Systematic review investigating the association between therapeutic alliance and treatment outcomes when working with individuals with Post-Traumatic Stress Disorder; and a grounded theory study of how clinicians understand Psychosis
Introduction. The therapeutic alliance has been shown to play a key role in improving outcomes when working with children and adults with mental health difficulties. This may be particularly the case for those with a trauma history and subsequent Post-Traumatic Stress Disorder and/or experiences of psychosis. Both of which can be characterised by marked inter-personal difficulties that can impact upon outcome and prognosis. Therefore, this thesis aimed to systematically review literature investigating the impact of therapeutic alliance on trauma-related outcomes when working with children and adults with Post-Traumatic Stress Disorder. It also aimed to construct an explanatory theory of how NHS clinicians, working within both child and adult services, are able to make sense of the difficulties experienced by individuals with psychosis. Methods. Two studies were conducted to address these aims. Study one searched electronic databases to find and systematically review literature on therapeutic alliance when working with children and adults with Post-Traumatic Stress Disorder. A quality assessment of all included studies was conducted, followed by a narrative synthesis. The second study used qualitative methodology in the form of social-constructivist grounded theory. Semi-structured interviews were conducted with fourteen NHS clinicians. An iterative process of data collection and analysis, and theoretical sampling was conducted until theoretical saturation was achieved. Results. The systematic review included nine studies. Evidence was found of a positive association between therapeutic alliance and Post-Traumatic Stress Disorder outcomes. There was not enough evidence to show an association between therapeutic alliance and other mental-health outcomes. Results from the second study indicate that staff can find it difficult to understand psychosis due to specific aspects of psychosis undermining attempts of both staff and service users to form therapeutic relationships. An interactional model details how the ‘not knowing’ can be maintained and reinforced, further impacting the ability of the staff member to accurately make sense of the individuals’ difficulties. Conclusions. Although there appears to be an association between therapeutic alliance and therapeutic outcomes when working with people with Post-Traumatic Stress Disorder, limited research and heterogeneity in the way in which alliance was measured limited the generalisability of the results. Clinical implications and recommendations for future research are given. Attachment/mentalization-based service approaches are recommended to enhance the ability of clinicians, when working with people with psychosis, to form therapeutic relationships from which accurate and meaningful understandings can be created.