The therapeutic relationship in secondary mental health care: a conceptual review of measures

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.

Cognitive Behavioral Therapy for Tinnitus: Addressing the Controversy of Its Clinical Delivery by Audiologists

Audiologists' role in providing care for tinnitus typically includes conducting an audiologic evaluation, fitting hearing aids when appropriate, assessing the impact of tinnitus, and facilitating use of sound to improve quality of life with tinnitus when appropriate. Cognitive behavioral therapy (CBT) is consistently judged by systematic reviews as having the strongest evidence relative to other therapies for improving quality of life with tinnitus. Because audiologists are already playing an active role in providing care for tinnitus, and the relative paucity of behavioral health providers who are experienced in implementing CBT for tinnitus, a logical question is whether audiologists can provide CBT and whether it is within their scope of practice. In this article, we present both sides of the argument as to whether audiologists can provide CBT and we make recommendations for appropriate administration of CBT for tinnitus management.

An exploration of the experience of trainee integrative psychotherapists on therapeutic alliance in the light of their attachment style

Therapeutic Relationship has been regarded as a profound element of the psychotherapeutic procedure and crucial for the outcome of therapy. Research evidence so far claims that both therapist’s and client’s personality can impact the Therapeutic Relationship. Based on the well-researched Attachment Theory there has been some research mostly focused on how clients’ attachment patterns can affect the Alliance. Limited research, though, on how therapists experience the Relationship in relation with their Attachment Styles do exist. The current study investigates trainee therapists’ experience of the Therapeutic Relationship in the light of their Attachment Style. A qualitative approach was used for this research to investigate in depth the experience of five trainee Integrative psychotherapists who were recruited to take part in semi-structured interviews. Interviews were transcribed and verbatim was divided into superordinate and subordinate themes and analyzed by Interpretative Phenomenological Analysis method. Four master themes were identified. Findings were then compared and discussed according to existing literature. All participants referred to the relevance of Attachment Theory in psychotherapy. They also agreed on the activation of their Attachment Styles during the therapeutic process. The securely attached therapist confirms previous studies on her capability to offer a secure base for her clients. On the other hand therapists with insecure Attachment Styles appeared sensitive in their collaboration mostly with insecure clients. Anxiously attached therapists proved to experience difficulty in the initial stages of the Therapeutic Relationship while the combination of avoidant therapist-avoidant client appeared to be the most demanding one, regarding the concept of trust and relationship ruptures. We suggest that the exploration of trainee therapists’ Attachment Styles as well as the study of the Attachment Theory should be added to all Counseling and Psychotherapy curricula regardless the therapeutic orientation because of its contribution to forming positive Therapeutic Relationships.

Interventions Incorporating Therapeutic Alliance to Improve Hemodialysis Treatment Adherence in Black Patients with End-Stage Kidney Disease (ESKD) in the United States: A Systematic Review

BACKGROUND

In the US, Blacks with end-stage kidney disease (ESKD) have a four-fold higher prevalence rate of hemodialysis treatment and higher subsequent rates of hemodialysis treatment nonadherence and hospitalization compared to their White peers. Nonadherence to prescribed dialysis therapy is an underestimated life-threatening behavior, because of its association with increased morbidity and mortality. Few studies have specified and systematically evaluated targeted methods of increasing hemodialysis treatment adherence among Black hemodialysis patients with added focus on therapeutic alliance, a rewarding patient-centered relationship between patients and providers, based on common goals and objectives. This review seeks to evaluate the state of the science to determine the salience of a therapeutic alliance for the development of effective interventions positively impacting hemodialysis treatment adherence among Black patients.

METHODS

Medline (via PubMed), Embase (OvidSP), Cumulative Index of Nursing and Allied Health Literature (CINAHL; EBSCOhost), and PsycInfo (ProQuest) databases were used to search for abstracts with the keywords "dialysis", "therapeutic alliance", and "treatment adherence and compliance", including all underlying index terms and alternative variations of terms, in order to cover the entire scope of the field. Only randomized clinical trials and pre/postintervention studies published in the previous 10 years (2009-2019) and including a proportion of Black patients >25% were included for review.

