Theory of Mind, emotion recognition, delusions and the quality of the therapeutic relationship in patients with psychosis – a secondary analysis of a randomized-controlled therapy trial.

Abstract

Background: Cognitive models of psychosis postulate an important role of Theory of mind (ToM) in the formation and maintenance of delusions, but research on this plausible conjecture has gathered conflicting findings. In addition, it is still an open question whether problems in emotion recognition (ER) - an important precondition to ToM - are associated with delusions. We examined the association of problems in ToM and ER with different aspects of delusions in a large sample of patients with psychosis enrolled in a therapy trial. This also enabled us to explore the possible impact of ToM and ER on one part of patients’ social life: the quality of their therapeutic relationship.Methods: Patients with psychotic disorders and delusions and/or hallucinations (n=185) and healthy controls (n=48) completed a ToM picture sequencing task and an ER task. Subsequently, patients were enrolled in a randomized-controlled Cognitive Behavior Therapy (CBT) trial (ISRCTN29242879). Patients and therapists rated the quality of the therapeutic relationship during the first five sessions of therapy.Results: In comparison to controls, patients were impaired in both ToM and ER. Patients with deficits in ER experienced more severe delusional distress, whereas ToM problems were not related to delusions. In addition, deficits in ER predicted a less favorable therapeutic relationship and interactional problems viewed by the therapist. Impaired ER also moderated (increased) the negative influence of delusions on the therapeutic relationship and interactional difficulties viewed by the therapist. Conclusions: Cognitive models on the formation and maintenance of delusions should consider ER as a potential candidate that might be related to the formation and maintenance of delusional distress, whereas problems in ToM might not be directly related to delusions and secondary dimensions of delusions. In addition, problems in ER in patients with psychosis might have an impact on the quality of the therapeutic relationship and patients with problems in ER are more likely to be viewed as problematic by their therapists. Nevertheless, training ER might be a way to improve the quality of the therapeutic relationship and potentially the effectiveness of CBT or other interventions for patients with psychosis.

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

“…Some studies show associations between insecure attachment styles and worse positive symptoms (Bucci et al, 2017). Emotion regulation difficulties, one of the consequences of insecure attachment styles, have been linked to poorer quality therapeutic relationships in people experiencing psychosis (Mehl et al, 2020). Prior research therefore suggests that attachment style may play a role in both the development of a secure therapeutic relationship and overall symptom severity, which may in turn influence therapy engagement and overall outcome (Berry et al, 2019).…”

Social cognition training improves recognition of distinct facial emotions and decreases misattribution errors in healthy individuals

“…Deficient recognition of angry and neutral faces has been tied to impaired social functioning, difficulty in establishing a therapeutic relationship with a clinician, and illness severity (1,3,17,(51)(52)(53). Therefore, this training program's potential to improve recognition of angry and neutral faces could significantly impact the lives of individuals with Parkinson's disease and individuals who are at risk for schizophrenia, as they both struggle with recognizing angry and neutral faces (4,(10)(11)(12)(17)(18)(19)(20)(21).…”