Therapeutic relationships between mental health service users with psychotic disorders and their clinicians: a critical interpretive synthesis

Individuals with schizophrenia and other psychotic disorders remain among the most marginalised in our communities. There has been increasing criticism of the current state of clinical treatment of such individuals as technological developments in medication provide little, if any, improvement in the lived experiences of mental health service users (SUs). In this context, there is a call for a re-orientation away from medication in the treatment of 'common factors' such as the therapeutic relationship (TR). The TR is well researched in psychotherapy settings; however, the components of beneficial TRs in the treatment of individuals with psychotic disorders are poorly understood. A critical interpretive synthesis was conducted to determine the current understanding of the TRs between individuals with psychotic disorders and their clinicians in community case management settings. A search of MEDLINE, PsycINFO, EMBASE and Social Policy and Practice Databases and grey literature between 1990 and 2011 identified 13 papers to be included in the synthesis. Three key components of beneficial TRs were identified: mutual trust, demonstration of mutual respect and shared decision-making. However, the synthesis revealed that such interactions are difficult to achieve in routine practice. The main barrier identified was a lack of clarity regarding the goal of interactions, which in turn created stakeholders with poorly defined roles and possibly oppositional needs. In this context of ambiguity, clinicians appear to de-emphasise interactions characteristic of beneficial TRs, and prioritise interactions that protect the SU and themselves in the case of a relapse. Structural symbolic interactionism is used to interpret these findings. For interactions characteristic of TRs to be prioritised in the treatment of individuals with psychotic disorders, a clearer evidence base for the importance of the TR and a clear statement of purpose of treatment are required.