RESULTS

Only three intervention studies met these criteria, for a total aggregated sample of 130 - mean age 58.1 years and 53% female. None of these studies was composed exclusively of Black patients (range 62%-91.3%), nor did they present data specifically for Blacks. Despite the lack of robust data informing strategies to improve hemodialysis adherence among Blacks with ESRD, a limited number of intervention studies have reported positive effects on hemodialysis attendance.

DISCUSSION/CONCLUSION

Further research is warranted to fill this significant gap in our understanding of theoretically based, therapeutic alliance-enhanced, and culturally tailored hemodialysis treatment-adherence interventions among Blacks.

Roles of Psychiatry Nurses Within a Therapeutic Environment of Psychiatry Clinics in Turkey

OBJECT

The object of this study is to determine the roles of psychiatry nurses within the therapeutic environment of psychiatry clinics in Turkey.

METHODS

This study was performed in a cross-sectional and descriptive design in 195 institutes comprising psychiatry clinics in Turkey.

RESULTS

When the responsibilities of nurses for clinical activities were asked, the following answers were obtained: playing with patients or painting at a rate of 54,4%. It was determined that in the majority of psychiatry clinics, there were educational activities which were conducted by nurses.

CONCLUSION

The researchers propose that the increase in the roles and responsibilities of nurses in such activities be supported.

Can the therapeutic relationship predict 18 month outcomes for individuals with psychosis?

Therapeutic relationships (TRs) are considered a key component of good psychiatric care, yet its association with outcomes for individuals with psychosis remains unclear. Five hundred and sixty-nine service users with psychotic disorders and care coordinators in community settings rated their therapeutic relationship; outcomes were assessed 18 months later. In multivariate analyses, a small but significant association was found between service user ratings and instances of psychiatric hospital admissions, self harm and suicide attempts over an 18 month period. Care coordinator ratings were associated with instances of psychiatric hospital admissions and harm to others over the 18 months and level of functioning at 18 months. The differential findings and small effect size suggests that the therapeutic relationship needs further definition for this patient group in this setting. Nevertheless, clinicians should prioritise interactions that strengthen therapeutic relationships.

Development and feasibility of a self-management intervention for chronic obstructive pulmonary disease delivered with motivational interviewing strategies

BACKGROUND

Self-management is proposed as the standard of care in chronic obstructive pulmonary disease (COPD), but details of the process and training required to deliver effective self-management are not widely available. In addition, recent data suggest that patient engagement and motivation are critical ingredients for effective self-management. This article carefully describes a self-management intervention using motivational interviewing skills, aimed to increase engagement and commitment in severe COPD patients.

METHODS

The intervention was developed and pilot tested for fidelity to protocol, for patient and interventionist feedback (qualitative) and effect on quality of life. Engagement between patient and interventionists was measured by the Working Alliance Inventory. The intervention was refined on the basis of the results of the pilot study and delivered in the active arm of a prospective randomized study.

RESULTS

The pilot study suggested improvements in quality of life, fidelity to theory, and patient acceptability. The refined self-management intervention was delivered 540 times in the active arm of a randomized study. We observed a retention rate of 86% (patients missing or not available for only 14% the scheduled encounters).

CONCLUSIONS

A self-management intervention that includes motivational interviewing as the way if guiding patients into behavior change is feasible in severe COPD and may increase patient engagement and commitment to self-management. This provides a very detailed description of the process for the specifics of training and delivering the intervention, which facilitates replicability in other settings and could be translated to cardiac rehabilitation.

