Process analysis of trauma-focused cognitive behavioural therapy for individuals with schizophrenia.

OBJECTIVE: Therapeutic alliance, modality, and ability to engage with the process of therapy have been the main focus of research into what makes psychotherapy successful. Individuals with complex trauma histories or schizophrenia are suggested to be more difficult to engage and may be less likely to benefit from therapy. This study aimed to track the in-session 'process' of working alliance and emotional processing of trauma memories for individuals with schizophrenia.

DESIGN: The study utilized session recordings from the treatment arm of an open randomized clinical trial investigating trauma-focused cognitive behavioural therapy (TF-CBT) for individuals with schizophrenia (N = 26).

METHOD: Observer measures of working alliance, emotional processing, and affect arousal were rated at early and late phases of therapy. Correlation analysis was undertaken for process measures. Temporal analysis of expressed emotions was also reported.

RESULTS: Working alliance was established and maintained throughout the therapy; however, agreement on goals reduced at the late phase. The participants appeared to be able to engage in emotional processing, but not to the required level for successful cognitive restructuring.

CONCLUSION: This study undertook novel exploration of process variables not usually explored in CBT. It is also the first study of process for TF-CBT with individuals with schizophrenia. This complex clinical sample showed no difficulty in engagement; however, they may not be able to fully undertake the cognitive-emotional demands of this type of therapy. Clinical and research implications and potential limitations of these methods are considered.

PRACTITIONER POINTS: This sample showed no difficulties engaging with TF-CBT and forming a working alliance. However, the participants may not have achieved a level of active involvement required for successful cognitive restructuring of trauma memories. This discrepancy may relate to the mediating role of both working alliance and cognitive-emotional processing. The results underscore the importance of therapists understanding the relationship between alliance and other process factors which may be implicit in facilitating change.