Longitudinal assessments of therapeutic alliance predict work performance in vocational rehabilitation for persons with schizophrenia

Abstract

To promote functional recovery in persons diagnosed with a psychotic disorder, vocational interventions have emerged over the last few decades which range from sheltered employment to supported employment in the community. Using data from a 6-month vocational rehabilitation programme, we examined whether assessments of the therapeutic alliance were related to the quality of work performed in this work placement. Our first hypothesis was that stronger alliances would be related to better work performance. Second, we expected that client assessments of the TA would better predict outcomes than therapist assessments. Third, we expected that the discrepancy between assessment scores from the client and therapist (client rating minus therapist rating) would be a better predictor for outcome than individual assessments by the therapists or clients. Clients systematically rated the alliance higher than therapists. Modelling the data longitudinally, we found both therapist and client ratings predictive of outcome, though client assessments over time were inversely related to work performance. Discrepancy in scores was also shown to be predictive of work performance during the program. Clinicians are advised to routinely assess the therapeutic alliance from both client and therapist perspectives and calculate the discrepancy between them as they may indicate ruptures are occurring and thus hamper the intervention. Clinicians are advised to regularly assess the therapeutic alliance from both their own and the client's perspective. Growing discrepancy in scores may impede intervention effectiveness. Therapeutic alliance may help buffer against work stresses experienced by participants in a vocational programme. Be aware that therapists tend to rate the alliance lower than their clients.