Therapeutic alliance is a key predictor of therapy outcomes. Alliance may be particularly pertinent for people with schizophrenia as this group often have a history of interpersonal trauma and relationship difficulties including difficult relationships with mental health staff. This review aimed to determine (a) the quality of therapeutic alliance between people with schizophrenia and their therapists; (b) whether alliance predicts therapeutic outcomes; and (c) variables associated with alliance. Databases were searched from inception up to April 2015. The search yielded 4,586 articles, resulting in 26 eligible studies, involving 18 independent samples. Weighted average client and therapist Working Alliance Inventory-Short Form total scores were 64.51 and 61.26, respectively. There was evidence that alliance predicts overall psychotic symptomatic outcomes and preliminary evidence for alliance predicting rehospitalization, medication use, and self-esteem outcomes. There was evidence for specific client-related factors being linked to different perspectives of alliance. For example, poorer insight and previous sexual abuse were associated with worse client-rated alliance, whereas baseline negative symptoms were associated with worse therapist-rated alliance. Therapist and therapy-related factors, including therapists' genuineness, trustworthiness, and empathy were associated with better client-rated alliance, whereas suitability for therapy, homework compliance, and attendance were associated with better therapist-rated alliance. Key clinical implications include the need to consider alliance from both client and therapist perspectives during therapy and training and supervision to enhance therapist qualities that foster good alliance. Future research requires longitudinal studies with larger samples that include pan-theoretical, well-validated alliance measures to determine causal predictor variables.
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