‘Someone on my level’: A Meta-Ethnographic Review of Therapeutic Relationships in Cognitive Behavioural Therapy for Psychosis

Abstract

Objectives: Cognitive Behavioural Therapy for Psychosis (CBTp) demonstrates variable and at times mild to moderate effect sizes; thus, its therapeutic processes are important to explore. Establishing a secure therapeutic relationship is one such key process where barriers may exist, including those related to psychotic symptoms and associated stigma. This review synthesizes the available qualitative research pertaining to the experience of the therapeutic relationship from the perspective of those experiencing psychosis. Methods: A systematic review was undertaken using PRISMA guidelines. Search terms included variants of ‘psychosis’, ‘therapy’ and ‘qualitative’. PsycInfo, CINAHL, EmBase, MedLine and Web of Science were searched, and reference lists were hand-scanned. Yardley's quality appraisal tool was utilized and Noblit and Hare's seven-stage process for conducting a meta-ethnographic review. A line-of-argument synthesis is presented. Results: Fourteen papers were identified using inclusion and exclusion criteria. Twelve papers were deemed to have satisfactory quality. The line-of-argument synthesis used attachment theory to propose four semi-distinct stages to establishing a therapeutic relationship: beginning; safety, hope and trust; the practicalities of therapy; and branching out. Findings suggest that the therapist's persona and use of CBTp techniques such as collaboration and shared agency over the process were important in establishing for the patient a sense of self as normal, equal and worthwhile. Conclusions: Attachment security may be an important strand of CBTp and warrants further research and clinical investigation as a process and an outcome. Future research can benefit from increased transparency regarding researcher positionality as a potential source of bias.