Negative Symptoms and Poor Insight as Predictors of the Similarity Between Client and Therapist Ratings of Therapeutic Alliance in Cognitive Behavior Therapy for Patients With Schizophrenia
Abstract
Recent studies have found that clients with schizophrenia rate therapeutic alliance more highly than therapists. Unclear is whether there are clinical characteristics which predict the degree of difference in client and therapist ratings. To explore this, we correlated client and therapist ratings of therapeutic alliance with baseline assessments of positive negative, and disorganized symptoms and awareness of need for treatment. Participants were 40 adults with schizophrenia enrolled in a 6-month program of cognitive behavior therapy. Results indicated that clients produced higher ratings of therapeutic alliance than therapists and that therapist and client general ratings were more disparate when clients had fewer negative symptoms and better insight. Higher overall client ratings of therapeutic alliance were linked to lower levels of positive, negative, and disorganized symptoms and better awareness of need for treatment. Higher overall therapist ratings were linked only to lower levels of disorganized symptoms among clients.
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Computerised delivery may be particularly beneficial in cases where paranoia hinders the development of trust in the therapist or reduces the therapeutic alliance.
“Moreover, computerised delivery may be particularly beneficial in cases where paranoia hinders the development of trust in the therapist or reduces the therapeutic alliance [8].”
From A qualitative study of the acceptability of cognitive bias modification for paranoia (CBM-pa) in patients with psychosis (2019) · cites this paper as [8]
Cites
The Positive and Negative Syndrome Scale (PANSS) for schizophrenia.
Kay, S. R., Fiszbein, A., & Opler, L. A. (1987) · Schizophrenia Bulletin · doi:10.1093/schbul/13.2.261 · Cited by 21,378 · see citing works
A new scale of social desirability independent of psychopathology.
Crowne, D. P., & Marlowe, D. (1960) · Journal of Consulting Psychology · doi:10.1037/h0047358 · Cited by 8,686 · see citing works
Development and validation of the working alliance inventory
Horvath, A. O., & Greenberg, L. S. (1989) · Journal of Counseling Psychology · doi:10.1037//0022-0167.36.2.223 · Cited by 3,520 · see citing works
Relation of the therapeutic alliance with outcome and other variables: a meta-analytic review
Martin, D. J., Garske, J. P., & Davis, M. K. (2000) · Journal of Consulting and Clinical Psychology · doi:10.1037//0022-006x.68.3.438 · Cited by 3,355 · see citing works
Structured clinical interview for DSM-IV axis I disorders : SCID-I : clinical version : scoresheet
First, M. B., Spitzer, R. L., Gibbon, M., & Williams, J. B. W. (1997) · American Psychiatric Press eBooks · Cited by 3,101 · see citing works
Relation between working alliance and outcome in psychotherapy: A meta-analysis
Horvath, A. O., & Symonds, B. D. (1991) · Journal of Counseling Psychology · doi:10.1037/0022-0167.38.2.139 · Cited by 2,673 · see citing works
Factor structure of the working alliance inventory
Tracey, T. J., & Kokotovic, A. M. (1989) · Psychological Assessment: A Journal of Consulting and Clinical Psychology · doi:10.1037/1040-3590.1.3.207 · Cited by 1,501 · see citing works
Awareness of Illness in Schizophrenia and Schizoaffective and Mood Disorders
AMADOR, X. F. (1994) · Archives of General Psychiatry · doi:10.1001/archpsyc.1994.03950100074007 · Cited by 898 · see citing works
Structured Clinical Interview for DSM-IV
(2007) · Sage eBooks · doi:10.4135/9781412952644.n443 · Cited by 725 · see citing works
Frank, A. F. (1990) · Archives of General Psychiatry · doi:10.1001/archpsyc.1990.01810150028006 · Cited by 552 · see citing works
Theory and research on the therapeutic working alliance: New directions.
