A recent study by researchers at The University of Manchester and the University of Liverpool showed that the patient-therapist relationship was the most important issue—more important even than which therapy was used—in predicting therapeutic outcomes in psychosis patients.
There tends to be a misconception that the therapeutic relationship is not as central in cognitive behavioral therapy as in some other therapeutic orientations. But the integrative, CBT-based approach for treating psychosis developed by Nicola Wright, Douglas Turkington, and colleagues is in-line with the findings of the study cited above; their approach highlights the importance of a therapeutic relationship that is characterized by warmth, empathy, caring, genuineness, positive regard, and active involvement of the client.
The therapeutic goals in working with psychosis are typically reducing distress, enhancing understanding and acceptance, and increasing quality of life so clients can be freer to focus on valued goals and directions. Client goals are pursued by collaboratively identifying and constructing values and valued life goals. The pursuit of meaningful goals inherently involves clients’ acceptance of their lived experience and symptoms, as well as clinicians’ working with them to help them to be open to experiencing symptoms as they pursue their valued goals. Given that clients who have lived experience of psychosis have often experienced invalidating responses by others or stigma associated with their symptoms or diagnosis, it is important that you welcome and explicitly support the discussion of distressing thoughts and unusual experiences in an understanding and empathetic manner. A stance of gentle curiosity and respect is a corrective experience in and of itself, as this stance is implicitly normalizing, destigmatizing, and validating.
As clinicians, the importance of exploring our thoughts, beliefs, and attitudes toward mental health issues and our clients has often been underemphasized. ACT emphasizes not only the values of the client but also the values of the clinician. As such, our understanding of the lived experience of others and our values are critical in the therapeutic work that we do.
At times in the therapeutic relationship or over the course of therapy sessions, you may be incorporated into your client’s thoughts, voices, or delusional beliefs or system. Voices may comment on therapy or on your intentions, abilities, or personal qualities. Your clinical judgment is important here; it is possible to express explicitly at the beginning of therapy the importance of transparency and bidirectional feedback in the therapeutic relationship. As with any cognitive behavioral therapy work, feedback (both positive and constructive or negative) should be requested at the beginning and end of the session, as well as periodically during each session and across multiple sessions.
Clearly, it is a sophisticated and clinically individualized dance we do to be present with clients in a way that creates a safe environment for the therapy experience. Of course, we as clinicians cannot purport to be the experts on our clients’ experiences, but we can try to do a delicate and graceful dance in exploring and seeking to understand distressing experiences, even as we intertwine that dance with judicious psychoeducation.
Given the often-fluctuating nature of psychoses, any or all of the above issues can be dynamic; they can change and evolve through the course of therapy. It is important for you and your clients to be aware of the tendency for psychotic symptoms to be exacerbated during times of stress and experiences of vulnerability. Again, it is important to problem-solve in advance what might help clients, based on coping skills they’ve developed as well as previous experience. Soliciting input from clients about what you can do to help eases anticipatory concerns and enhances their experience of you as client centered, understanding, and empowering.
Another issue that may come up in the therapy that impacts therapeutic rapport is active voices during the session that are distracting or demeaning to clients or you. Again, proactively agreeing on the best way to deal with this possibility can enhance client efficacy and engagement. For example, an agreed-upon hand gesture by your client to slow the pace, discontinue the session, or explore the experience of the voices in session can be extremely helpful. Your acknowledgment and understanding of the difficulty in focusing and engaging at these times is beneficial.
As in any type of therapy, symptoms such as paranoia or voices may actually increase initially or at different times during the therapy process. Therefore, it is important to indicate to your clients proactively that symptoms (and distressing affect) can increase at times in therapy. Together you can then collaboratively problem-solve how an increase in symptoms can be dealt with, thereby reducing premature termination or concerns regarding the benefits of therapy. In addition, work done at the beginning of therapy on enhancement and development of coping skills and emotion regulation strategies can be emphasized and reinforced by the clinician.
Strategies such as a stop hand sign or “panic button” are respectful and empowering. Through these types of strategies, your clients have control over the pace at which assessment and therapy are conducted, the ability to take a break or disengage at any time, and the agency to reengage when ready. This client-driven approach not only applies to the frequency, length, and content of the sessions but also to how much clients share and at what pace. The experience in therapy of having a sense of control in the session speaks to the issues of “power” and “control” in the therapeutic relationship and implicitly speaks to the issue of power and control in client relationships with others and with voices. Your clients can apply the experience of being able to set limits, give direction, and be empowered in the therapeutic relationship to their relationships outside of therapy and with their voices.
“The therapeutic relationship is the thread we use to tie together the therapeutic tapestry of empathy, understanding, meaning, and connection,” says Wright. “Without this secure, caring, and empowering therapeutic base, progress toward valued goals is more limited, and the therapeutic impact of feeling heard and understood in a strengths-oriented manner is diminished.”
For more information about Wright, Turkington, and colleagues’ integrative approach to treating psychosis, check out their book, Treating Psychosis.