007; Wade, Post,

Cornish, Vogel, & Tucker, 2011), it seems important that researchers investigate the

relationships between stigma and alliance. These studies should include measures of public

stigma, self-stigma and stigmatizing attitudes of therapists. Interventions to reduce stigma

21

might include public health campaigns to address public and therapist stigma and

normalising information or providing psychosocial explanations for symptoms to address

self-stigma (Morrison, Burke, Murphy, Pyle, Bowe, Varese et al., 2016; Schreiber & Hartrick,

2002).

The review found heterogeneity across studies in their design and variables

investigated, preventing a meta-analysis of effect sizes. Future research should consider

uniformity across measures of psychological outcomes and alliance, particularly as alliance

has undergone several conceptual changes making it difficult to compare across different

measures of alliance (Elvins & Green, 2008). Different perspectives of alliance were

associated with different factors, suggesting the need to assess alliance from client,

therapist and observer perspectives.

Goal agreement is considered an essential component of alliance, which may be

particularly important for clients with psychosis and their therapists as they may have

different views regarding illness beliefs and treatment goals (Hasson-Ohayon, Kravetz, &

Lysaker, 2016). Therefore, pan-theoretical measures of alliance that encompasses goal

agreement, such as the Working Alliance Inventory-Short Form (Tracey & Kokotovic, 1989)

are recommended for future research.

Using longitudinal rather than cross-sectional studies assessing alliance over time

offer the opportunity to determine what stage of therapy alliance formation is crucial and

whether it predicts outcomes over the course of therapy. This review highlighted varied and

mixed findings regarding factors predicting alliance at different time points. Therapist-

related factors are under-researched (Nissen-Lie, Havik, Høglend, Rønnestad, & Monsen et

al., 2014), but this review suggests they are important for client-rated alliance and should be

included in future alliance research. Future studies must be large enough to have adequate

power to detect effects and would benefit from using advance statistical procedures, like

SEM, as used in Goldsmith et al. (2015), to better understand the potential causal

relationship between alliance and outcome. In doing so, studies will provide greater

certainty about what factors are most important to alliance. Finally, evidence of associations

between alliance and symptoms comes predominantly from early psychosis samples. There

22

is a need for well-designed studies to investigate whether these findings generalise to

samples with longer histories of psychosis

Conclusion

This is the first review to summarise studies investigating alliance in psychological

therapy for people with psychosis. It makes an important contribution to the literature by

establishing average alliance ratings and demonstrates that alliance can be established early

and maintained or improved over the course of therapy. There is some evidence to suggest

that better client and therapist-rated alliance predicts improved overall psychotic

symptomatic outcomes. Additionally, outcomes such as rehospitalisation, medication use

and self-esteem were associated with client or therapist-rated alliance.

There was some evidence for specific client-related factors such as insight and

negative symptoms, being uniquely associated with either client or therapist reports of

alliance. Therapist-related factors, such as perceived genuineness and empathy, were

associated client-rated alliance and therapy-related factors, such as suitability for therapy

and homework compliance were associated with therapist-rated alliance. These findings

suggest establishing a good quality alliance and building engagement might be crucial for

positive outcomes of therapy. Therapist training and supervision should focus on factors

that are amenable to change and associated with better therapeutic relationships, such as

empathetic responding, to foster good alliance throughout therapy. The findings from this

review suggest that future alliance research needs to include longitudinal studies with large

samples (to detect effects over time) using pan-theoretical well-validated measures of

alliance.

Declaration of Interests

None

Conflict of Interests

None

23

24

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Figure 1: Search Results (based on PRISMA flow diagram).

Identification

Screening

Eligibility

Included

Total citations(n= 6,980)

Duplicates removed(n= 2,394)

Total citations screened at title level(n= 4,586)

Total citations screened at abstract level(n= 160)

Rejected at title level(n= 4,426)

Rejected at abstract level(n=105)

Total rejected at full-text level(n=30)

No psychological therapy (n=24)Review paper (n=1)

No dyadic measure of alliance between client and therapist (n=3)

Not in English (n=1)Did not meet SMI criteria (n=1)

Total citations screened at full-text level(n= 55)

Total papers included(n= 26)

Identified through full-text reference list(n=1)

Table 1: Study characteristics and key findings

Sample Characteristics

Author, year; country

Design Setting N

Age; years (SD)

Gender;% male

% non-affective psychosis

Alliance Measure

Alliance Perspective

Key Measures

Key Findings

Cechnicki et al. 2000; Poland

Cross-sectional

Two therapies (SWT and LTIP) for people with schizophrenia; outpatient.