Bordin, E. S. (1994) · Cited by 540 · see citing works
Bell, M. D., Lysaker, P. H., Goulet, J. L., Milstein, R. M., & Lindenmayer, J. (1994) · Psychiatry Research · doi:10.1016/0165-1781(94)90075-2 · Cited by 422 · see citing works
Self-citationThe positive and negative syndrome scale for schizophrenia
Obermeier, M. (2012) · Elektronische Hochschulschriften der LMU München (Ludwig-Maximilians-Universität München) · doi:10.5282/edoc.14936 · Cited by 226 · see citing works
Therapeutic alliance and outcome in a VA intensive case management program
Neale, M. S., & Rosenheck, R. A. (1995) · Psychiatric Services · doi:10.1176/ps.46.7.719 · Cited by 222 · see citing works
The working alliance and consumer case management
Solomon, P., Draine, J., & Delaney, M. A. (1995) · The Journal of Behavioral Health Services & Research · doi:10.1007/bf02518753 · Cited by 171 · see citing works
Lysaker, P. H., Glynn, S. M., Wilkniss, S. M., & Silverstein, S. M. (2010) · Psychological Services · doi:10.1037/a0019115 · Cited by 139 · see citing works
Self-citationColli, A., & Lingiardi, V. (2009) · Psychotherapy Research · doi:10.1080/10503300903121098 · Cited by 116 · see citing works
Svensson, B., & Hansson, L. I. (1999) · Acta Psychiatrica Scandinavica · doi:10.1111/j.1600-0447.1999.tb07226.x · Cited by 112 · see citing works
Lysaker, P. H., Davis, L. W., BRYSON, G. J., & Bell, M. D. (2008) · Schizophrenia Research · doi:10.1016/j.schres.2008.10.018 · Cited by 96 · see citing works
Self-citationTherapeutic alliance evaluation in personality disorders psychotherapy
Lingiardi, V., Filippucci, L., & Baiocco, R. (2005) · Psychotherapy Research · doi:10.1080/10503300512331327047 · Cited by 95 · see citing works
Predicting Therapeutic Alliance in Clients With Psychosis and Substance Misuse
Barrowclough, C., Meier, P. S., Beardmore, R., & Emsley, R. (2010) · The Journal of Nervous and Mental Disease · doi:10.1097/nmd.0b013e3181da4d4e · Cited by 84 · see citing works
Wittorf, A., Jakobi, U. E., Bechdolf, A., Müller, B. W., Sartory, G., Wagner, M., Wiedemann, G., Wölwer, W., Herrlich, J., Buchkremer, G., et al. (2009) · European Psychiatry · doi:10.1016/j.eurpsy.2008.12.015 · Cited by 76 · see citing works
Psychotherapeutic Management Techniques in the Treatment of Outpatients With Schizophrenia
Weiden, P. J., & HAVENS, L. L. (1994) · Psychiatric Services · doi:10.1176/ps.45.6.549 · Cited by 73 · see citing works
The Therapeutic Relationship in CBT for Psychosis: Client, Therapist and Therapy Factors
Evans-Jones, C., Peters, E., & Barker, C. (2009) · Behavioural and Cognitive Psychotherapy · doi:10.1017/s1352465809990269 · Cited by 71 · see citing works
Smerud, P. E., & Rosenfarb, I. S. (2008) · Journal of Consulting and Clinical Psychology · doi:10.1037/0022-006x.76.3.505 · Cited by 52 · see citing works
Therapeutic Alliance and Improvements in Work Performance Over Time in Patients With Schizophrenia
Davis, L. W., & Lysaker, P. H. (2007) · The Journal of Nervous and Mental Disease · doi:10.1097/01.nmd.0000261954.36030.a1 · Cited by 43 · see citing works
Self-citationJohnson, D. P., Penn, D. L., Bauer, D. J., Meyer-Kalos, P., & Evans, E. (2008) · British Journal of Clinical Psychology · doi:10.1348/014466507x241604 · Cited by 42 · see citing works
Ogrodniczuk, J. S., Piper, W. E., Joyce, A. S., & McCallum, M. (2000) · The Canadian Journal of Psychiatry · doi:10.1177/070674370004500505 · Cited by 40 · see citing works
RATIONALE FOR A NEW MEASURE OF COMPETENCE IN THERAPY
Milne, D. L., Claydon, T., Blackburn, I., James, I. A., & Sheikh, A. I. (2001) · Behavioural and Cognitive Psychotherapy · doi:10.1017/s1352465801001047 · Cited by 40 · see citing works
Crits-Christoph, P. F., Gibbons, M. B. C., Temes, C. M., Elkin, I., & Gallop, R. (2010) · Journal of Consulting and Clinical Psychology · doi:10.1037/a0019549 · Cited by 33 · see citing works
Dimaggio, G., Carcione, A., Salvatore, G., Semerari, A., & Nicolò, G. (2010) · Psychology and Psychotherapy Theory Research and Practice · doi:10.1348/147608310x485256 · Cited by 33 · see citing works
Neurocognitive Correlates of Therapeutic Alliance in Schizophrenia
Davis, L. W., & Lysaker, P. H. (2004) · The Journal of Nervous and Mental Disease · doi:10.1097/01.nmd.0000131919.60151.a7 · Cited by 28 · see citing works
Self-citationLysaker, P. H., & Gumley, A. I. (2009) · Psychosis · doi:10.1080/17522430903026385 · Cited by 20 · see citing works
Self-citationHasson‐Ohayon, I., Roe, D., Kravetz, S., Levy‐Frank, I., & Meir, T. (2011) · Community Mental Health Journal · doi:10.1007/s10597-011-9380-2 · Cited by 19 · see citing works
Buck, K. D., & Lysaker, P. H. (2010) · Perspectives In Psychiatric Care · doi:10.1111/j.1744-6163.2010.00258.x · Cited by 11 · see citing works
Self-citation
Flagged first, then by citations
2 of the 37 references couldn’t be matched to a known paper.
