title: Therapist-client relationships in a psychological therapy trial for psychosis and substance misuse.
abstract: BACKGROUND
  This study aimed to explore factors associated with outcomes in a randomised controlled trial of integrated motivational interviewing and cognitive behavioural therapy for psychosis and substance misuse.
  
  
  METHODS
  Clients and therapists completed self-report measures of alliance and clients completed a self-report measure of adult attachment. Trial therapists were also asked to identify challenges in therapy, client strengths and reasons for client making and not making changes in relation to substance misuse.
  
  
  RESULTS
  Neither therapist-rated nor client-rated alliance was significantly related to objective outcomes. Client insecure attachment avoidance was associated with poorer symptoms and functioning at 12 and 24 months; although not changes in substance misuse. Therapists' perceptions of therapeutic processes (e.g., challenges to therapy, client strengths, client reasons for change and alliance) were consistent with previous literature. Therapists' perceptions of client improvement were associated with reductions in substance use at the end of treatment and their ratings of therapeutic alliance.
  
  
  CONCLUSIONS
  Insecure adult attachment styles may be a potentially important predictor of symptom outcomes for people with psychosis and substance misuse. Trial therapists may also provide an important source of information about therapeutic processes and factors associated with outcome.
authors.affiliation: School of Psychological Sciences, University of Manchester, Manchester, UK. Electronic address: katherine.berry@manchester.ac.uk.
authors.forename: Katherine
authors.initials: K
authors.lastname: Berry
authors.affiliation: School of Psychological Sciences, University of Manchester, Manchester, UK.
authors.forename: Lynsey
authors.initials: L
authors.lastname: Gregg
authors.affiliation: School of Psychological Sciences, University of Manchester, Manchester, UK.
authors.forename: Rosalyn
authors.initials: R
authors.lastname: Hartwell
authors.affiliation: School of Psychological Sciences, University of Manchester, Manchester, UK.
authors.forename: Gillian
authors.initials: G
authors.lastname: Haddock
authors.affiliation: School of Psychological Sciences, University of Manchester, Manchester, UK.
authors.forename: Mike
authors.initials: M
authors.lastname: Fitzsimmons
authors.affiliation: School of Psychological Sciences, University of Manchester, Manchester, UK.
authors.forename: Christine
authors.initials: C
authors.lastname: Barrowclough
mesh_terms: D000328:Adult; D001291:Attitude of Health Personnel; D015928:Cognitive Behavioral Therapy; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D062405:Motivational Interviewing; D009769:Object Attachment; D011369:Professional-Patient Relations; D011618:Psychotic Disorders / Q000150:complications / Q000628:therapy*; D019966:Substance-Related Disorders / Q000150:complications / Q000628:therapy*; D016896:Treatment Outcome
keywords: Alliance; Attachment; Cognitive behavioural therapy; Motivational interviewing; Psychosis; Substance misuse