Perceived Therapist Characteristics and the Therapeutic Alliance in CBT for Psychosis: Evidence for a Special Role of Genuineness

Purpose The therapeutic alliance plays a key role in enabling symptom improvement in CBT for psychosis. However, so far it remains unclear which therapist characteristics are particularly relevant for building alliance in CBT for psychosis compared to CBT for other diagnoses. Methods Participants with psychotic disorders (PSY, n = 102) and other mental disorders (CG, n = 64) received disorder specific variants of CBT. We used structural equation models (SEM) with multiple-group comparisons to assess differences between PSY and CG in associations between patients’ perceptions of therapists’ empathy, genuineness, positive regard, competence, and convincingness at baseline and the therapeutic alliance after 5 therapy sessions. In SEM-based mediation analyses, we tested whether latent symptom change was predicted by perceived therapist characteristics via the therapeutic alliance and whether these associations differed between PSY and CG. Results Multiple-group SEM revealed partial invariance across diagnostic groups, with perceived genuineness showing a stronger association with therapeutic alliance in PSY than in CG. Perceived positive regard was positively associated with the therapeutic alliance across groups. There were no direct, indirect, or total effects of perceived therapist characteristics via the therapeutic alliance on symptom change. Conclusions Perceived therapist genuineness seems to be particularly important for a strong alliance in CBT for psychosis and could therefore be addressed in CBT training and supervision.