The therapeutic relationship in community mental health services: a systematic review of the literature

Purpose: This systematic review aimed to investigate the therapeutic relationship (TR) between mental health professionals (MHPs) and their patients in community mental health services (CMHS). Methods: PubMed (Medline), PsycINFO, CINAHL, CENTRAL, and Web of Science were searched for studies that assessed TR in CMHS using quantitative measures developed specifically for this setting (i.e., Helping Alliance Scale [HAS] and the Scale to Assess the Therapeutic Relationship [STAR]). Studies were included if they considered adult patients with a psychiatric disorder and/or any MHP working in CMHS. Meta-analysis and narrative synthesis assessed the association between patients' and MHPs' ratings and identified predictors of TR. Results: Of 1934 studies, 15 were included in the review, including 3004 patients. A total of 1127 patients and 963 MHPs were considered in the meta-analysis. The heterogeneity of the studies was high, and there was no significant difference between the patients' and MHPs' TR ratings in the random-effects model (standardized mean difference [SMD]: - 0.39 [95% CI: - 1.03; 0.24]). In the multivariable meta-regression, only duration of illness was significantly associated with TR ratings (unstandardized regression coefficient [B]: 0.388 [95% CI: 0.217; 0.558]). A recovery-oriented service, shared decision-making, and the recognition of patient needs contributed to more positive TR ratings. Conclusion: Patients and MHPs converged in their TR ratings, although patients gave lower ratings. Routine assessment of TR in CMHS can inform reflective practice and service development, as TR can be assessed easily and early in the treatment process. Future research should focus on developing and testing interventions to improve TR in CMHS.