Relationsship between staff that provide professional support and clients with complex psychiatric needs

A good and trusting relationship with the person who provides professional support can be a factor that affects how a client with complex psychiatric problems recovers and engages in treatment and support. When the support provided is in the form of therapy, this relationship is often called the therapeutic alliance.

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SBU Enquiry Service

Consists of structured literature searches to highlight studies that can address questions received by the SBU Enquiry Service from Swedish healthcare or social service providers. We assess the risk of bias in systematic reviews and when needed also quality and transferability of results in health economic studies. Relevant references are compiled by an SBU staff member, in consultation with an external expert when needed.

Question

What systematic reviews have been published regarding the relationsship between those that provide professional support for complex psychiatric needs and their clients.

Method

A systematic literature search was performed using the following databases: MedLine (Ovid), Scopus and PsycInfo.
Two authors independently assessed the abstracts of all identified studies.
Risk of bias in relevant systematic reviews was assessed using an assessment tool based on AMSTAR.

Identified literature

One relevant systematic reviews with moderate risk of bias were identified [1]. The results and conclusions are presented in Table 1. In fourteen relevant systematic reviews, the risk of bias was considered to be high, therefore the results and conclusions are not reported [2-15].

Table 1 Systematic reviews with low/moderate risk of bias.
CBT = Cognitive Behaviour Therapy; CI = Confidence interval; TA = Therapeutic Alliance
Included studies Population, Intervention, Control Outcome and Results
Bourke et al, 2021 [1] Systematic review and meta-analysis of therapeutic alliance, engagement, and outcome in psychological therapies for psychosis
24 articles13 articles included in meta-analyses Setting:United Kingdom: 10 studiesUSA: 6 studiesCanada: 3 studiesAustralia: 2 studiesIreland, Netherlands, Sweden: 1 study each Population:
Patients with affective or non-affective psychosis, or dual diagnosis of psychosis and substance use disorder (n=1656). Exposure:
Alliance in psychological therapies (CBT (different combinations and focus), skills training, cognitive remediation therapy, individual psychotherapy, behavioural family management or acceptance and commitment therapy).Alliance measure: Working Alliance Inventory (WAI), WAI short form, WAI group, Psychotherapy Status Report, California Psychotherapy Alliance Scale, Vanderbilt Therapeutic Alliance Scale, Agnew Relationship Measure, Working Alliance Inventory, System for Observing Family Therapy Alliances.		 Global psychiatric symptoms and Client-rated alliance
(5 studies)r=0.29 (95% CI, 0.13 to 0.45)

Global psychiatric symptoms and Therapist-rated alliance
(6 studies)r=0.24 (95% CI, 0.09 to 0.39)

Psychotic symptoms and Client-rated alliance
(5 studies)r=0.17 (95% CI, 0.04 to 0.30)

Psychotic symptoms and Therapist-rated alliance(3 studies)r=0.30 (95% CI, 0.14 to 0.46)

Engagement in therapy and Client-rated alliance
(5 studies)r=0.36 (95% CI, 0.13 to 0.60)

Engagement in therapy and Therapist-rated alliance
(4 studies)r=0.40 (95% CI, 0.12 to 0.68)
Authors' conclusion: “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.”