57 NR; range 21-56

44% 100% Polish version of Stark’s questionnaire

Client and therapist

PANSS; BPRS

‘Acceptance’ domain of client-rated alliance significantly associated with overall psychotic symptoms (r=-.59, p<.01).

Evans-Jones et al. 2009; UK

Cross-sectional

CBT; outpatient

24 39.5 (8.4)

70% 100% WAI Client and therapist

SENS; BCIS; CRF; RI; SAPS; PSYRATS;PAF; RTHC

No client variables related to therapist or client-related alliance. Therapist characteristics, including empathy (r=.64, p=.001), expertness (r=.714, p=.001), trustworthiness (r=.786, p=.001) significantly associated with client-rated alliance. Association between therapy factors (presentation of formulation) and client-rated alliance approached significance (t (22) = -2.23, p

= .036).

Johansen et al. 2013a; Norway

Cross-sectional

Data from Thematically Organised Psychosis study; inpatient and outpatient

42 27.5 (5.6)

66.7%

100% WAI-SF Client and therapist

PANSS; NEO-FFI; IPP-64C

Client-rated alliance was predicted by submissive/hostile interpersonal problems (β=-.39, p=.006), age (β=.27, p=.049) and excitative symptoms (β=-.25, p=.06). Therapist-rated alliance was associated with negative symptoms (Spearman’s ρ= -.338, p<.05), client agreeableness (r=317, p<.05), client neuroticism (r=-.325, p<.05) and client insight (r=-.338, p<.05), but only predicted by insight (β=-.36, p=.015) in multivariate analysis.

Johansen et al. 2013b; Norway

Cross-sectional

Data from Thematically Organised Psychosis study; inpatient and outpatient (drawn from same sample as Johansen et al. 2013a)

42 27.5 (5.6)

66.7%


PANSS; WAIS-III subscales; CVLT-II; WCST; CPT-II

Client-rated alliance was predicted by age (β=.36, p=.015) and excitative symptoms (β=-.28, p=.05) Therapist-rated alliance was significantly

associated with by insight (β=-.41, p=.008).

Kvrgic et al. 2013; Switzerland

Cross-sectional

ST; outpatient

156 44.5 (11.67)

65.4%

100% STAR-P Client RAS; Corrigan’s Self-stigma in Mental Illness Scale; BIS; PANSS; PAM; Modified Global Assessment of Functioning

Better client-rated alliance predicted by more recovery orientation (β=.39, p<.01), less self-stigma (β=-.15, p<.05) and more insight (β=0.161, p<0.05)

Davis & Lysaker, 2004; USA

Alliance baseline

Therapy arms (CBT or ST) of larger study investigating therapy on work outcomes for people with schizophrenia; outpatient (drawn from same sample as Davis et al. 2011)

24 47 100%


HVLT; WAIS-III subtests; WCST; CPT-II

Better client-rated alliance associated with poorer performance on verbal memory (r=-.49, p=.05). Better therapist-rated alliance associated with better performance on visual spatial reasoning (r=.50, p=.05).

Couture et al. 2006; USA

Alliance baseline

Therapy arms (CBT and psychoeducation) of RCT for people with chronic schizophrenia; outpatient.

30 40.87 (11.74)

57.7%

100% WAI Client and therapist

PANSS; SFS

Therapist-rated alliance associated by baseline measures of social functioning (r=.411, p=.041) and autistic preoccupation (r= -.490, p<.05) and activation (r=-.563, p<.008). Client-rated alliance not

predicted by any measures.

