Therapeutic alliance in schizophrenia: the role of recovery orientation, self-stigma, and insight.

The present study examined variables related to the quality of the therapeutic alliance in out-patients with schizophrenia. We expected recovery orientation and insight to be positively, and self-stigma to be negatively associated with a good therapeutic alliance. We expected these associations to be independent from age, clinical symptoms (i.e. positive and negative symptoms, depression), and more general aspects of relationship building like avoidant attachment style and the duration of treatment by the current therapist. The study included 156 participants with DSM-IV diagnoses of schizophrenia or schizoaffective disorder in the maintenance phase of treatment. Therapeutic alliance, recovery orientation, self-stigma, insight, adult attachment style, and depression were assessed by self-report. Symptoms were rated by interviewers. Hierarchical multiple regressions revealed that more recovery orientation, less self-stigma, and more insight independently were associated with a better quality of the therapeutic alliance. Clinical symptoms, adult attachment style, age, and the duration of treatment by current therapist were unrelated to the quality of the therapeutic alliance. Low recovery orientation and increased self-stigma might undermine the therapeutic alliance in schizophrenia beyond the detrimental effect of poor insight. Therefore in clinical settings, besides enhancing insight, recovery orientation, and self-stigma should be addressed.

Validation of the Illness Perception Questionnaire for Schizophrenia in a German-speaking sample of outpatients with chronic schizophrenia.

BACKGROUND: Because the mere definition of insight from the therapist's viewpoint may not be sufficient to identify treatment targets for adherence enhancement, we need assessment strategies which are more sensitive to the patient's perspective. Illness perception (IP), defined as the beliefs a patient holds about his/her health problems, has been shown to affect coping in the context of a physical or mental illness, e.g. compliance behaviour. To assess IP in people diagnosed with schizophrenia, the Illness Perception Questionnaire for Schizophrenia (IPQS) was developed. The aim of the present study was to analyse the psychometric properties of the German version of the IPQS. SAMPLING AND METHODS: The study sample consisted of 128 German-speaking outpatients suffering from chronic schizophrenia or schizoaffective disorder. To achieve comparability with the validation of the English scale version, the same constructs were assessed: psychopathology, depression, and beliefs about medication. Furthermore, insight into one's illness was assessed. Internal consistency, test-retest reliability and construct validity including convergent and discriminant validity were analysed. RESULTS: Five of eight IPQS subscales were found to be internally reliable and all subscales demonstrated high stability over time. Correlations with validity measures indicated that the subscales assess dimensions of a construct, which is distinct from psychopathology, depression, beliefs about medication and insight, except for the Identity subscale which substantially overlapped with measures of insight. CONCLUSIONS: The German version of the IPQS is an essentially reliable and valid measure of IP for German-speaking people with a schizophrenia spectrum disorder. This may encourage its usage in further studies investigating the impact of subjective beliefs about mental health problems on outcome and recovery in schizophrenia.

The role of subjective illness beliefs and attitude toward recovery within the relationship of insight and depressive symptoms among people with schizophrenia spectrum disorders.

OBJECTIVE: Low levels of insight are a risk factor for treatment nonadherence in schizophrenia, which can contribute to poor clinical outcome. On the other hand, high levels of insight have been associated with negative outcome, such as depression, hopelessness, and lowered quality of life. The present study investigates mechanisms underlying the association of insight and depressive symptoms and protective factors as potential therapeutic targets. METHODS: One hundred and forty-two outpatients with schizophrenia or schizoaffective disorder (35.2% women, mean age of 44.83 years) were studied using questionnaires and interviews to assess insight, depressive symptoms, recovery attitude, and illness appraisals with regard to course, functional impairments, and controllability. Psychotic and negative symptoms were assessed as control variables. The cross-sectional data were analyzed using structural equation models and multiple linear regression analyses with latent variables. RESULTS: Higher levels of insight and psychotic symptoms were associated with more depressive symptoms. The association of negative symptoms with depressive symptoms was not significant. The relationship between insight and depressive symptoms was mediated by the participants' perception of their illness as being chronic and disabling, as well as suppressed by their expectation of symptom control due to treatment. Finally, the association of insight and depressive symptoms was less pronounced in the patients with a positive recovery attitude than in those without this protective factor. CONCLUSIONS: To achieve recovery, which includes symptom reduction, functional improvement, and subjective well-being, it is necessary to prevent depressive symptoms as indicators of a demoralization process, which may arise as a consequence of growing insight. Possible treatment strategies focusing on changes of dysfunctional beliefs about the illness and the self and inducing a positive recovery attitude are discussed.

Do patients with schizophrenia distinguish between attitudes toward antipsychotic medication and pharmacotherapy in general? Validation of the Beliefs About Medication Questionnaire.

Attitudes toward medication are important predictors of medication adherence in schizophrenia. However, monitoring their strength and influence in clinical settings is challenged by the absence of assessments separating them from adherence and subjective response and distinguishing between attitudes toward pharmacotherapy in general and antipsychotic medications. This study examined the applicability of the Beliefs about Medication Questionnaire (BMQ) in outpatients with schizophrenia (N = 131). Confirmatory factor analysis (CFA) could not support the original four-factor structure. A subsequent exploratory factor analysis revealed the factors Antipsychotics Necessity, Antipsychotics Concern, and Pharmacotherapy Distrust were supported by an acceptable fit of a completing CFA. These subscales have satisfactory internal reliability, test-retest reliability, and local fit indices. Modest correlations with insight and illness perception indicate construct validity. Criterion validity was supported by a significantly higher medication adherence of accepting patients compared with skeptical patients. The BMQ is a psychometrically sound and valid measure of attitudes toward medication in outpatients with schizophrenia.

