Building Trust in Schizophrenia Care: How the Therapeutic Alliance Shapes Outcomes

At the Southern California Psychiatry Conference in Huntington Beach, California, Gerald A. Maguire, MD, argued that decisions about long-acting injectable (LAI) antipsychotics are inseparable from the therapeutic alliance a psychiatrist builds with a patient over time. Maguire, who serves as chief of staff and chair of psychiatric residency training at College Medical Center in Long Beach and as faculty director of graduate medical education at Oroville Hospital in Northern California, told Psychiatric Times that trust is not a soft add-on to treatment planning, but the mechanism that makes shared decision-making possible in the first place.

"What really predicts whether our patients respond is not necessarily, say, the school of psychotherapy that you may utilize," Maguire told attendees. "It's whether they feel that you, as a clinician, are there to help them, that you have their best interest, and they can open up."

To illustrate his point, Maguire invited his patient of nearly 30 years, Jackie, on stage to discuss her challenges and journey. In doing so, Jackie shared a recent episode when she began hearing the voice of a friend who had died, a classic early symptom of the kind of episode that had previously landed her in the hospital. She called Maguire, and due to her trust in him, told him exactly what was happening, even though she feared potential hospitalization. Instead, because she had caught it early on, he was able to adjust her medications and avoid hospitalization. That decision she made to disclose the information demonstrated the importance of building a therapeutic alliance and resulted in a better outcome for her.

Trust Begins With Being Truly Seen

For Jackie, building trust began with a correct diagnosis. "I was misdiagnosed for 5 years until I met you,” she explained during the session. Originally she received a bipolar diagnosis and the prescribed antidepressants brought suicidal thoughts and repeated hospitalizations. What changed with Maguire wasn't only the medication; it was the sense that a clinician had actually seen her clearly. "He's the best diagnostician, and he just took me off those antidepressants," she said.

For Maguire, that moment says something specific about trust: Patients don't extend an alliance to a clinician in the abstract. They extend it to the clinician whose read of them finally matches their own experience.

A Deliberate Rogerian Framework, Not Just Good Bedside Manner

Maguire was explicit that his approach is a deliberate clinical framework, not an intuitive style. "We should all begin as a Rogerian therapist," he told attendees. He shared principles from psychologist Carl Rogers, namely to leverage open questions, active listening, and avoiding judgmental statements.

In addition, Maguire reminded attendees that words have an impact on that alliance. For instance, he advised avoiding phrases like “I understand," because claiming to understand an experience (eg, trauma, psychosis, homelessness) that the clinician hasn't lived can subtly undercut a patient's trust.

Alternatively, he uses, "I can only imagine." He pairs that with a commitment to being true and genuine with patients rather than performing empathy, what person-centered therapy calls congruence.

Partnering With the Patient in Choosing the Treatment

That same foundation carries into how Maguire approaches the actual decision point on treatment, including LAIs. In an interview with Psychiatric Times, he described starting not with a recommendation, but with a question about what the patient wants.

"Very commonly, the goals may be: I want to get out of the hospital. I want to have my own place to live. I want to be financially independent," he told Psychiatric Times. From there, he frames the conversation around what has stood between the patient and those goals, and walks through options together. "I always say I'm the coach, but you're the player," he said. "I can help guide this, but it's your life... it's your decision."

At the end of the day, Maguire reminded attendees that the biggest threat to a therapeutic alliance is often the clinician's own workflow.

"I think so often clinicians, we think, ‘I have to get my information, I have got to fill out this progress note, this template on the electronic medical record,’” he told Psychiatric Times. “But if you just let your patients talk and form that open environment where they feel they can share and open up to you, and have that nonjudgmental, empathic, compassionate, positive regard, the information will flow."

Dr Maguire is director of residency training and chair of psychiatry at College Medical Center in Long Beach, California, founder of Stuttering Treatment and Research Society (STARS), and a member of the Psychiatric Times Editorial Board.