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

Abstract

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.

Introduction

Therapeutic alliance is defined as the affective and collaborative bond existing between a therapist and his patient (Svensson and Hansson, 1999). It has also been referred to as the therapeutic bond, working alliance or helping alliance. The theoretical definitions of the alliance have three elements in common: (1) the collaborative nature of relationship, (2) the affective bond between patient and therapist, and (3) the patient's and therapist's ability to agree on treatment goals and tasks (Bordin, 1979). The quality of the therapeutic alliance is a key predictor of adherence (Lecomte et al., 2008) and was also found to be associated with higher psychosocial functioning, reduced symptom severity and better quality of life (Frank and Gunderson, 1990, Gehrs and Goering, 1994, Svensson and Hansson, 1999). Because of the consistent association between therapeutic alliance and service engagement it is important to identify variables that predict a good therapeutic alliance (Gibbons et al., 2003). But building a strong therapeutic alliance in schizophrenia may be a challenging endeavor due to the nature of the clinical presentation of the illness (Frank and Gunderson, 1990, Evans-Jones et al., 2009). For example, patients may distrust or hold delusional beliefs about their therapist, and therapists may find it difficult to empathize with patients' unusual experience (Evans-Jones et al., 2009). Given these difficulties it is important to understand factors which improve or undermine building therapeutic alliance.

Because agreement between therapist and patient on treatment goals was found to be important for the development of a strong therapeutic alliance (Martin et al., 2000, Webb et al., 2011) variables undermining goal orientation of the patient may be important to address. Besides impeding effects of depression (Webb et al., 2011) and negative symptoms (Lysaker et al., 2011) on goal orientation of the patients also self-stigma was identified to undermine goal orientation in therapy as well (Corrigan et al., 2009). In contrast, motivational aspects like a strong recovery orientation were identified to facilitate goal orientation in therapy (Waldheter et al., 2008, Corrigan et al., 2004a).

Self-stigmatizing means applying negative stereotypes of mental illness to oneself (Corrigan and Watson, 2002) and it is followed by feelings of shame and by coping strategies like secrecy and withdrawal (Rüsch et al., 2006, Vauth et al., 2007). Further, self-stigma undermines help seeking behavior (Vogel et al., 2006), adherence to psychosocial treatment (Livingston and Boyd, 2010), more generally social relationships (Yanos et al., 2008), and is a risk factor for psychiatric hospitalization (Rüsch et al., 2009). Because continuing feelings of unworthiness and incompetency were found to be associated with self-stigma as well as a demoralization in engagement in therapy (the ‘why try’-effect; Corrigan et al., 2009), all these consequences underline that self-stigma may undermine engagement in therapy (Livingston and Boyd, 2010) and the building of a strong therapeutic alliance in schizophrenia, respectively.

Recovery as a motivational process (for a review see Cavelti et al., 2011) may promote engagement in therapeutic alliance as it is supposed to facilitate the patients' striving for the attainment of individual life goals by successful therapy. Recovery orientation refers to regaining a self-determined and meaningful life in spite of mental illness. It might be achieved by finding hope that important life goals can be attained, re-establishing a positive identity, developing meaning in life, taking control of one's life through individual responsibility, spirituality, empowerment, and having supporting relationships (Chiu et al., 2009).

Variables already found to be associated with quality of therapeutic alliance in individuals with schizophrenia and other forms of severe mental illness (SMI) were patient-related factors including older age (Draine and Solomon, 1996), avoidant attachment style (Dozier et al., 2001, Berry et al., 2008, Kvrgic et al., 2011) and more prior service contact (Klinkenberg et al., 1998) as well as illness-related factors like less severe symptoms (Frank and Gunderson, 1990, McCabe and Priebe, 2003, Lysaker et al., 2011) or higher insight into illness (Johnson et al., 2008, Wittorf et al., 2009, Barrowclough et al., 2010). Actually, insight in patients with schizophrenia is the only variable which consistently was associated with patient-rated therapeutic alliance in most studies (Dunn et al., 2006, Wittorf et al., 2009, Barrowclough et al., 2010, Lysaker et al., 2011). Insight is a multidimensional construct and it is defined as the awareness of having a mental disorder, of specific symptoms, and their attribution to the disorder, the awareness of social consequences and of need for treatment (Mintz et al., 2003). Low insight was also found to be linked to difficulties to form sustaining bonds with others (Lysaker et al., 1998, Francis and Penn, 2001). Low levels of insight are a risk factor for nonadherence to treatment, which is associated with poor clinical outcome (Lincoln et al., 2007), but on the other hand, high levels of insight have been linked to depression, hopelessness, suicidal tendency as well as to lowered self-esteem (Drake et al., 2004, Hasson-Ohayon et al., 2009, Restifo et al., 2009). Self-stigma as a moderating variable can be decisive whether more insight leads to better or worse outcome. On the other hand, self-stigma can act as a mediator between insight and outcomes (Lysaker et al., 2007, Staring et al., 2009, Cavelti et al., 2012). Finally, insight is suggested to be positively associated with recovery orientation (Mohamed et al., 2009).

Based on these studies, we expected lower self-stigma and higher recovery orientation to uniquely contribute to the variance of better quality of therapeutic alliance above and beyond of possible confounding variables such as younger age, clinical symptoms, avoidant attachment style, and duration of treatment by the current therapist. Second, because of the consistent findings of an association of insight and therapeutic alliance, we hypothesize that insight contributes additional explanatory power to the model of therapeutic alliance, independently from recovery orientation and self-stigma.