Associated factors of the quality of therapeutic alliance in people with severe mental illness: A systematic review

Introduction Given the high rates of disengagement of psychological and/or psychopharmacological treatment in individuals with severe mental illness (SMI), building a strong therapeutic alliance (TA) in treatment is crucial. Despite the awareness of a favorable role of the TA in mental health care for people with SMI, there is a paucity of research that contributes to the formulation of concrete guidelines for establishing a strong TA. Objectives This review aims to systematically synthesize existing literature of associated factors of the TA across six domains: client, mental health professionals (MHPs), clinical, social, care, and other. These include the views of clients with SMI, MHP, and independent raters of the TA. Methods Parallel literature searches in PsycInfo, Medline, and PubMed between 2000-2022 identified 2699 possible articles, of which n=53 met inclusion criteria. Results Associated factors of better client-rated TA were: high insight, secure attachment, higher outcome expectancy at baseline, specific personality traits, less internalized stigma, more therapists’ empathy and frequent use of supportive techniques by MHP. MHP-rated and/or independent observer-rated TA was significantly related to: more insight, sex of client (female), MHP without anxious attachment, and less severe symptomatology of client. Conclusions Clinical symptom severity only affected TA when rated by MHP, but not when rated by clients. Attachment style affects the TA bidirectionally: clients’ secure attachment to the MHPs may help modify maladaptive attachment patterns, and anxious/insecure attachment style from either client or MHP affects the TA negatively. Furthermore, having an early positive click with the client builds the foundation for a later stable and supportive relationship, making the client more likely to continue perceiving the alliance as positively as treatment progresses. It is therefore crucial to provide a warm and supporting environment from the start of treatment, where clients have the opportunity to overcome perceived (self-)stigma and develop a positive mindset towards outcome expectations. Focusing on supportive techniques like providing feedback or shared agenda setting instead on the clients clinical symptomatology solely might result in a more favorable perception of the TA. Notably, current TA measurements assume a one-on-one relationship between clients and MHP, while nowadays multiple MHPs are involved. We recommend re-evaluating the assessment of TA within SMI care. Disclosure of Interest None Declared