Therapeutic alliance in schizophrenia: the role of recovery orientation, self-stigma, and insight

The present study examined variables related to the quality of the therapeutic alliance in out-patients with schizophrenia. We expected recovery orientation and insight to be positively, and self-stigma to be negatively associated with a good therapeutic alliance. We expected these associations to be independent from age, clinical symptoms (i.e. positive and negative symptoms, depression), and more general aspects of relationship building like avoidant attachment style and the duration of treatment by the current therapist. The study included 156 participants with DSM-IV diagnoses of schizophrenia or schizoaffective disorder in the maintenance phase of treatment. Therapeutic alliance, recovery orientation, self-stigma, insight, adult attachment style, and depression were assessed by self-report. Symptoms were rated by interviewers. Hierarchical multiple regressions revealed that more recovery orientation, less self-stigma, and more insight independently were associated with a better quality of the therapeutic alliance. Clinical symptoms, adult attachment style, age, and the duration of treatment by current therapist were unrelated to the quality of the therapeutic alliance. Low recovery orientation and increased self-stigma might undermine the therapeutic alliance in schizophrenia beyond the detrimental effect of poor insight. Therefore in clinical settings, besides enhancing insight, recovery orientation, and self-stigma should be addressed.

Therapeutic relationship in the context of perceived coercion in a psychiatric population

The relationship between patient and therapist in mental health care is one of the most important treatment factors. It is a reliable predictor of treatment outcome, regardless of diagnosis, setting or of the type of therapy used. On the other hand, influence and coercion occur in patient-physician relationships in psychiatry. We investigated the associations between patients' perceived coercion and the therapeutic relationship. A total of 116 psychiatric patients, who have been admitted to the Psychiatric University Hospital Zurich, were interviewed using a structured interview. Data were collected by using Scale To Assess the Therapeutic Relationship (STAR) (therapeutic relationship) and Mac Arthur Admission Experience Survey (AES) (perceived coercion). Associations were investigated using bivariate and multivariate methods. Perceived coercion predicts the patients' appraisal of the therapeutic relationship. We found a moderate relation between the patients' and the clinicians' view of their relationship. Perceived coercion is related to a higher symptom level and a lower level of global functioning at admission, and higher perceived coercion is related to a more negative patient-therapist relationship rated by the patient. Perceived loss of autonomy goes hand in hand with a more negative relationship between the patient and the clinician. This phenomenon has to be impeded, regarding the unambiguous impact relationship quality has on treatment outcome.

Case managers' perspectives on the therapeutic alliance: a qualitative study

PURPOSE

In order to understand the nature of the therapeutic alliance in intensive case management, this study used qualitative methods to assess the dynamics of the case managers' relationships with their consumers by examining their perspectives on their own and their consumers' likeability, how helpful consumers perceive them to be, as well as their expectations for their relationships with their consumers.

METHODS

The study employed content analysis of open-ended responses from 49 intensive case managers about their consumers.

RESULTS

From case managers' responses, four themes emerged describing the dynamics of the case manager/consumer relationship: motivation, monitoring, creating dependency, and being there.

CONCLUSIONS

The current qualitative findings suggest that current constructions and measures of the therapeutic alliance developed in psychotherapy research are not fully capturing the ways in which the unique structure and constraints of intensive case management influence relationships between workers and consumers.

Measuring patient-reported outcomes in psychosis: conceptual and methodological review

BACKGROUND

There are calls to use patient-reported outcomes (PROs) routinely across mental health services. However, the use of PROs in patients with psychosis has been questioned.

AIMS

To examine the concepts and measures of four widely used PROs: treatment satisfaction, subjective quality of life, needs for care and the quality of the therapeutic relationship.

METHOD

We conducted a literature search of academic databases on concepts, characteristics and psychometric properties of the four PROs in patients with psychosis.

RESULTS

Although numerous concepts and measures have been published, evidence on the methodological quality of existing PROs is limited. Measures designed to assess distinct PROs showed a considerable conceptual, operational and empirical overlap, and some of them also included specific aspects. The impact of symptoms and cognitive deficits appears unlikely to be of clinical significance.