References

  1. Bourke E, Barker C, Fornells-Ambrojo M. Systematic review and meta-analysis of therapeutic alliance, engagement, and outcome in psychological therapies for psychosis. Psychol Psychother. 2021;94(3):822-53. Available from: https://doi.org/10.1111/papt.12330.
  2. Andrade-González N, Hernández-Gómez A, Álvarez-Sesmero S, Gutiérrez-Rojas L, Vieta E, Reinares M, Lahera G. The influence of the working alliance on the treatment and outcomes of patients with bipolar disorder: A systematic review. J Affective Disord. 2020;260:263-71. Available from: https://doi.org/10.1016/j.jad.2019.09.014.
  3. Browne J, Wright AC, Berry K, Mueser KT, Cather C, Penn DL, Kurtz MM. The alliance-outcome relationship in individual psychosocial treatment for schizophrenia and early psychosis: A meta-analysis. Schizophr Res. 2021;231:154-63. Available from: https://doi.org/10.1016/j.schres.2021.04.002.
  4. da Costa H, Martin B, Franck N. Determinants of Therapeutic Alliance With People With Psychotic Disorders: A Systematic Literature Review. J Nerv Ment Dis. 2020;208(4):329-39. Available from: https://doi.org/10.1097/NMD.0000000000001125.
  5. Elliott R, Bohart AC, Watson JC, Murphy D. Therapist empathy and client outcome: An updated meta-analysis. Psychotherapy (Chic). 2018;55(4):399-410. Available from: https://doi.org/10.1037/pst0000175.
  6. Ellis AE, Simiola V, Brown L, Courtois C, Cook JM. The role of evidence-based therapy relationships on treatment outcome for adults with trauma: A systematic review. J Trauma Dissociation. 2018;19(2):185-213. Available from: https://doi.org/10.1080/15299732.2017.1329771.
  7. Fahlgren MK, Berman ME, McCloskey MS. The role of therapeutic alliance in therapy for adults with problematic aggression and associated disorders. Clin Psychol Psychother. 2020;27(6):858-86. Available from: https://doi.org/10.1002/cpp.2475.
  8. Graves TA, Tabri N, Thompson-Brenner H, Franko DL, Eddy KT, Bourion-Bedes S, et al. A meta-analysis of the relation between therapeutic alliance and treatment outcome in eating disorders. Int J Eat Disord. 2017;50(4):323-40. Available from: https://doi.org/10.1002/eat.22672.
  9. Howard R, Berry K, Haddock G. Therapeutic alliance in psychological therapy for posttraumatic stress disorder: A systematic review and meta-analysis. Clin Psychol Psychother. 2022;29(2):373-99. Available from: https://doi.org/10.1002/cpp.2642.
  10. Marsh JC, Angell B, Andrews CM, Curry A. Client-Provider Relationship and Treatment Outcome: A Systematic Review of Substance Abuse, Child Welfare, and Mental Health Services Research. J Soc Social Work Res. 2012;3(4):233-67. Available from: https://doi.org/10.5243/jsswr.2012.15.
  11. Priebe S, Richardson M, Cooney M, Adedeji O, McCabe R. Does the therapeutic relationship predict outcomes of psychiatric treatment in patients with psychosis? A systematic review. Psychother Psychosom. 2011;80(2):70-7. Available from: https://doi.org/10.1159/000320976.
  12. Shattock L, Berry K, Degnan A, Edge D. Therapeutic alliance in psychological therapy for people with schizophrenia and related psychoses: A systematic review. Clin Psychol Psychother. 2018;25(1):e60-e85. Available from: https://doi.org/10.1002/cpp.2135.
  13. Thompson L, McCabe R. The effect of clinician-patient alliance and communication on treatment adherence in mental health care: a systematic review. BMC Psychiatry. 2012;12:87. Available from: https://doi.org/10.1186/1471-244X-12-87.
  14. Werz J, Voderholzer U, Tuschen-Caffier B. Alliance matters: but how much? A systematic review on therapeutic alliance and outcome in patients with anorexia nervosa and bulimia nervosa. Eat Weight Disord. 2022;27(4):1279-95. Available from: https://doi.org/10.1007/s40519-021-01281-7.
  15. Zaitsoff S, Pullmer R, Cyr M, Aime H. The role of the therapeutic alliance in eating disorder treatment outcomes: a systematic review. Eat Disord. 2015;23(2):99-114. Available from: https://doi.org/10.1080/10640266.2014.964623.
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Published: Report no: ut202402 Registration no: SBU 2023/1122
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Search strategies