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Shattock, L., Berry, K., Degnan, A., & Edge, D. (2018) · Clinical Psychology & Psychotherapy · doi:10.1002/cpp.2135 · Cited by 137 · see citing works
The Effect of Working Alliance on Adherence and Outcome in Cognitive Remediation Therapy
Huddy, V. C., Reeder, C., Kontis, D., Wykes, T., & Stahl, D. R. (2012) · The Journal of Nervous and Mental Disease · doi:10.1097/nmd.0b013e31825bfc31 · Cited by 82 · see citing works
Therapeutic alliance in schizophrenia: The role of recovery orientation, self-stigma, and insight
Kvrgic, S., Cavelti, M., Beck, E., Rüsch, N., & Vauth, R. (2012) · Psychiatry Research · doi:10.1016/j.psychres.2012.10.009 · Cited by 73 · see citing works
Browne, J., Nagendra, A., Kurtz, M., Berry, K., & Penn, D. L. (2019) · Clinical Psychology Review · doi:10.1016/j.cpr.2019.05.002 · Cited by 60 · see citing works
Jung, E., Wiesjahn, M., Rief, W., & Lincoln, T. M. (2014) · British Journal of Clinical Psychology · doi:10.1111/bjc.12059 · Cited by 60 · see citing works
Johansen, R. E. B., Melle, I. S., Iversen, V. C., & Hestad, K. A. (2013) · Comprehensive Psychiatry · doi:10.1016/j.comppsych.2013.05.016 · Cited by 53 · see citing works
The Therapeutic Relationship After Psychiatric Admission
Roche, E., Madigan, K., Lyne, J. P., Feeney, L., & O’Donoghue, B. (2014) · Journal of Nervous & Mental Disease · doi:10.1097/nmd.0000000000000102 · Cited by 48 · see citing works
Jung, E., Wiesjahn, M., & Lincoln, T. M. (2013) · Psychotherapy Research · doi:10.1080/10503307.2013.851425 · Cited by 42 · see citing works
Therapeutic alliance in early schizophrenia spectrum disorders: a cross-sectional study
Johansen, R. E. B., Iversen, V. C., Melle, I. S., & Hestad, K. A. (2013) · Annals of General Psychiatry · doi:10.1186/1744-859x-12-14 · Cited by 33 · see citing works
The Impact of Legal Coercion on the Therapeutic Relationship in Adult Schizophrenia Patients
Höfer, F. X. E., Habermeyer, E., Mokros, A., Lau, S., & Gairing, S. K. (2015) · PLoS ONE · doi:10.1371/journal.pone.0124043 · Cited by 32 · see citing works
the CEDAR Study Group, Slade, M., Jordan, H., Clarke, E., Williams, P. R., Kaliniecka, H., Arnold, K., Fiorillo, A., Giacco, D., Luciano, M., et al. (2014) · BMC Health Services Research · doi:10.1186/1472-6963-14-323 · Cited by 30 · see citing works
Mulligan, J., Haddock, G., Hartley, S., Davies, J., Sharp, T., KELLY, J. A., Neil, S. T., Taylor, C. D. J., Welford, M., Price, J., et al. (2014) · Psychology and Psychotherapy Theory Research and Practice · doi:10.1111/papt.12018 · Cited by 26 · see citing works
Working Alliance in Patients with Severe Mental Illness Who Need a Crisis Intervention Plan
Ruchlewska, A., Kamperman, A. M., van der Gaag, M., Wierdsma, A. I., & Mulder, N. C. L. (2016) · Community Mental Health Journal · doi:10.1007/s10597-015-9839-7 · Cited by 24 · see citing works
Leung, C. J., Fosuaah, A., Frerichs, J., Heslin, M., Kabir, T., Lee, T. M. C., McGuire, P., Meek, C., Mouchlianitis, E., Nath, A. S., et al. (2019) · BMC Psychiatry · doi:10.1186/s12888-019-2215-3 · Cited by 20 · see citing works
