‘Someone on my level’: A Meta‐Ethnographic Review of Therapeutic Relationships in Cognitive Behavioural Therapy for Psychosis

Abstract

Objectives Cognitive Behavioural Therapy for Psychosis (CBTp) demonstrates variable and at times mild to moderate effect sizes; thus, its therapeutic processes are important to explore. Establishing a secure therapeutic relationship is one such key process where barriers may exist, including those related to psychotic symptoms and associated stigma. This review synthesizes the available qualitative research pertaining to the experience of the therapeutic relationship from the perspective of those experiencing psychosis. Methods A systematic review was undertaken using PRISMA guidelines. Search terms included variants of ‘psychosis’, ‘therapy’ and ‘qualitative’. PsycInfo, CINAHL, EmBase, MedLine and Web of Science were searched, and reference lists were hand‐scanned. Yardley's quality appraisal tool was utilized and Noblit and Hare's seven‐stage process for conducting a meta‐ethnographic review. A line‐of‐argument synthesis is presented. Results Fourteen papers were identified using inclusion and exclusion criteria. Twelve papers were deemed to have satisfactory quality. The line‐of‐argument synthesis used attachment theory to propose four semi‐distinct stages to establishing a therapeutic relationship: beginning; safety, hope and trust; the practicalities of therapy; and branching out. Findings suggest that the therapist's persona and use of CBTp techniques such as collaboration and shared agency over the process were important in establishing for the patient a sense of self as normal, equal and worthwhile. Conclusions Attachment security may be an important strand of CBTp and warrants further research and clinical investigation as a process and an outcome. Future research can benefit from increased transparency regarding researcher positionality as a potential source of bias.

A life more ordinary: A peer research method qualitative study of the Feeling Safe Programme for persecutory delusions

“…It may have also humanised the therapist, rather than them just being seen as a health professional. The importance of a therapist who is emotionally invested and interested is consistent with the findings of previous reviews of qualitative studies of CBTp (Pipkin et al, 2021 ; Wood et al, 2015 ). In a meta‐ethnographic review, participants described the use of collaboration and shared agency as promoting a sense of self‐efficacy and levelling power in the therapeutic relationship (Pipkin et al, 2021 ).…”

“…The importance of a therapist who is emotionally invested and interested is consistent with the findings of previous reviews of qualitative studies of CBTp (Pipkin et al, 2021 ; Wood et al, 2015 ). In a meta‐ethnographic review, participants described the use of collaboration and shared agency as promoting a sense of self‐efficacy and levelling power in the therapeutic relationship (Pipkin et al, 2021 ). In Feeling Safe, joint decisions were made about which tasks to do, and the order in which to do them, and there was flexibility within the intervention to focus on what mattered to the individual.…”

Restoring Trust for People With Psychosis Through Psychotherapy

“…First, therapists should consider the simultaneous importance and pitfalls of therapist warmth, given that many patients with psychosis are mistrustful and fearful of closeness and attachment (Weijers et al, 2020). Research studies have found that therapist warmth and caring are factors that can promote trust and closeness (Laugharne et al, 2012; Pipkin et al, 2021). However, it has long been observed that warmth can sometimes exacerbate mistrust.…”

“…Although trust is known to be a crucial ingredient for the therapeutic relationship with people experiencing psychosis (Bjornestad et al, 2018; Laugharne et al, 2012; Pipkin et al, 2021), less is known about the stance the therapist should take to facilitate a trusting relationship. Multiple therapies have proven to be effective for treating psychosis (Ridenour et al, 2019a), but little has been written explicitly about how to foster trust within the context of the therapeutic relationship.…”

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

“…Positive symptoms, particularly paranoia, may also limit the establishment of a collaborative approach (Lawlor et al., 2015). Interestingly, both qualitative and quantitative research papers on therapeutic alliance in psychotherapeutic settings have shown the important role of attachment styles in SSD (Berry et al., 2015; Pipkin et al., 2021).…”