Wittorf et al. 2009; Germany

Alliance baseline

Therapy arms (CBT and ST) of RCT for people with persistent positive symptoms; outpatient (drawn from the same sample as Wittorf et al. 2010)

80

38.4 (9.1)

52.5%

100% BSQ, TSQ, PSQ


PANSS; SUMD

Higher client-rated alliance was predicted by more insight (r=-.233, p=0.038) into psychosis. Higher therapist-rated alliance was predicted by less positive (r=-.308, p=.006) and negative r= -0.253, p=.023) symptoms.

Barrowclough et al. 2010; UK

Alliance baseline

Therapy arms (MI and CBT) of RCT for people with psychosis and substance misuse; outpatient.

116 37.7 (9.8)

89% 100% WAI-SF Client and therapist

PANSS; GAF; CDSS; Readiness to Change Questionnaire; Drug Attitude Inventory

Therapist-rated alliance predicted by client’s living situation (β=.28, p=.004), depression (β=.23, p=.013), insight (β=-1.664, p=0.004) and attitude towards medication (r=.25, p=.004). Better therapist-rated alliance working with White clients (relative to Black clients; β=-7.312, p=.006). Client-rated alliance predicted by insight

(β=-1.664, p<.001).

Wittorf et al. 2010; Germany

Alliance baseline

Therapy arms (CBT and ST) of RCT for people with persistent positive symptoms; outpatient

67 37.78 (8.44)

52.2%

100% BSQ, TSQ, PSQ


PANSS; SUMD; GAF

Clients classified as ‘low’ alliance showed significantly less insight (z=-2.611, p=0.009) and scored higher positive symptoms compared to clients in ‘high’ alliance group. Therapist rated alliance showed that clients in ‘low’ alliance group scored higher negative symptoms compared to clients in ‘high’ alliance group (t (65) = 3.49, p=.039).

Lysaker et al. 2011; USA

Alliance baseline

Therapy arm (CBT) of RCT for people with schizophrenia spectrum disorders; outpatient

40 45.8 (8.99)


SUMD; PANSS; CTS-R; Marlowe-Crowne Social Desirability Scale

Higher client-rated alliance was significantly associated with lower levels of positive (r=-0.32, p<.05), negative (r=-0.36, p<.05) and better awareness of need for treatment (r= -0.44, p<.05). Higher therapist-rated alliance was

associated with lower levels of disorganised symptoms (r=-0.40, p<.05).

Mulligan et al. 2014; UK

Alliance baseline

Therapy arm (telephone CBT) of participant preference trial for people with psychosis; outpatient

22 36.7 (7.32)


PANSS; CDS; PSP; therapist information form; interview to determine preference for psychological treatment

Client-rated therapeutic significantly associated with depression scores (r=.472, p=.027) and strength of preference for treatment. Therapist-rated alliance was associated with perceived change (r=.39, p=.049) and number of therapy sessions missed (r=-.44, p=.025).

Jung et al. 2015 Germany

Alliance baseline

Therapy arm (CBT) of trial; outpatient

48 37.31 (12.84)

54% 100% HAQ; PSBS (self-generated scale)


Bonner Questionnaire for Therapy and Counselling; Questionnaire to Assess Relevant Therapy Conditions; GAF; PANSS

Client-rated alliance was positively associated with therapist characteristics such as perceived genuineness (r=.63, p<0.01) and perceived therapist competence (r=.41, p<.01). Client characteristics did not predict alliance.

Frank & Gunderson., 1990;

Alliance outcome

Therapy arms (EIO and RAS) of trial for

143 at baseline, 95 receivin

NR; Range 18-

NR 100% PSR Therapist

PSS; IMPS; MHSRS; CDAS;

Clients rated as having ‘good’

USA people with non-chronic schizophrenia; outpatient

g systematic follow-up.

35 WAIS; KAS; SATIQ

alliance in first 6 months of therapy significantly associated with better symptomatic outcomes (R=.50, p<.05); ‘Good’ alliance significantly associated with fewer hospitalisations (r=.18, p<.05) and were more likely to take their medication (r=.37, p<.01).

