Behandlung psychotischer Störungen - Aspekte der Therapiebeziehung und Untersuchung unmedizierter Menschen mit psychotischen Störungen

The first topic of this dissertation is the therapeutic alliance in cognitive behavioral therapy for psychosis (CBTp). The efficiency and effectiveness of CBTp has been demonstrated in various studies, also in patients not taking antipsychotic medication. Less is known about mechanisms of change over the course of therapy. One relevant factor associated with therapeutic outcome is the therapeutic alliance. Regardless of treatment orientation, research design or alliance measure, therapeutic alliance shows a consistent positive associations with therapy outcome across a variety of disorders. Knowing predictors of the alliance is important in order to understand what helps and what hinders in establishing a good alliance. In study 1, we analyzed patient characteristics as predictors for the therapeutic alliance in CBTp. Results revealed negative symptoms as a negative predictor for patients’ and therapists’ ratings of the therapeutic alliance. In study 2, we focused on therapist characteristics as predictors of the therapeutic alliance. Results revealed therapist genuineness and competence to significantly predict higher patient rated alliance. The results of our studies indicate that negative symptoms might be a barrier for therapists’ perception of the alliance. Thus, therapists working with patients with prominent negative symptoms should monitor the alliance precisely and openly discuss perceived difficulties with the patient. Concerning patient rated alliance, our results indicate that basic therapeutic qualities, especially genuineness, are important for establishing a good alliance. Training and supervision should focus more on these basic therapeutic qualities. The second focus of this dissertation was the investigation of persons with psychosis who do not take antipsychotic medication. Although treatment with antipsychotic medication is widely considered as standard care in patients with psychosis, a considerable proportion of people with psychosis do not take antipsychotic medication but seem to be functioning well. Studies indicate that non-medicated persons with psychosis have a higher level of functioning and lower levels of psychotic symptoms than continuously medicated patients. However, little is known about how non-medicated persons with psychosis cope with occurring symptoms. To test the assumption that these patients compensate lack of medication by more effective coping, we compared symptoms, functioning, social support and coping strategies in non-medicated and medicated individuals with psychosis (Study 3). In line with previous results, non-medicated participants had significantly higher levels of general functioning than medicated participants. A longer duration of being non-medicated was significantly associated with a higher level of general functioning. The groups did not differ significantly with regard to symptom severity, evaluation of symptoms, symptom related distress, social functioning, social support, and the number of coping strategies employed or their perceived effectiveness. The findings indicate that some individuals with psychosis function well without antipsychotic medication. This questions the widespread assumption that medication is the only means of recovery. Future research should use longitudinal designs and focus on predictors of positive outcome in non-medicated psychosis. In order to further improve treatment of psychosis, the broader implementation of alternative treatment approaches in addition to routine care, especially CPTp, seems to be an important step.