Key Points for an Effective Therapeutic Relationship in Psychosis Treatment

The therapeutic relationship has repeatedly shown to be a determining factor in positive outcomes in psychosis treatment. But how specifically do clinicians ensure that this alliance is the best it can be? When it comes to therapeutic engagement, there are a number of important areas to consider: Building trust, developing agency, control and empowerment, enhancing strengths and skills, honoring the meaning and function of clients’ experiences, addressing potential therapeutic barriers, and finally enhancing an empowering understanding of the past and how it relates to the present.

Therapeutic engagement and alliance building is not static. It continues throughout the therapy process. In their book, Treating Psychosis: A Clinician’s Guide to Integrating Acceptance and Commitment Therapy, Compassion-Focused Therapy, and Mindfulness Approaches within the Cognitive Behavioral Therapy Tradition, authors Nicola Wright, Douglas Turkington, and colleagues present the following ways to build and sustain an effective alliance throughout treatment.

Build trust.

Safety, trust, compassion, and empathy are paramount. This may be one of the first times clients have been able to share their experience while experiencing another person’s understanding and validation. Start with safer material first.

Develop agency…

Put your clients in the driver’s seat with respect to pace, speed, frequency, venue, and depth of exploration. Enhance self-efficacy and empowerment in your clients by giving them control over appropriate areas of the therapy.

…but keep a controlled pace.

Never go too fast. The experience of safety in the therapeutic relationship, including understanding and a sense of the valuing of your clients’ lived experience, is critical. A client may take multiple sessions, months, or even years to share about certain experiences.

Empower the client.

Respect your clients’ right to not share details and aspects that they do not feel comfortable or safe sharing at this time. Try comments and questions like:

• I’m so glad you let me know.

• This therapy is for you and we want to go at a pace that feels right for you.

• What would need to be different for you to share more?

• Perhaps we can come back to this later in the therapy.

Enhance client strengths and skills.

Inform your client that symptoms may get worse at the very start of therapy and at other times during the therapy. Work on grounding and other emotion regulation strategies that can be used both during the therapy session and/or between sessions. Take a strengths-focused, normalizing, and value-driven recovery approach that engenders motivation and hope. Develop coping and emotion regulation skills as a foundation for assessment and therapeutic work; build on these key skills and integrate them throughout therapy. Work on self-valuing and self-compassion (as well as trust) can have a powerful impact on the distress, content, and frequency of symptoms. A challenging stance is neither a clinically useful nor advisable approach, as it can create distance between you and your client and contribute to greater “entrenchment” on the part of your client.

Honor the meaning and function of client experiences.

What is the purpose of your client’s experiences and symptoms? Be curious about your clients’ experience and the meaning of the experiences and symptoms to your clients. For example, voices may serve a compensatory role. Hearing voices can make a client who struggles with low self-esteem feel special. Voices can also serve as company to stave off loneliness. The experience of having a psychotic illness is frequently very isolating and marginalizing. Voices may be experienced as friends or entertainment. Clients may also withdraw to avoid symptoms. Value and goal work can be an effective way to address gaps and potential compensatory functions of symptoms.

Address potential therapeutic barriers.

Be alert for instances when you, as a clinician, are incorporated into beliefs, delusions, and voices. Also be alert for potential commentary by the voices about the therapy or you as a clinician. Be aware of the possibility that voices may threaten clients who discuss them. Address these possibilities in a proactive, transparent, and collaborative manner prior to starting assessment and therapy, thereby developing an agreed-upon action plan should these issues occur. Be watchful for signs of symptoms such as voices distracting clients in session, which may impact client concentration and understanding.

Enhance understanding of the past and how it relates to the present.

Highlight coping strategies or strengths that clients have used at times of difficulty in the past. Validate what your clients have been through. Emphasize client courage and resiliency—both in the past and currently. Reinforce that your clients were doing what they could at the time. Normalize by indicating that your clients’ responses were understandable given their previous experiences or the situation at the time. Be alert to and highlight client strengths, coping strategies, and circumstances that are different now.

For more about the therapeutic relationship in psychosis treatment, check out Treating Psychosis.