Svensson & Hansson, 1999a; Sweden

Alliance outcome

Part of process-outcome study (CT); inpatient

26 25 53% 69% PSR; items from Allen et al. 1985 scale


CFQ; SEQ Depth of session was significantly associated with client (r=.688, p<.001) and therapist-rated (r=.569, p<.01) alliance more during the early phases, whereas ‘smoothness’ of sessions was significantly associated with client (working r-.592, p<.01; discharge r=.587 p<.01) and therapist-rated (working r=.463, p<.05, discharge r=.459, p<.05) alliance in the working

and discharge phases.

Svensson & Hansson, 1999b; Sweden

Alliance outcome

Part of process-outcome study (CT); inpatient (drawn from the same sample as Svensson & Hansson, 1999a)

26 24.8 53.57%

67% PSR; items from Allen et al. 1985 scale


HSCL-90; symptom rating scale; quality of life interview; TC; GAF; pre-admission functioning

Client-rated alliance associated with general psychopathology (r=.84, p<.05). Social functioning associated with therapist-rated alliance (r=.51, p<.05). Therapist-rated alliance associated with social relationships (r=.51, p<.05). Non-significant associations between client-rated alliance and symptom change scores. Therapist-rated alliance significantly associated with general functioning change scores (r=.42, p<.05) but not symptom outcome.

Chadwick et al. 2003; UK

Alliance outcome

CBT for clients with drug-resistant distressing positive symptoms; outpatient

15 31.5 (NR)

53.8%

100% HAQ Client and therapist

HADS; semi-structured interview; Case formulation

Therapist-rated alliance significantly changed after presentation of case formulation (T=-2.12, p<.05); confirmed by

interviews. Non-significant differences in client-rated alliance when case formulation was presented (non-significant differences between times 2 and 3 and/or 2 and 4 when formulation was presented).

Dunn et al. 2006; UK

Alliance outcome

Effectiveness study (CBT); outpatient

29 session 3; 21 session 9

38 (11.7)

76% 100% CAPLAS Client and therapist

PANSS; Suitability for Cognitive Therapy measure; homework compliance measure

Lower client suitability for therapy (r=.47, p<.01) and lower insight (r=-.41, p<.05) at session 3 significantly predicted with lower alliance. Therapist-rated alliance significantly associated with level of homework compliance (r = 0.66, p < 0.001).

Lysaker et al. 2010; USA

Alliance outcome

Therapy arm (CBT) of RCT for people with schizophrenia spectrum disorders; outpatient (drawn from the same sample as Lysaker et al. 2011)

40 45.8 (8.99)


TAA; PANSS; CTS-R

Clients who had experienced sexual assault rated lower alliance than clients without sexual assault history (F(1,37) = 3.01, p=.09) after controlling for positive symptoms. No time differences (F(5,185) =1.63, p=.15)

or group differences (F(1,37) = 1.69, p=.20) in therapist-rated alliance between clients with or without sexual assault.

Davis et al. 2011; USA

Alliance outcome

Therapy arms (CBT or ST) of larger study investigating therapy on work outcomes for people with schizophrenia; outpatient

63 46.89 (8.10)

84% 100% WAI-SF Client IPII; MAS; PANSS; WAIS-III subscale; HVLT

Clients with ‘high’ or ‘intermediate’ mastery ability significantly associated with better client-rated alliance than client with ‘minimal’ mastery ability (overall group effect F=3.25, p=0.046). Results approached significance when controlling for neurocognitive factors (F=2.25, p=0.068).

Smerud & Rosenfarb, 2011; USA

Alliance outcome

Therapy arm of TSS study (BFM); inpatient and outpatient

28 30.2 (7.5)

57% 100% SOFTA Observer

BPRS; PRS; SAS-II; Days until first rescue medication and first rehospitalisation.

Therapist alliance significantly higher when working with Black compared to White families ( t(26) = 2.49, p<.05). When relative were observed having a good alliance, patients were less likely to show signs of relapse

and be hospitalised over 2 years. Better client alliance associated with less overall psychotic symptoms (r= -.55, p<.01).