CONCLUSIONS

The popularity of PROs has not been matched with progress in their conceptualisation and measurement. Based on current evidence, some recommendations can be made. Distinct and short measures with clinical relevance and sufficient psychometric properties should be preferred. Future research should optimise the validity and measurement precision of PROs, while reducing assessment burden.

Comparison of patients' and clinicians' views of the therapeutic relationship: a pilot project

OBJECTIVE

Our aim was to find out whether psychiatrists' views of the quality of the therapeutic relationship were shared by their patients, and to ascertain a feasible way to explore these relationships routinely.

METHOD

Sixty-one outpatients selected by two receptionists completed the Helping Alliance Scale (HAS), client version and the Relationship Questionnaire. The two participating psychiatrists were not involved in patient selection and were blind to patients' responses. They recorded their view of the relationships using the clinician version of HAS. The Big Five Inventory and Relationship Questionnaire were also utilized. Without identifying patients, each psychiatrist analysed the data of the other clinician.

RESULTS

Both clinicians had an agreement rate above 75%. The differences in the details reflected gender and personality differences. There was no benchmark with which to compare these results.

CONCLUSIONS

Assessing and recording the therapeutic relationship in community practice is feasible and provides invaluable knowledge. The next challenge is to consider whether and how this could be done routinely.

The therapeutic relationship and adherence to antipsychotic medication in schizophrenia

Objective

Previous research has shown that a better therapeutic relationship (TR) predicts more positive attitudes towards antipsychotic medication, but did not address whether it is also linked with actual adherence. This study investigated whether the TR is associated with adherence to antipsychotics in patients with schizophrenia.

Methods

134 clinicians and 507 of their patients with schizophrenia or a related psychotic disorder participated in a European multi-centre study. A logistic regression model examined how the TR as rated by patients and by clinicians is associated with medication adherence, adjusting for clinician clustering and symptom severity.

Results

Patient and clinician ratings of the TR were weakly inter-correlated (r_s = 0.13, p = 0.004), but each was independently linked with better adherence. After adjusting for patient rated TR and symptom severity, each unit increase in clinician rated TR was associated with an increase of the odds ratio of good compliance by 65.9% (95% CI: 34.6% to 104.5%). After adjusting for clinician rated TR and symptom severity, for each unit increase in patient rated TR the odds ratio of good compliance was increased by 20.8% (95% CI: 4.4% to 39.8%).

Conclusions

A better TR is associated with better adherence to medication among patients with schizophrenia. Patients' and clinicians' perspectives of the TR are both important, but may reflect distinct aspects.

Attachment to the clinical team and its association with therapeutic relationships, social networks, and clinical well-being

OBJECTIVES

To determine (1) inter-relationships between social network size and quality and therapeutic relationship ratings and (2) inter-relationships between attachment style, team attachment, therapeutic relationships, social networks, and clinical and social functioning.

DESIGN

A cross-sectional survey.

METHOD

A sample of 93 people using community mental health teams were assessed on their attachment status, social networks, relationship to the keyworker, attachment to the team, characteristics, and clinical and social functioning. Network size and the number friends and confidants were tested for associations with user- and professional-rated therapeutic relationship. Regression analysis was used to determine variables associated with team attachment.

RESULTS

There was no evidence that network size or number of confidants was associated with therapeutic relationship ratings. Therapeutic relationship was strongly associated with team attachment, but of the four attachment dimensions, only preoccupied attachment was associated with team attachment.

CONCLUSION

There is no evidence that therapeutic relationships are associated with the service user's 'affability' or predisposition to form relationships, suggesting that measures of therapeutic relationship and service attachment do measure something distinct about service users' experience of their care. Team attachment and therapeutic relationship measures seem likely to be measuring very similar constructs. It is possible that service users with more preoccupied attachment styles may find it particularly difficult to form positive attachments to services undergoing frequent change.