Medline via OvidSP 30 October 23
/ = Term from the MeSH controlled vocabulary:.sh = Term from the MeSH controlled vocabulary;exp= Term from MeSH including terms found below this term in the MeSH hierarchy;;.ti,ab = Title or abstract;;.tw = Title or abstract;.kf = Keywords;.kw = Keywords, exact;.bt = Book title. NLM Bookshelf.;.pt = Publication type;.ja = Journal abbreviation;.af = All fields;adjn = Adjacent. Proximity operator retrieving adjacent words, adj3 retrieves records with search terms within two terms from each other.;* or $ = Truncation;“ “ = Citation Marks; searches for an exact phrase
  Search terms Items found
  Population
1. Mental Disorders/ 178 539
2. "feeding and eating disorders"/ or anorexia nervosa/ or binge-eating disorder/ or bulimia nervosa/ 34 174
3. exp "Schizophrenia Spectrum and Other Psychotic Disorders"/ 163 829
4. mood disorders/ or exp "bipolar and related disorders"/ or depressive disorder, major/ or depressive disorder, treatment-resistant/ 95 112
5. anxiety disorders/ or exp obsessive-compulsive disorder/ 57 362
6. exp Stress Disorders, Post-Traumatic/ 41 759
7. exp Autism Spectrum Disorder/ 43 170
8. exp Attention Deficit Disorder with Hyperactivity/ 35 066
9. exp Substance-Related Disorders/ 312 322
10. exp Personality Disorders/ 45 365
11. exp "Diagnosis, Dual (Psychiatry)"/ 3735
12. 1 or 2 or 3 or 4 or 5 or 6 or 7 or 7 or 9 or 10 or 11 887 538
13. eating adj3 disorder*.mp 35 964
14. (psychos* or psychoti* or Schizoaffective or Schizophren*).mp. 389 247
15. ((major or severe) adj2 depress*).mp. 78 196
16. (bipolar or (manic adj3 depress*) or Paraphreni*).mp. 93 054
17. (Obsessive-Compulsive or Anankastic or hoarding).mp. 26 631
18. (Post-Traumatic Stress Disorder* or Post Traumatic Stress Disorder* or PTSD or Posttraumatic stress disorder* or cPTSD).mp. 46 614
19. (autism or autistic*).mp 71 439
20. ((attention adj3 deficit) or adhd).mp. 52 401
21. ((substance or drug or alcohol or opioid or opiate or cocaine or amphetamine or methamphetamine) adj5 (abus* or dependen* or addiction* or disorder* or misuse)).mp. 292 370
22. ((personality adj3 (disorder* or avoidant or inadequate or narcissistic or borderline or compulsive or syndrome*)) or (emotionally unstable adj3 (personality or disorder* or syndrome*)) or EIPD).mp. 52 212
23. Dual Diagnos*.mp 2323
24. 13 or 14 or 15 or 16 or 17 or 18 or 19 or 20 or 21 or 22 or 23 986 685
25. 12 or 24 1 265 225
Intervention
26. exp Professional-Patient Relations/ 148 617
27. Case Management/ 10 658
28. Case Managers/ 287
29. (therapeutic adj3 alliance*).mp 3781
30. therapeutic relation*.mp. 4289
31. (Working adj3 alliance*).mp. 1363
32. Working relation*.mp. 2064
33. (collaborative adj3 alliance*).mp 156
34. collaborative relation*.mp. 1349
35. (helping adj3 alliance*).mp 161
36. helping relation*.mp. 312
37. rapport.mp. 10 112
38. client relation*.mp 610
39. (client adj3 alliance*).mp 217
40. patient relation*.mp 164 376
41. (patient adj3 alliance*).mp 657
42. case management relation*.mp. 17
43. (case management adj3 alliance*).mp. 7
44. case manager relation*.mp. 11
45. (case manager adj3 alliance*).mp 11
46. 26 or 27 or 28 or 29 or 30 or 31 or 32 or 33 or 34 or 35 or 36 or 37 or 38 or 39 or 40 or 41 or 42 or 43 or 44 or 45 194 395
Study types: systematic reviews and meta-analysis
47. ((Systematic Review/ or Meta-Analysis/ or Cochrane Database Syst Rev.ja. or ((systematic adj4 review) or "meta analys*" or metaanalys*).ti,bt,ab.) not (editorial/ or letter/ or case reports/)) 453 522
Combined sets:
48. 25 AND 46 23 544
Final result
49. 47 AND 48 440

 

Scopus via scopus.com 30 October 23
TITLE-ABS-KEY = Title, abstract or keywords (including indexed keywords and author keywords); ALL = All fields; W/n = Within. Proximity operator retrieving terms within n words from each other.; PRE/n = Precedes by. Proximity operator, the first term in the search must precede the second by n words.; LIMIT-TO (X) = Includes only results of specified type, e.g., publication type or time range.; DOCTYPE = Publication type; “re” = review; “le” = letter; “ed” = editorial; “ch” = book chapter; “cp” = conference proceedings; * = Truncation; “ “ = Citation Marks; searches for an exact phrase
Search terms Items found
Population
1.          TITLE-ABS-KEY ((eating W/3 disorder*) OR psychosis OR psychotic OR schizophreni* OR schizoaffective OR paraphreni* OR bipolar OR (manic W/1 depress*) OR ((major OR severe) W/1 depressi*) OR "obsessive compulsive" OR ptsd OR "post traumatic stress" OR "posttraumatic stress") 745 421
2.          TITLE-ABS-KEY ((substance* OR drug* OR alcohol OR opioid OR opiate OR cocaine OR amphetamine OR methamphetamine) W/3 (abus* OR dependen* OR addiction* OR disorder* OR misuse)) 412 383
3.          TITLE-ABS-KEY ((personality W/2 (disorder* OR avoidant OR inadequate OR narcissistic OR borderline OR compulsive OR syndrome)) OR ("emotionally unstable" W/2 (personality OR disorder* OR syndrome* )) OR (autism OR autistic* OR (attention W/2 deficit) OR adhd)) 263 001
4.          #1 OR #2 OR #3 1 302 286
Intervention
5.          TITLE-ABS-KEY (relation* W/1 (therapeutic OR working OR collaborative OR professional* OR helping OR client* OR patient* OR "case manage*" )) 267 422
6.          TITLE-ABS-KEY (alliance* W/3 (therapeutic OR working OR collaborative OR professional* OR helping OR client* OR patient* OR "case manage*")) 10 608
7.          TITLE-ABS-KEY (rapport OR "professional-patient") 61 913
8.          #5 OR #6 OR #7 297 259
Study types: systematic reviews and meta-analysis
9.          TITLE-ABS-KEY ( ( systematic  W/2  review )  OR  "meta analy*"  OR  metaanaly* ) AND (EXCLUDE (DOCTYPE, “le”) OR EXCLUDE (DOCTYPE, “ed”) OR EXCLUDE (DOCTYPE, “ch”) OR EXCLUDE (DOCTYPE, “cp”))   665 796
Combined sets:
10.       #4 AND #9 17 682
Final result
11.       #9 AND #10 464