Lecomte et al. 2012; Canada

Alliance outcome

Therapy arms (CBT group and group skills training) of RCT for early psychosis; outpatient (drawn from the same sample as Lecomte et al. 2014)

36 25 (4.8)

61.1%

75% WAI-SF; client and therapist


BPRS; SERS-SF; BIS; SPS; CASIG; measure of session participation

Client rated alliance predicted total symptoms (R²=.17, p<.05), positive and self-esteem (R²=.16, p<.05) post-therapy. Both client (R²=.25, p<.01) and therapist-rated (R²= .23, p<.01) alliance predicted attendance and participation (client R²=.27, p<.01; therapist R²=.72, p<.001). Baseline measure of capacity for attachment predicted clients’ overall alliance scores.

Jung et al. 2014. Germany

Alliance outcome

Therapy arm of trial (CBT); outpatient (drawn from the same sample as Jung et al. 2015)

56 33.4 (10.4)

55% 100% Three items from the STEP


PANSS; CDSS; SCL-90-R; GAF; RFS; task to assess Theory of Mind

Better client (Spearman’s ρ =-.32, p<.01) and therapist-rated alliance (Spearman’s ρ =-.32, p<.01) significantly associated

with lower negative symptoms. Client-rated depression significantly associated with depression (r=-.26, p<0.05). Social functioning was significantly associated with therapist-rated alliance r=.20, p<.05). General functioning was associated with client-rated alliance (r=.27, p<.05).

Lecomte et al. 2014; Canada

Alliance outcome

Group CBT for early psychosis; outpatient

66 26 (6)


QuickLL; The Cohesion Questionnaire; BPRS-E; SERS-SF; Choice of Outcome

Certain therapist-rated alliance subscales predicted fewer psychotic symptoms post-therapy (β=-.18, p<.01). At 6 month follow-up fewer symptoms were predicted by different subscales of therapist-rated alliance (β=-.22, p<.01).

Berry et al. 2015; UK

Alliance outcome

Therapy arms (MI and CBT) of RCT for people with psychosis and substance

164 baseline; 135 post-therapy;129 at 12 month

NR NR 100% WAI-SF Client and therapist

PAM; PANSS; GAF; substance use measures; end of therapy

Therapist and client-rated alliance did not predict symptomatic outcome

misuse; outpatient (drawn from same sample as Barrowclough et al. 2010).

follow-up

forms post-therapy or at 12-month follow-up (p<.05).

Goldsmith et al. 2015, UK

Alliance outcome

Therapy arms (CBT and SC) of RCT; inpatient and outpatient

207 (in therapy arms)

NR; Range 21-35

NR 100% CALPAS Client PANSS; years of education

Improving the alliance improves symptomatic outcome. With a good alliance, attending more sessions cases a significantly better outcome (Causal estimands: -2.66, p<.001). Poorer alliance was considered actively detrimental (causal estimands: 7.74, p=.007).

Table 2: Quality Assessment Ratings

Author Selection Bias

Confounders

Data collection methods

Withdrawal and dropouts

Analyses

Global Rating

Barrowclough et al. 2010 M S S M S S

Berry et al. 2015 M S S M M S

Cechnicki et al. 2000 W W M N/A W W

Chadwick et al. 2003 W W M M S W

Couture et al. 2006 M S S W M M

Davis et al. 2011 M S S M M S

Davis & Lysaker 2004 W W S W M W

Dunn et al. 2006 M W S M M M

Evans-Jones et al. 2009 W M S N/A M M

Frank & Gunderson, 1990 M S S M S S

Goldsmith et al. 2015 S S S W S M

Johansen et al. 2013a M W S N/A M M

Johansen et al. 2013b M M S N/A M S

Jung et al. 2015 W W S M M W

Jung et al. 2014 M M S M S S

Kvrgic et al. 2013 W M S N/A M M

Lecomte et al. 2014 W M S W M W

Lecomte et al. 2012 M S S W M M

Lysaker et al. 2011 M S S W M M

Lysaker et al. 2010 M S S W M M

Mulligan et al. 2014 W M S S S M

Smerud & Rosenfarb, 2011 M M S W M M

Svensson & Hansson, 1999a M W S M M M

Svensson & Hansson, 1999b M M S S M M

Wittorf et al. 2010 W S W M M W

Wittorf et al. 2009 W S W S M W

Note: W, weak; M, moderate; S, strong; N/A, not applicable. Each domain was rated either ‘weak’, ‘moderate’ or ‘strong’. Papers were assigned an overall rating of ‘strong’ (no ‘weak’ domain ratings), ‘moderate’ (one ‘weak’ domain rating) or ‘weak’ (more than one ‘weak’ domain rating).

