The influence of self-esteem and quality of the therapeutic alliance on psychotic symptom severity

Nadine MIDDELKOOP1,2, Melina TETZLAFF1,3, Stynke CASTELEIN1,3,4, Jojanneke BRUINS1,4

1Lentis Research, Lentis Psychiatric Institute, Groningen, Netherlands
2PsyQ, Department of mood disorders, Groningen, Netherlands
3Faculty of Behavioural and Social Sciences, University of Groningen, Groningen, Netherlands
4Rob Giel Research Center, University Medical Center Groningen, Groningen, Netherlands

Introduction. The therapeutic alliance (TA) is increasingly acknowledged as a fundamental quality of care indicator. Numerous guidelines advocate TA awareness in practice, but lack specifics on building a strong TR. Yet, previous studies have found independent associations between levels of self-esteem, the quality of TA and severity of clinical symptoms in people with psychotic disorders. It suggests that the TA possibly mediates the relationship between self-esteem and psychotic symptoms. The present study therefore examined the relationships between these three factors in people with psychotic disorders. Methods. The associations between the severity of self-esteem, psychotic symptoms and the TA were examined in a cross-sectional study (n=109). The short forms of the Self-Esteem Rating Scale and the Working Alliance Inventory, respectively, were used to assess self-esteem and TA. Psychotic symptoms were evaluated using the Positive and Negative Syndrome Scale. Linear regression models were applied, followed by a mediation-model when appropriate. Results. A higher self-esteem significantly predicted less severe psychotic symptoms (B = -.312; β = -.46, p <.001) and better TA (B = .123, β = .255, p = .009). There was no significant relation between TA and psychotic symptom severity (B = -.161; β = -0.109, p = .289), therefore no mediation-analysis was performed. Discussion-conclusion. We found no association between TA and psychotic symptoms, which may be explained by the mild psychotic symptoms and overall high satisfaction scores on TA in our chronic sample. Another factor might be that current measurements assume a one-on-one relationship between a client and a professional, while nowadays multiple professionals are involved. Therefore, we recommend re-evaluating the definition and assessment of the TA within chronic psychiatric populations. Our study results also offer practical guidelines for clinicians to improve their quality of care, such as the recommendation to focus on enhancing self-esteem in people with psychosis.