 

PSYCINFO via EBSCO 01 November 23
TI = Title; AB = Abstract; SU = Keyword, exact or part (including all other fields for indexed and author keywords); DE = Exact keyword ; TX = All text; MR = Methodology; Nn = Near. Proximity operator retrieving terms within n words from each other.; * = Truncation; “ “ = Citation Marks; searches for an exact phrase
Search terms Items found
Population
1.          SU (eating N3 disorder*) OR SU (psychosis OR psychotic OR schizophreni* OR bipolar) OR SU (manic N1 depress*) OR SU ((major OR severe) N1 depressi*) OR SU ("obsessive-compulsive" OR ptsd OR "post-traumatic stress" OR "posttraumatic stress") OR SU ((personality N3 (disorder* OR avoidant OR inadequate OR narcissistic OR borderline OR compulsive OR syndrome*)) OR SU ("emotionally unstable" N3 (personality OR disorder* OR syndrome* )) OR SU ((substance* OR drug* OR alcohol OR opioid OR opiate OR cocaine OR amphetamine OR methamphetamine) N3 (abus* OR dependen* OR addiction* OR disorder* OR misuse)) 567 690
2.          TI (eating N3 disorder*) OR TI (psychosis OR psychotic OR schizophreni* OR bipolar) OR TI (manic N1 depress*) OR TI ((major OR severe) N1 depressi*) OR TI ("obsessive-compulsive" OR ptsd OR "post-traumatic stress" OR "posttraumatic stress") OR TI ((personality N3 (disorder* OR avoidant OR inadequate OR narcissistic OR borderline OR compulsive OR syndrome*)) OR TI ("emotionally unstable" N3 (personality OR disorder* OR syndrome* )) OR TI ((substance* OR drug* OR alcohol OR opioid OR opiate OR cocaine OR amphetamine OR methamphetamine) N3 (abus* OR dependen* OR addiction* OR disorder* OR misuse)) 247 660
3.          AB (eating N3 disorder*) OR AB (psychosis OR psychotic OR schizophreni* OR bipolar) OR AB (manic N1 depress*) OR AB ((major OR severe) N1 depressi*) OR AB ("obsessive-compulsive" OR ptsd OR "post-traumatic stress" OR "posttraumatic stress") OR AB ((personality N3 (disorder* OR aviodant OR inadequate OR narcissistic OR borderline OR compulsive OR syndrome*)) OR AB ("emotionally unstable" N3 (personality OR disorder* OR syndrome* )) OR AB ((substance* OR drug* OR alcohol OR opioid OR opiate OR cocaine OR amphetamine OR methamphetamine) N3 (abus* OR dependen* OR addiction* OR disorder* OR misuse)) 477 167
4.          1 OR 2 OR 3 674 619
Intervention
5.          SU (relation* N1 (therapeutic OR working OR collaborative OR professional* OR helping OR client* OR patient* OR "case manage*" )) OR SU (alliance* N3 (therapeutic OR working OR collaborative OR professional* OR helping OR client* OR patient* OR "case manage*")) OR SU (rapport OR "professional-patient") 46 012
6.          TI (relation* N1 (therapeutic OR working OR collaborative OR professional* OR helping OR client* OR patient* OR "case manage*" )) OR TI (alliance* N3 (therapeutic OR working OR collaborative OR professional* OR helping OR client* OR patient* OR "case manage*")) OR TI (rapport OR "professional-patient") 8 410
7.          AB (relation* N1 (therapeutic OR working OR collaborative OR professional* OR helping OR client* OR patient* OR "case manage*" )) OR AB (alliance* N3 (therapeutic OR working OR collaborative OR professional* OR helping OR client* OR patient* OR "case manage*")) OR AB (rapport OR "professional-patient") 47 712
8.          5 OR 6 OR 7 80 354
Study types: systematic reviews and meta-analysis
9.          TI((systematic n3 review) OR "meta analys*" OR metaanalys*) OR AB((systematic n3 review) OR "meta analys*" OR metaanalys*) OR SU((systematic n3 review) OR "meta analys*" OR metaanalys*) OR (MR "Systematic Review" OR MR "meta analysis") 95 413
Combined sets:
10. 4 AND 8 11 141
Final result
11. 9 AND 10 218
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