Table 1: Effect size for alliance and outcome

Study Alliance Alliance measured

Symptomatic outcome Outcome measured

Correlation Other relevant statistic

Other outcomes

Outcome measured

Correlation (r)

Other relevant statistic

Berry et al. 2015

Client (WAI-SF) Session 4 PANSS total Post-therapy -.18 General functioning (GAF)

Post-therapy -.13

Berry et al. 2015

Client (WAI-SF) Session 4 PANSS total 12 month follow-up

-.13 General functioning (GAF)

12 month follow-up

β=2.96

Berry et al. 2015

Therapist (WAI-SF) Session 4 PANSS total Post-therapy .059 General functioning (GAF)

Post-therapy .16

Berry et al. 2015

Therapist (WAI-SF) Session 4 PANSS total 12 month follow-up

.16 General functioning (GAF)

12 month follow-up

-.04

Dunn et al. 2006

Client (CALPAS) Session 3 Change in PANSS positive symptoms

Post-therapy -.20

Frank & Gunderson, 1990

Therapist (PSR) Six months Global Psychopathology (check)

Post-therapy .50* Rehospitalisation

24 month study period

.18*


Therapist (PSR) Six months Social functioning


.27*


Therapist (PSR) Six months Medication usage


.37**

Goldsmith et al. 2015

Client (CALPAS) Session 4 PANSS total 18 month follow-up

Causal estimate (effect of sessions at best alliance) 2.91**

Goldsmith et al. 2015

Client (CALPAS) Session 4 PANSS total 18 month follow-up

Causal estimate (effect of sessions at worse alliance) 7.74*

Jung et al. 2014

Client (STEP) Average initial alliance

PANSS positive symptoms

Post-therapy -.41 General functioning (GAF)

Post-therapy .025

Jung et al. 2014

Therapist (STEP) Average initial alliance

PANSS positive symptoms

Post-therapy -.35 General functioning (GAF)

Post-therapy -.02

Jung et al. 2014

Client (STEP) Average initial alliance

PANSS negative symptoms

Post-therapy -.49 Social functioning (RFS)

Post-therapy -.14

Jung et al. 2014

Therapist (STEP) Average initial alliance

PANSS negative symptoms

Post-therapy .11 Social functioning (RFS)

Post-therapy .09

Lecomte et al. 2014

Therapist (bond; WAI-SF)

Post-therapy BRPS total Post-therapy -.18**

Lecomte et al. 2014

Therapist (Task; WAI-SF)

Post-therapy BRPS total Six month follow-up

-.33**

Lecomte et al. 2012

Client (WAI-SF) Overall ratings BPRS total Post-therapy -.39* Self-esteem (SERS)

Post-therapy .41*

Lecomte et al. 2012

Client and therapist (WAI-SF)

Overall ratings BPRS positive and negative symptoms

Post-therapy NS

Smeurd & Rosenfarb, 2011

Relatives (SOFTA; Observer-rated

Approx. session 6 Time until rehospitalisation

24 month period

Wald’s x²(1)= 4.85*

Smeurd & Rosenfarb, 2011

Relatives (SOFTA; Observer-rated

Approx. session 6 Time until use of emergency medication

24 month period

Wald’s x² (1) = 6.52**

Svensson & Hansson, 1999b

Client & Therapist (PSR)

Initial Residual change in SCL-90-R score

Post-therapy NS General functioning

Post therapy .56*

WAI-SF, Working Alliance Inventory-short version; PANSS, Positive and Negative Symptom Scale; GAF, General Assessment of Functioning Scale; CALPAS, California Psychotherapy Alliance Scale; BRPS, Brief Psychotic

Symptom Rating Scale; SERS, Self-esteem Rating Scale; STEP, Short Inventory for Individual Psychotherapy and Counseling; RFS, Role Functioning Scale; PSR, Psychotherapy Status Report; SOFTA, Scale of Assess the

Therapeutic Relationship; NS, non-significant (cases where statistics was not reported).

*p<.05; **p<.01

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