The influence of therapeutic alliance and insight on medication adherence in schizophrenia

BACKGROUND

Poor adherence is one of the leading problems affecting the effectiveness of treatment in schizophrenia. It is an identified factor for relapse and hospitalizations with major social and economic consequences. Various determinants of poor adherence have been identified but few studies investigate the role of therapeutic alliance on medication adherence in routine mental healthcare.

AIMS

To investigate links between therapeutic alliance insight and medication adherence in routine care and community psychiatry.

METHODS

In this cross-sectional study, 38 inpatients that met ICD-10 criteria for schizophrenia or schizoaffective disorder were recruited and independently interviewed just before discharge. Various rating scales were used: the self-reported 4-Point ordinal Alliance Scale (4PAS), the Medication Adherence Rating Scale (MARS) and the Scale to assess Unawareness of Mental Disorder (SUMD). In addition, we investigated the relationships between medication adherence and clinical variables through uni- and multivariate analysis.

RESULTS

Therapeutic alliance was significantly correlated with adherence (r = 0.663, P < 0.0001) and insight (r =-0.664, P < 0.0001). Poor adherence was associated in patients with substance or alcohol use disorders (5.4 vs. 2.9, P = 0.0075, t = 2.83). No significant difference was found between the demographic characteristics of the sample, the characteristics of the treatments and adherence.

CONCLUSIONS

A weak therapeutic alliance and low insight are associated with poor adherence in patients with schizophrenia or schizoaffective disorder who were hospitalized. Specific psycho-educational programs to improve therapeutic alliance and insight should be implemented to achieve better therapeutic adherence and outcome.

Psychometric Properties of the German Version of the Scale to Assess the Therapeutic Relationship in Community Mental Health Care (D-STAR)

Objective: There are presently no instruments available in German language to assess the therapeutic relationship in psychiatric care. This study validates the German version of the Scale to Assess the Therapeutic Relationship in Community Mental Health Care (D-STAR). Method: 460 persons with severe mental illness and 154 clinicians who had participated in a multicenter RCT testing a discharge planning intervention completed the D-STAR. Psychometric properties were established via item analysis, analyses of missing values, internal consistency, and confirmatory factor analysis. Furthermore, convergent validity was scrutinized via calculating correlations of the D-STAR scales with two measures of treatment satisfaction. Results: As in the original English version, fit indices of a 3-factor model of the therapeutic relationship were only moderate. However, the feasibility and internal consistency of the D-STAR was good, and correlations with other measures suggested reasonable convergent validity. Conclusions: The psychometric properties of the D-STAR are acceptable. Its use can be recommended in German-speaking countries to assess the therapeutic relationship in both routine care and research.

Therapeutic relationships: their specificity in predicting outcomes for people with psychosis using clinical and vocational services

OBJECTIVE

To determine the distinctions between the client-keyworker relationship and the client-vocational worker relationship by assessing their impact on clinical outcomes and exploring the associations between the two.

METHODS

As part of an international randomised controlled trial of supported employment (n = 312), client-keyworker relationship and client-vocational worker relationship were each tested against clinical and social functioning 6 months later. Associations between the two relationships over time were explored.

RESULTS

Client-keyworker relationship predicted quality of life, while client-vocational worker relationship, as rated by the client, did not predict any clinical or social functioning outcomes. Vocational worker-rated relationship predicted reduced depression. The client-keyworker and client-vocational worker relationships were correlated, but this did not change over time.

CONCLUSION

The impact of the client-vocational worker is likely to be on the shared task of finding employment, rather than on clinical and social functioning. Good client-vocational worker relationships do not detract from client-keyworker relationships.

