‘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) demonstratesvariable and at times mild to moderate effect sizes; thus, its therapeutic processesare important to explore. Establishing a secure therapeutic relationship is one suchkey process where barriers may exist, including those related to psychotic symptomsand associated stigma. This review synthesizes the available qualitative researchpertaining to the experience of the therapeutic relationship from the perspective ofthose experiencing psychosis.Methods: A systematic review was undertaken using PRISMA guidelines. Searchterms 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-argumentsynthesis is presented.Results: Fourteen papers were identified using inclusion and exclusion criteria.Twelve papers were deemed to have satisfactory quality. The line-of-argumentsynthesis used attachment theory to propose four semi-distinct stages to establishinga therapeutic relationship: beginning; safety, hope and trust; the practicalities of ther-apy; and branching out. Findings suggest that the therapist's persona and use ofCBTp techniques such as collaboration and shared agency over the process wereimportant in establishing for the patient a sense of self as normal, equal andworthwhile.Conclusions: Attachment security may be an important strand of CBTp and warrantsfurther research and clinical investigation as a process and an outcome. Futureresearch can benefit from increased transparency regarding researcher positionalityas a potential source of bias.