Lawford, B. J., Bennell, K. L., Campbell, P. K., Kasza, J., & Hinman, R. S. (2019) · Arthritis Care & Research · doi:10.1002/acr.23890 · Cited by 23 · see citing works
Igra, L., Michal Lavidor, B., Atzil–Slonim, D., Arnon-Ribenfeld, N., de Jong, S., & Hasson‐Ohayon, I. (2020) · European Psychiatry · doi:10.1192/j.eurpsy.2020.67 · Cited by 22 · see citing works
Desire for information of people with severe mental illness
The CEDAR study group, Giacco, D., Luciano, M., Vecchio, V. D., Sampogna, G., Slade, M., Clarke, E., Nagy, M., Égerházi, A., Munk‐Jørgensen, P., et al. (2014) · Social Psychiatry and Psychiatric Epidemiology · doi:10.1007/s00127-014-0901-5 · Cited by 20 · see citing works
Rathee, R., Luhrmann, T. M., Triptish Bhatia, A., & Deshpande, S. N. (2017) · Psychiatry Research · doi:10.1016/j.psychres.2017.09.032 · Cited by 19 · see citing works
Wykes, T., Rose, D. S., Williams, P. R., & David, A. S. (2013) · BMC Psychiatry · doi:10.1186/1471-244x-13-28 · Cited by 17 · see citing works
Insight and recovery in schizophrenic patients
Cannavò, D., Minutolo, G., Battaglia, E., & Aguglia, E. (2016) · International Journal of Psychiatry in Clinical Practice · doi:10.3109/13651501.2016.1141960 · Cited by 16 · see citing works
Vancampfort, D., Wyckaert, S., Sienaert, P., Hert, M. D., Soundy, A., Rosenbaum, S., Richards, J. A., & Probst, M. (2016) · PubMed · Cited by 16 · see citing works
Process analysis of trauma‐focused cognitive behavioural therapy for individuals with schizophrenia
O’Driscoll, C., Mason, O. J., Brady, F., Smith, B., & Steel, C. (2015) · Psychology and Psychotherapy Theory Research and Practice · doi:10.1111/papt.12072 · Cited by 15 · see citing works
Hasson‐Ohayon, I., de Jong, S., Igra, L., Carter, S., Faith, L. A., & Lysaker, P. H. (2021) · Clinical Psychology & Psychotherapy · doi:10.1002/cpp.2572 · Cited by 13 · see citing works
Self-citationPredictors of working alliance in cognitive behaviour therapy adapted for traumatic brain injury
Zelencich, L. M., Kazantzis, N., Wong, D. K., McKenzie, D. P., Downing, M. G., & Ponsford, J. L. (2019) · Neuropsychological Rehabilitation · doi:10.1080/09602011.2019.1600554 · Cited by 12 · see citing works
Snipes, C., Dorner‐Ciossek, C., Hare, B. D., Besedina, O., Campellone, T. R., Petrova, M., Lakhan, S. E., & Pratap, A. (2025) · JMIR Mental Health · doi:10.2196/64959 · Cited by 11 · see citing works
Browne, J., Bass, E., Mueser, K. T., Meyer-Kalos, P., Gottlieb, J. D., Estroff, S. E., & Penn, D. L. (2018) · Schizophrenia Research · doi:10.1016/j.schres.2018.07.035 · Cited by 10 · see citing works
Determinants of Therapeutic Alliance With People With Psychotic Disorders
da Costa, H., Martin, B., & Nicolas Franck, B. (2020) · The Journal of Nervous and Mental Disease · doi:10.1097/nmd.0000000000001125 · Cited by 9 · see citing works
Stobbe, J., Wierdsma, A. I., Kok, R., Kroon, H., Depla, M. F. I. A., & Mulder, C. L. (2014) · Social Psychiatry and Psychiatric Epidemiology · doi:10.1007/s00127-014-0918-9 · Cited by 9 · see citing works