The 4-Point ordinal Alliance Self-report: a self-report questionnaire for assessing therapeutic relationships in routine mental health

BACKGROUND

The quality of the relationship between patient and therapist can be considered a cornerstone of psychiatric practice. Nonadherence is one of the leading problems affecting antipsychotic effectiveness in schizophrenic patients and represents a poor prognostic factor for schizophrenia. Among the factors influencing adherence, the clinician's style of communication and the therapeutic relationship (TR) are recognized as key points. The measures of TR have been broadly explored in psychotherapy process but have received little attention in the treatment of severe mental illness in the context of routine mental health. Our objective was to build a self-rating scale easy to use in clinical psychiatric practice to assess TR, including drug-taking aspects and the relationship with the clinician on a day-to-day basis. A secondary objective was to assess the scale's validity and the association between TR and adherence.

METHODS

The study was conducted with 92 consenting inpatients who met specified criteria for schizophrenia and schizoaffective disorders (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition). Assessments of TR were obtained by the 4-Point ordinal Alliance Self-report and an 8-cm visual analog scale completed by the patient 1 week before discharge, after the remission of acute symptomatology. Adherence behavior was estimated with a new valid and reliable questionnaire called the Medication Adherence Rating Scale. Factor analysis was performed.

RESULTS

Internal consistency was assessed by calculating Cronbach alpha, which revealed a highly satisfactory value (alpha = .91). After oblique rotation was run, 2 understandable factors were extracted that we termed empathy experienced and psychoeducation.

CONCLUSIONS

Therapeutic relationship with the clinician can be considered a prerequisite for positive treatment course and outcome. The detection of subpopulations characterized by determinants of poor TR could be the first step toward improving schizophrenia prognosis linked to poor adherence.

Evidence that the Two-Way Communication Checklist identifies patient-doctor needs discordance resulting in better 6-month outcome

OBJECTIVE

To assess an intervention aimed at reducing patient-professional carer needs discordance.

METHOD

In a group of 460 patients with schizophrenia, the Two-Way Communication Checklist (2-COM), an instrument to rate needs, was completed at baseline, 2 months and 6 months by both the patient and the professional carer, allowing for the quantification of patient-carer needs discordance.

RESULTS

Reduction in patient-reported 2-COM needs in the group with low baseline needs discordance was much greater at 2 and 6 months (2 months: beta = -0.65, P < 0.001; 6 months: beta = -1.00, P < 0.001) than in the group with high baseline discordance (2 months: beta = -0.35, P < 0.001; 6 months: beta = -0.49, P < 0.001). Reduction in needs discordance between baseline and 2 months (beta = -0.07, P = 0.004) as well between 2 and 6 months (beta = -0.05, P = 0.020) was associated with greater levels of CGI clinical improvement.

CONCLUSION

The fact that patient-carer needs discordance impacts negatively, and its reduction positively, on 6-month outcome suggests that systematic inventory of patient-carer views on needs is necessary.

Predictors of employment for people with severe mental illness: results of an international six-centre randomised controlled trial

BACKGROUND

An international six-centre randomised controlled trial comparing individual placement and support (IPS) with usual vocational rehabilitation for people with serious mental illness found IPS to be more effective for all vocational outcomes.

AIMS

To determine which patients with severe mental illness do well in vocational services and which process and service factors are associated with better outcomes.

METHOD

Patient characteristics and early process variables were tested as predictors of employment outcomes. Service characteristics were explored as predictors of the effectiveness of IPS.

RESULTS

Patients with previous work history, fewer met social needs and better relationships with their vocational workers were more likely to obtain employment and work for longer. Remission and swifter service uptake were associated with working more. Having an IPS service closer to the original IPS model was the only service characteristic associated with greater effectiveness.

CONCLUSIONS

The IPS service was found to be more effective for all vocational outcomes. In addition, maintaining high IPS fidelity and targeting relational skills would be a valuable focus for all vocational interventions, leading to improved employment outcomes. Motivation to find work may be decreased by satisfaction with current life circumstances.