In people with non-affective psychosis, suicidal experiences such as urges, plans, or attempts are amplified, resulting in suicide being the leading cause of death in this group of people (Bolton et al., 2007; Ko et al., 2018; Zaheer et al., 2018), with the most severe experiences of psychosis being linked with more severe suicidal ideation and behaviours (Bornheimer et al., 2021; Bornheimer, 2016; Yates et al., 2021).
In a meta-analytic review including those with non-affective psychosis, it was found that cognitive-based therapies reduced suicidal thoughts, plans and attempts, compared to treatment as usual. This has led to the introduction of Cognitive Behavioural Suicide Prevention therapy for people with psychosis (CBSPp), which addresses both suicidal experiences and psychosis symptoms. There is a growing evidence base that supports psychotherapies that are tailored for the treatment of suicidal ideation and non-affective psychosis as it has been found to be feasible to deliver (Tarrier et al., 2014; Haddock et al., 2019) and effective in improving suicidal ideation compared to treatment as usual.
Two therapeutic factors that are crucial for people with non-affective psychosis and suicidal experiences are the ‘therapeutic alliance’ and the ‘dose’ of therapy. The former refers to the client-therapist bond and is related to the collaboration regarding goals and tasks within the therapy (Bordin, 1979). For people with psychosis, a stronger perceived therapeutic alliance has been linked to less severe symptoms; and for people with suicidal experiences, a stronger therapeutic alliance during therapy has been consistently linked to a greater reduction in suicidal thoughts (Gysin-Maillart et al., 2017; Turner, 2000) and fewer suicide attempts (Bedics et al., 2015).
‘Dose’ of therapy refers to components such as the number, duration, quality and/or content of therapy sessions, which have been found to be linked to the strength of the therapeutic alliance. Interestingly, even at a higher number of sessions, if the clients’ perceived therapeutic alliance was poor, it was found that symptoms of psychosis increased.
It is encouraging that research is focussing on the issues of therapeutic alliance in relation to either symptoms of psychosis or suicidal experiences, however, there is a gap in the literature where the ‘dose of therapy’ is concerned, particularly in relation to people who experience non-affective psychosis. The aim of the current study was to investigate the relationship between the therapeutic alliance in CBSPp and suicide ideation, plans and attempts in people with non-affective psychosis (Huggett et al, 2021).
It was hypothesised that:
- Client suicidal experiences (ideation, plans and attempts) prior to therapy will be related to the therapeutic alliance;
- The therapeutic alliance will be negatively associated with suicidal experiences post-therapy (2a), whilst controlling for suicidal ideation, depression, and hopelessness at baseline (2b);
- The negative relationship between the therapeutic alliance and suicidal experiences post-therapy will be amplified by the dose of therapy.
Participants: A total of 64 participants were included; ICD-10 diagnoses within the sample comprised of schizophrenia (n=50), schizoaffective disorders (n=9) persistent delusional disorders, unspecified non-organic psychosis, or transient psychotic disorders (n=5).
Intervention: CBSPp therapy places emphasis on developing a therapeutic relationship with clients. Therapists aim to create a collaborative and trusting environment that enables clients to talk about their suicidal experiences, which are explored in the context of their experiences of psychosis, current problems, and life events. Participants attended 5-24 CBSPp therapy sessions, averaging approximately 900 minutes of therapy. Individual sessions lasted an average of 51.4 mins.
Measures: The following measures were used on this study: Working Alliance Inventory—Short Revised (WAI-SR), Adult Suicide Ideation Questionnaire (ASIQ), Suicide Plans and Attempts Self Report Measure, Beck Hopelessness Scale (BHS), Calgary Depression Scale for Schizophrenia (CDSS), Dose of Therapy (quantified as the total number of minutes of therapy summed for each participant).
Hypothesis 1 – Is there a relationship between suicidal experiences prior to starting therapy and the therapeutic alliance (Session 4)?
As there were no significant correlations between suicidal ideation at baseline and either the client or therapists’ perceptions of the therapeutic alliance, the severity of clients’ suicidal ideation prior to starting therapy does not appear to be related to the quality of the therapeutic alliance as perceived by either clients or therapists.
Hypothesis 2 – Does the therapeutic alliance predict suicidal experiences measured post-therapy?
There was a significant negative correlation between the client rating of the therapeutic alliance and the severity of suicidal ideation at the end of the therapy sessions.
Only 33 out of 64 participants reported making suicide plans during the delivery of the study and there were no significant differences in client ratings of the initial therapeutic alliance between those who had made plans versus those who had not. Similarly, there were no significant differences in therapist ratings of the initial therapeutic alliance between those who had made plans vs those who had not.
There were no significant differences in client or therapist ratings of the therapeutic alliance between clients who had made at least one suicide attempt vs those who had not.
Hypothesis 3 – Does the number of minutes of CBSPp therapy session attendance amplify the relationship between the therapeutic alliance and suicidal experiences post-therapy?
There was a significant main effect of client therapeutic alliance on the severity of suicidal ideation. When this interaction was investigated further, results indicated that when the total amount of psychotherapy was shorter, or at the mean value, there was a significant negative relationship between client therapeutic alliance and severity of suicidal ideation at the end of therapy. Whereas when the total amount of psychotherapy was higher than average, there was no relationship between client therapeutic alliance and severity of suicidal ideation at the end of therapy.
The authors concluded:
A stronger, client viewed, therapeutic alliance was predictive of lower severity in suicidal ideation, which appeared to be moderated by total number of minutes spent in therapy.
Overall, suicidal experiences in the 6 months prior to starting therapy were not related to the therapeutic alliance, as rated by both client and therapists; a higher therapeutic alliance score rated early on in the therapeutic process predicted less severe suicidal thoughts at the end of therapy; a higher therapeutic alliance score is associated with less severe suicidal ideation at the end of therapy. And finally, statistical models suggest that a higher score on the therapeutic alliance, rated by clients, predicted less severe suicidal ideation, but only when the total minutes of therapy was lower or at the mean total length of therapy sessions (i.e. 923.7 mins).
Strengths and limitations
Five key limitations were identified by the authors themselves:
- Firstly, the sample size means the study was likely underpowered, and as such the study should be replicated in the future.
- Secondly, the design and statistics implemented do not provide causality or direction of causality.
- Third, the therapy was delivered by 8 therapists which could introduce some variability in therapeutic alliance development.
- Next, there was a lack of diversity in both the client and therapist samples, making findings hard to generalize.
- And lastly, there was missing client and therapist WAI data, which could have introduced some biases in the findings.
Moreover, extending the scope of the research would be useful. For example, capturing longitudinal associations would tell us more about whether higher therapeutic relationship predicts suicidal outcomes (or not). Similarly, if we are looking to explore the topic in-depth, qualitative research would be helpful to determine how people define therapeutic rapport within the delivery of CBSPp, as for some participants it may be difficult to quantify their experiences in a self-reported measure. Capturing specific therapist skills or factors within the relationship influencing suicidal experiences might be helpful in delivering this intervention within public healthcare settings. Despite the methodological limitations, the study still provides ground to reflect on the therapeutic rapport and its impact in the group of people with non-affective psychosis.
Implications for practice
The current study demonstrates that the principles identified can be applied to people with non-affective psychosis. More specifically therapists working with suicidal clients should place an emphasis on building and maintaining a stronger therapeutic alliance, as well as endeavour to understand what that means from the client’s perspective. Further, the study highlights how longitudinal studies should investigate the relationship between therapeutic alliance and suicidal experiences in order to provide evidence for, and direction of, causality.
Statement of interests
No interest to declare.
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