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.

Reading time approx. 11 minutes Published: February 26, 2024 Publication type:

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.
Included studies	Population, Intervention, Control	Outcome and Results
CBT = Cognitive Behaviour Therapy; CI = Confidence interval; TA = Therapeutic Alliance
Bourke et al, 2021 [1] Systematic review and meta-analysis of therapeutic alliance, engagement, and outcome in psychological therapies for psychosis
24 articles 13 articles included in meta-analyses Setting: United Kingdom: 10 studies USA: 6 studies Canada: 3 studies Australia: 2 studies Ireland, 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

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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.

Search strategies

Medline via OvidSP 12 Jan 2024
Search terms		Items found
/ = 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; adjn = Adjacent. Proximity operator retrieving adjacent words, adj3 retrieves records with search terms within two terms from each other.; * or $ = Truncation
Population:
1.&	“Diagnosis, Dual (Psychiatry)”/	3739
2.	Mental Disorders/	179 383
3.	“Bipolar and related disorders”/ or Depressive Disorder, Major/ or Depressive Disorder, Trestment-Resistant/ or Borderline Personality Disorder/	48 773
4.	exp Substance-Related Disorders/	314 219
5.	Vulnerable Populations/	12 927
6.	Financial Stress/	1165
7.	Housing Instability/ or Ill-Housed Persons/	10 086
8.	or / 1-7	542 459
9.	(((complex or severe) adj4 (psychiatric or mental)) or dual diagnosis).ab,bt,kf,ti.	22 108
10.	(psychosis or psychotic or schizophreni* or schizoaffective or paraphreni* or bipolar or (manic adj2 depress) or ((major or severe) adj2 depressi) or borderline).ab,bt,kf,ti.	358 359
11.	(homeless* or ((unstable or insecur* or instability) adj2 (housing or financial)) or vulnerab* or poverty).ab,bt,kf,ti.	241 946
12.	or / 9-11	593 264
13.	8 or 12	1 039 666
Intervention:
14.	Community mental health services/	19 076
15.	Social work, Psychiatric/	2699
16.	House Calls/	4209
17.	(outreach or visiting or "home visit" or contact or "door to door" or (assertive adj3 (community or treatment or care))).ab,bt,kf,ti.	540 353
18.	or / 14-17	561 550
Study types: systematic reviews and meta-analysis
19.	((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/))
Combined sets:
20.	13 and 18 and 19	1334
Final result
21.		1334

Scopus via scopus.com 12 Jan 2024
Search terms		Items found
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
Population:
1.	TITLE-ABS-KEY(((complex OR severe) W/3 (psychiatric OR mental)) OR "dual diagnosis")	31 233
2.	TITLE-ABS-KEY ( psychosis OR psychotic OR schizophreni* OR schizoaffective OR paraphreni* OR bipolar OR ( manic W/1 depress* ) OR ( ( major OR severe ) W/1 depressi* ) OR borderline )	663 749
3.	TITLE-ABS-KEY(homeless* OR ((unstable OR insecur* OR instability) W/1 (housing OR financial)) OR vulnerab* OR poverty)	725 227
4.	1 OR 2 OR 3	1 392 197
Intervention:
5.	TITLE-ABS-KEY ( outreach OR visiting OR "home visit" OR contact OR "door to door" OR “risk management” OR ( assertive W/2 ( community OR treatment OR care)) OR (check* W/1 (welfare OR wellness OR in)))	1 789 580
Study types: systematic reviews and meta-analysis
6.	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”))
Combined sets:
7.	4 AND 5 AND 6	1279
Final result
8.		1279

PSYCINFO via EBSCO 12 Jan 2024
Search terms		Items found
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
Population:
1.	TI ( (((complex OR severe) N3 (psychiatric OR mental)) OR "dual diagnosis" OR psychosis OR psychotic OR schizophreni* OR schizoaffective OR paraphreni* OR bipolar OR ( manic N1 depress* ) OR ( ( major OR severe ) N1 depressi* ) OR borderline OR homeless* OR ((unstable OR insecur* OR instability) N1 (housing OR financial)) OR vulnerab* OR poverty ) OR AB ( (((complex OR severe) N3 (psychiatric OR mental)) OR "dual diagnosis" OR psychosis OR psychotic OR schizophreni* OR schizoaffective OR paraphreni* OR bipolar OR ( manic N1 depress* ) OR ( ( major OR severe ) N1 depressi* ) OR borderline OR homeless* OR ((unstable OR insecur* OR instability) N1 (housing OR financial)) OR vulnerab* OR poverty ) OR SU ( (((complex OR severe) N3 (psychiatric OR mental)) OR "dual diagnosis" OR psychosis OR psychotic OR schizophreni* OR schizoaffective OR paraphreni* OR bipolar OR ( manic N1 depress* ) OR ( ( major OR severe ) N1 depressi* ) OR borderline OR homeless* OR ((unstable OR insecur* OR instability) N1 (housing OR financial)) OR vulnerab* OR poverty )	537 855
Intervention:
2.	TI ( outreach OR visit* OR contact* OR ”door to door” OR “risk management” OR (check* N1 (welfare OR wellness OR in)) OR ( assertive N2 ( community OR treatment ) ) ) OR SU ( outreach OR visit* OR contact* OR ”door to door” OR “risk management” OR (check* N1 (welfare OR wellness OR in)) OR ( assertive N2 ( community OR treatment ) ) ) OR AB ( outreach OR visit* OR contact* OR ”door to door” OR “risk management” OR (check* N1 (welfare OR wellness OR in)) OR ( assertive N2 ( community OR treatment ) ) )	158 281
Study types: systematic reviews and meta-analysis
3.;	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")
Combined sets:
4.;	1 AND 2 AND 3	480
Final result
5.		480

Page published February 26, 2024