Fusar‐Poli, L., Panariello, F., Berry, K., Rocchetti, M., Casiraghi, L., Malvezzi, M., Starace, F., Zamparini, M., Zarbo, C., & de Girolamo, G. (2023) · British Journal of Clinical Psychology · doi:10.1111/bjc.12450 · Cited by 8 · see citing works
Abel, D. B., Cruz, L. N., Lukachko, A. M., Roché, M. W., & Silverstein, S. M. (2020) · Psychosis · doi:10.1080/17522439.2020.1779796 · Cited by 6 · see citing works
Alkan, E., & Evans, S. (2022) · Schizophrenia · doi:10.1038/s41537-022-00243-x · Cited by 4 · see citing works
de Jong, S., Hasson‐Ohayon, I., Lavi‐Rotenberg, A., Carter, S. A., Castelein, S., & Lysaker, P. H. (2021) · Psychology and Psychotherapy Theory Research and Practice · doi:10.1111/papt.12346 · Cited by 3 · see citing works
Self-citationIs cognitive behavioural therapy effective for individuals experiencing thought disorder?
Shryane, N. M., Drake, R., Morrison, A. P., & Palmier‐Claus, J. E. (2020) · Psychiatry Research · doi:10.1016/j.psychres.2020.112806 · Cited by 3 · see citing works
Harper, S. F. (2011) · Clinical Psychology & Psychotherapy · doi:10.1002/cpp.771 · Cited by 2 · see citing works
Richards, M. (2020) · Western CEDAR (Western Washington University) · doi:10.25710/87em-cn07
Service users' perceptions of cognitive behavioural therapy for psychosis: A review
Stevens, H. (2017) · British Journal of Mental Health Nursing · doi:10.12968/bjmh.2017.6.4.183
Woolridge, S. M., Vincent, N., Leibovitz, T., Jagtap, S., Romanowska, S., Aidelbaum, R., D’Arcey, J., Kessaris, M., Hamzai, H. V., Ibrahim, A., et al. (2026) · Psychotherapy Research · doi:10.1080/10503307.2026.2661045
- Authors
- Lysaker, P. H., Davis, L. W., Buck, K. D., Outcalt, S., & Ringer, J. M.
- Affiliations
- Richard L. Roudebush VA Medical Center (US)
- Corresponding author
- Lysaker, Paul H.
- Davis, Louanne W.
- Buck, Kelly D.
- Outcalt, Samantha
- Ringer, Jamie M.
- Venue
- Journal of Nervous & Mental Disease
- Published
- 2011-03
- Volume
- 199
- Issue
- 3
- Pages
- 191-195
- ISSN
- 0022-3018 (ISSN-L)
- OpenAlex
- W1990458121
- Cited by
- 37
- References
- 37
- Citations by year
- 2026: 1 · 2025: 1 · 2023: 1 · 2022: 1 · 2021: 2 · 2020: 5 · 2019: 4 · 2018: 1 · 2017: 3 · 2016: 2 · 2015: 3 · 2014: 6 · 2013: 4 · 2012: 2
- FWCI
- 4.48
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- The Journal of Nervous and Mental Disease (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Social Sciences › Psychology › Clinical Psychology › Psychotherapy Techniques and Applications
- Health Sciences › Medicine › Psychiatry and Mental health › Schizophrenia research and treatment
- Social Sciences › Psychology › Clinical Psychology › Psychoanalysis and Psychopathology Research
- Keywords
- therapeutic relationship, schizophrenia, cognitive behavioral therapy, client-therapist agreement, negative symptoms, insight, positive symptoms, disorganized symptoms, treatment outcome prediction
- MeSH terms
- Female, Humans, Male, Middle Aged, Professional-Patient Relations, Psychiatric Status Rating Scales, Psychological Tests, Psychotic Disorders, Schizophrenia, Schizophrenic Psychology, Cognitive Behavioral Therapy
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