Focusing on the adult attachment style in schizophrenia in community mental health centres: validation of the Psychosis Attachment Measure (PAM) in a German-speaking sample.

BACKGROUND: Assessing attachment style in people with schizophrenia may be important to identify a risk factor in building a strong therapeutic relationship and so indirectly to understand the development of mal-compliance as one of the major obstacles in the treatment of schizophrenia. AIMS: The present study analysed the psychometric properties of the German version of the Psychosis Attachment Measure (PAM), which assesses avoidant and anxious attachment style. METHODS: A sample of 127 patients suffering from chronic schizophrenia or schizoaffective disorder participated in this study. In testing discriminant validity, we assessed psychopathology, depression, therapeutic relationship and service engagement. Internal consistency, test-retest reliability and factor structure were analysed. RESULTS: The German version of PAM exhibited acceptable to good internal and test-retest reliabilities and the two-factor structure of the English version could be replicated. Avoidant attachment style was related to higher levels of positive symptoms and to a poorer therapeutic relationship. In the context of external validation, a regression analysis revealed that a poor therapeutic relationship correlated with avoidant attachment style, independent of anxious attachment style and depressive symptoms. Anxious attachment was associated with higher treatment adherence. Both insecure attachment styles (avoidant and anxious) were found to be correlated with higher levels of depression, but only attachment anxiety had an independent predictive value for self-reported depression in regression analysis. CONCLUSIONS: The German version of PAM displayed satisfactory psychometric properties and seems to be a reliable measure for assessing attachment style in individuals with schizophrenia. Validation of PAM led to the finding that only the avoidant attachment style might be a risk factor when building a strong therapeutic relationship in schizophrenia. In future studies, other factors influencing therapeutic relationship should be taken into account. Anxious attachment style may be a risk factor for depression, but it also has an enhancing effect on treatment adherence.

Self-stigma and its relationship with insight, demoralization, and clinical outcome among people with schizophrenia spectrum disorders.

BACKGROUND: Paradoxically, insight is associated with positive outcomes, such as better treatment adherence and recovery, and negative outcomes, such as depression, hopelessness, low self-esteem, and quality of life. Self-stigma as a moderating variable can be decisive whether more insight leads to better or worse outcome. On the other hand, self-stigma can act as a mediator between insight and outcomes. We therefore examined self-stigma both as a moderator and a mediator. METHODS: Insight, self-stigma, demoralization, symptoms, and functioning were assessed among 145 outpatients with schizophrenia spectrum disorders using questionnaires and structured interviews. Structural equation modeling was used to analyze the cross-sectional data. RESULTS: Results confirmed self-stigma as a moderator: The association of insight and demoralization was stronger as self-stigma increased. Self-stigma also partially mediated the positive relationship between insight and demoralization. Moreover, demoralization fully mediated the adverse associations of self-stigma with psychotic symptoms and global functioning. DISCUSSION: Given the decisive role of self-stigma regarding the detrimental consequences of insight, interventions should address self-stigma, particularly if psychoeducational or other interventions have increased insight. Therapeutic implications for changes of dysfunctional beliefs related to illness and self and change of self-concept in the context of recovery at the level of narrative identity are discussed.

Are we addressing the 'right stuff' to enhance adherence in schizophrenia? Understanding the role of insight and attitudes towards medication.

BACKGROUND: Despite the fact that medication adherence is among the most important health related behaviors in relapse prevention and recovery in schizophrenia, it is often not sufficiently endorsed by patients. Poor insight and negative attitudes towards medication are risk factors for non-adherence. Their relationship and the influence of more general attitudes towards pharmacotherapy besides attitudes towards antipsychotics have not been fully understood. The present study investigated whether these factors independently influence adherence or whether they mediate one another. METHODS: A cross-sectional sample of 150 outpatients completed the Beliefs about Medication Questionnaire. It assesses patients' beliefs about antipsychotic medication in terms of necessity and concerns and more general beliefs about pharmacotherapy in terms of distrust. Additionally, the patients' global awareness of illness (Scale to assess Unawareness of Mental Disorder), and medication adherence (Brief Adherence Rating Scale, Service Engagement Scale) were assessed. RESULTS: Using structural equation modeling, the study found evidence for a mediational model. Awareness of illness contributed to medication adherence via patients' perceived necessity of antipsychotics. The model further revealed a direct negative relationship between concerns regarding antipsychotics and adherence and an indirect negative effect of a general distrust regarding pharmacotherapy and adherence via antipsychotic specific attitudes. CONCLUSION: Interventions to enhance medication adherence may be more effective if they focus on treatment related attitudes rather than on global insight into illness. Clinicians may not only enhance the patients' perceived necessity of antipsychotic treatment but also explore and address concerns and the patients' distrust in pharmacotherapy in a more personalized way.