A systematic review and meta-ethnography of client and therapist perspectives of the therapeutic alliance in the context of psychotherapy and suicidal experiences.

This review aimed to develop a conceptual model of the therapeutic alliance in the context of psychotherapy and suicidal experiences from therapist and client perspectives. The protocol was pre-registered on PROSPERO (CRD42021268273). MEDLINE, PsycINFO, Web of Science, Embase and CINAHL were systematically searched from database inception to April 2024. Eligible studies were peer-reviewed, qualitative, and included client and/or therapist's perspectives of the therapeutic alliance in the context of psychotherapy and suicidal experiences. Studies were critically appraised and analysed using a meta-ethnography approach involving a reciprocal translation of studies and line of argument synthesis. Thirty-seven papers were included, generating two overarching themes; 'Working on the edge' and 'Being ready, willing, and able to build an alliance in the context of suicidal experiences'. Therapeutic alliance in the context of suicidal experiences is unique, fluid, potentially lifesaving, and influenced by multiple inter-connected internal and external processes and systems. Clinical implications emphasise the need to improve training, supervision, and support for therapists to equip them with the additional skills required in navigating the intricacies of the therapeutic alliance with clients who have suicidal experiences. Flexibly interweaving risk assessment into therapeutic conversation was beneficial to the alliance with suicidal clients and enhanced their safety.
Competing Interests: Declaration of competing interest PG and DP are among other co-authors of a suicide-focussed CBT treatment manual for people with psychosis (Tarrier et al., 2013), which is published under copyright as a book. Cognitive Behavioural Suicide Prevention Therapy has been applied, adapted, and assessed in pilot and phase 2 trials for several high-risk populations. The authors of the review have been and/or are currently funded to work on these trials and have published work arising from these trials.
(Copyright © 2024. Published by Elsevier Ltd.)