The Effect of Working Alliance on Adherence and Outcome in Cognitive Remediation Therapy

Institute of Psychiatry, Kings College London, London, England.
The Journal of nervous and mental disease (Impact Factor: 1.69). 07/2012; 200(7):614-9. DOI: 10.1097/NMD.0b013e31825bfc31
Source: PubMed


Cognitive remediation therapy (CRT) for schizophrenia has been effective in improving cognitive and global functioning outcomes. It is now important to determine what factors maximize benefit. The quality of relationship--or working alliance--between clients and therapists may be one such factor that improves outcome. To investigate this, 49 individuals with schizophrenia were recruited into a naturalistic study of the impact of CRT on work and structured activity outcomes. Participant's cognitive skills, severity of symptoms, and social skills were assessed at baseline. Both client and therapist working alliance ratings were gathered early in therapy. After controlling for depression, clients who rated the alliance more favorably stayed in therapy longer and were more likely to improve on their main target complaint but notably not on working memory performance or self-esteem. Therapist's ratings of the alliance were not associated with memory outcome. These findings indicate that working alliance is important for client satisfaction with therapy.

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Available from: Til Wykes, Mar 10, 2015
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    • "More generally, future research should investigate the importance of self-esteem as applied to cognitive rehabilitation treatments so that therapy programmes can limit self-esteem reduction in the context of awareness improvement. Evidence suggests that treatment effects are also influenced, to a significant extent, by therapists and it is likely that the extent of change in self-esteem resulting from improved metacognition may be associated with a therapist's experience (Medalia & Richardson, 2005; Huddy et al. 2012). "
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    ABSTRACT: Background People with a diagnosis of schizophrenia have limited metacognitive awareness of their symptoms. This is also evident for cognitive difficulties when neuropsychological assessments and self-reports are compared. Unlike for delusions and hallucinations, little attention has been given to factors that may influence the mismatch between objective and subjectively reported cognitive problems. Symptom severity, and also self-esteem and social functioning, can have an impact on cognitive problem perception and help to explain the gap between objective and subjective cognitive assessments in psychosis. Method One-hundred participants with a diagnosis of schizophrenia were recruited and assessed with a comprehensive neuropsychological battery, a measure of awareness of cognitive problems and measures of psychotic symptoms, social and behavioural functioning and self-esteem. Regression was used to investigate the influence of symptoms, social functioning and self-esteem, and patients with different levels of cognitive problem awareness were contrasted. Results Simple correlation analysis replicated the lack of association between objective cognitive measures and metacognitive awareness of cognitive problems. However, the results of the regression analyses highlight that self-esteem and negative symptoms predict metacognitive awareness. When significant predictors were controlled, individuals with better awareness had more impaired working memory but higher IQ. Conclusions Poor self-esteem and high negative symptoms are negatively associated with metacognitive awareness in people with schizophrenia. Interventions that aim to improve cognition should consider that cognitive problem reporting in people with schizophrenia correlates poorly with objective measures and is biased not only by symptoms but also by self-esteem. Future studies should explore the causal pathways using longitudinal designs.
    Full-text · Article · Jun 2013 · Psychological Medicine
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    • "Results from studies investigating patients’ and therapists’ agreement about the quality of the therapeutic alliance have been mixed, where some report a significant association between their ratings [21,22,24,25] and others do not [14,17,26]. Some studies however indicate that patients give higher ratings than the professional regarding the level of alliance [17,21,22,26,27] while others report no significant difference between patient and therapist scores [23]. "
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    ABSTRACT: Background The therapeutic alliance is related to better course and outcome of treatment in schizophrenia. This study explores predictors and characteristics of the therapeutic alliance in recent-onset schizophrenia spectrum disorders including the agreement between patient and therapist alliance ratings. Methods Forty-two patients were assessed with demographic, neurocognitive, and clinical measures including the Positive and Negative Syndrome Scale (PANSS). The therapeutic alliance was measured with the Working Alliance Inventory - Short Form (WAI-S). Results Patient WAI-S total scores were predicted by age and PANSS excitative symptoms. Therapist WAI-S total scores were predicted by PANSS insight. Patient and therapist WAI-S total scores were moderately associated. Neurocognition was not associated with working alliance. Conclusion Working alliance is associated with specific demographic and symptom characteristics in patients with recent-onset schizophrenia spectrum disorders. There is moderate agreement between patients and therapists on the total quality of their working alliance. Findings highlight aspects that may increase therapists’ specificity in the use of alliance-enhancing strategies.
    Full-text · Article · May 2013 · Annals of General Psychiatry
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    ABSTRACT: Research has consistently documented cognitive deficits across different domains in people with a diagnosis of schizophrenia. Cognitive remediation therapy (CRT) programs based on a number of psychological and learning principles were developed with the aim of improving cognitive and social cognitive deficits. Evidence across at least 40 studies shows that CRT can produce small to medium effects on cognition with this estimate unaffected by studies' methodological rigour. Domains where positive outcomes should be expected after CRT include memory, planning, reasoning, problem solving, attention and social cognition but also general functioning. Therapeutic mechanisms have rarely been examined but increasing evidence points at the role of brain plasticity and learning dependent reorganization as potential biological mechanisms responsible for change. Recent evidence has also begun to reveal mediators and moderators of successful treatment and these include age, symptoms at intake, premorbid executive skills but also relationship with the therapist. Given that there is now a large amount of evidence of success (and relatively few studies showing failure) increasing research efforts are considering pragmatic issues that may affect CRT service delivery such as cost effectiveness, therapy delivery format and patient acceptability. Despite evidence of efficacy there is still more research required to determine the best methods of delivery. We consider that the future research priorities should be: clarifying the translational pathway of CRT from basic science to service implementation, understand the contribution of non-specific factors such as the role of therapist to outcomes, identify which factors contribute to maximize the response to therapy and how therapy can be adapted to different clients presentations.
    Full-text · Article · Sep 2012
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