The therapeutic relationship in the treatment of severe mental illness: A review of methods and findings

Aims: To review the methods and findings from studies of the therapeutic relationship (TR) in the treatment of severe mental illness. Method: A literature search was conducted to identify all studies that used an operationalised measurement of the TR in the treatment of severe mental illness. Results: Fifteen scales - the majority of which were developed for psychotherapy - and the expressed emotion index have been used. Most scales have acceptable internal, inter-rater and test-retest reliability. As none of the scales has been used in more than five studies, no single scale is widely established in psychiatric research. A more positive relationship consistently predicts a better short- and long-term outcome. It appears that a large global factor accounts for the greatest proportion of the variance in the therapeutic relationship. Conclusions: The therapeutic relationship is a reliable predictor of patient outcome in mainstream psychiatric care. Valid assessments may need to take account of different, specific aspects of the relationship in psychiatric settings such as greater heterogeneity of treatment components and goals, increased variability of setting and the statutory responsibility of the clinician. Methodological progress may require conceptual work to ensure valid assessments of this central element of treatment.