Therapeutic Relationships and PTSD: A Systematic Review and Meta-Analysis, and an Empirical Study.

  • Ruth Howard

Student thesis: Doctor of Clinical Psychology


The thesis has been prepared in paper-based format and comprises three papers. Paper one provides a systematic review of 34 studies relating to therapeutic alliance in psychological therapy for post-traumatic stress disorder (PTSD). Potential predictors of therapeutic alliance were explored within a narrative synthesis. Twelve studies were entered into a meta-analysis of the association between therapeutic alliance and PTSD outcomes. Attachment, coping styles, and psychophysiological variables had some preliminary support as predictors of the alliance, whilst therapy variables did not appear to predict the alliance. Alliance predicted PTSD outcomes with a moderate effect size, across remote and in-person therapies. The literature was limited by selection bias and analytic approaches. This review demonstrated the importance of alliance in therapy for PTSD, across therapy models and formats. Clinical implications and research recommendations are discussed. Paper two is an empirical study of psychosis-related (PR) and treatment-related (TR) PTSD, nurse-patient relationships, and patient mental wellbeing and mental health symptoms, among 85 inpatients on acute psychiatric wards. Participants completed questionnaires relating to these constructs. Most participants had experienced at least one psychosis or treatment-related traumatic event (91%), and more than half met criteria for probable PTSD relating to their index trauma (51%). Correlation analyses identified moderate associations between PTSD, mental wellbeing, and mental health symptoms. Perceived criticism in the nurse-patient relationship was associated with PTSD and symptoms, but not with mental wellbeing. Perceived warmth was not associated with any of the mental health variables. PR/TR-PTSD was the only significant predictor of mental wellbeing in a regression model, controlling for demographics. These findings provide support for the implementation of trauma-informed care, including routine trauma screening, within inpatient services. Further clinical and research implications are discussed. Paper three provides a critical appraisal of the research conducted in paper one and paper two, including additional clinical implications and methodological considerations. It additionally presents the author’s personal reflections on the research process and the context of the research.
Date of Award31 Dec 2021
Original languageEnglish
Awarding Institution
  • The University of Manchester
SupervisorGillian Haddock (Supervisor) & Katherine Berry (Supervisor)


  • Psychosis-related PTSD
  • Therapeutic Alliance
  • PTSD
  • Trauma-informed Care

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