Predicting therapeutic alliance in clients with psychosis and substance misuse.

The importance of therapeutic alliance in predicting treatment outcomes is well established, but less is known about client characteristics that predict alliance. Clients with co-occurring psychosis and substance misuse (n = 116) who received integrated motivational interviewing and cognitive behavior therapy in the context of a large randomized controlled trial completed the Working Alliance Inventory. Their trial therapists also completed Working Alliance Inventories. Rating perspectives were compared, and in a cross-sectional study, client predictors of therapeutic alliance were examined. As hypothesized, clients' negative attitudes to treatment, including lack of insight, were predictive of poorer alliance. Therapist-rated alliance was also predicted by the client's attitude to medication, self-reported depression, and living situation. Symptom severity and substance use measures were unrelated to alliance. Consistent with previous studies, rating perspectives differed, with clients rating alliance more positive than therapists.