Rosemarie McCabe

The therapeutic relationship in the treatment of severe mental illness: a review of methods and findings.

Aims: To review the methods and findings from studies of the therapeutic relationship (TR) in the treatment of severe mental illness. Method: A literature search was conducted to identify all studies that used an operationalised measurement of the TR in the treatment of severe mental illness. Results: Fifteen scales–the majority of which were developed for psychotherapy–and the expressed emotion index have been used. Most scales have acceptable internal, inter-rater and test–retest reliability. As none of the scales has been used in more than five studies, no single scale is widely established in psychiatric research. A more positive relationship consistently predicts a better short-and long-term outcome. It appears that a large global factor accounts for the greatest proportion of the variance in the therapeutic relationship. Conclusions: The therapeutic relationship is a reliable predictor of patient outcome in mainstream psychiatric care. Valid assessments may need to take account of different, specific aspects of the relationship in psychiatric settings such as greater heterogeneity of treatment components and goals, increased variability of setting and the statutory responsibility of the clinician. Methodological progress may require conceptual work to ensure valid assessments of this central element of treatment.

A new scale to assess the therapeutic relationship in community mental health care: STAR

BACKGROUND No instrument has been developed specifically for assessing the clinician-patient therapeutic relationship (TR) in community psychiatry. This study aimed to develop a measure of the TR with clinician and patient versions using psychometric principles for test construction. METHOD A four-stage prospective study was undertaken, comprising qualitative semi-structured interviews about TRs with clinicians and patients and their assessment of nine established scales for their applicability to community care, administering an amalgamated scale of more than 100 items, followed by Principal Components Analysis (PCA) of these ratings for preliminary scale construction, test-retest reliability of the scale and administering the scale in a new sample to confirm its factorial structure. The sample consisted of patients with severe mental illness and a designated key worker in the care of 17 community mental health teams in England and Sweden. RESULTS New items not covered by established scales were identified, including clinician helpfulness in accessing services, patient aggression and family interference. The new patient (STAR-P) and clinician scales (STAR-C) each have 12 items comprising three subscales: positive collaboration and positive clinician input in both versions, non-supportive clinician input in the patient version, and emotional difficulties in the clinician version. Test-retest reliability was r=0.76 for STAR-P and r=0.68 for STAR-C. The factorial structure of the new scale was confirmed with a good fit. CONCLUSIONS STAR is a specifically developed, brief scale to assess TRs in community psychiatry with good psychometric properties and is suitable for use in research and routine care.

The therapeutic relationship in psychiatric settings

Objective:  To discuss the current climate of research on the therapeutic relationship (TR) in mainstream psychiatric settings.

Does the therapeutic relationship predict outcomes of psychiatric treatment in patients with psychosis? A systematic review

Background: Numerous studies have shown that the quality of the therapeutic relationship (TR) between the patient and the clinician is an important predictor of the outcome of different forms of psychotherapy. It is less clear whether the TR also predicts outcomes of psychiatric treatment programmes in patients with psychosis (i.e. outside conventional psychotherapy). Methods: We conducted a systematic review and identified 9 primary studies that prospectively tested the association of the TR with 3 outcomes, i.e. hospitalisation, symptom levels and functioning. Because of the heterogeneity of the methods used, a meta-analysis was not feasible. A vote counting method was used to determine the number of statistically significant effects in the hypothesised direction (i.e. that a more positive TR predicts more favourable outcomes). Results: For each outcome, a χ2 analysis showed that the number of statistically significant findings in the hypothesised direction was greater than expected if the null hypothesis of no association were true. However, studies had methodological shortcomings, and the effect sizes of positive associations were rather small. Conclusion: It may be concluded that there is some, but not overwhelming, evidence that the TR predicts outcomes of complex psychiatric treatment programmes in patients with psychosis, and that methodologically more rigorous research is required. Such research should measure the TR at initial stages of treatment and use validated assessment instruments for both TR and outcomes.

Therapeutic relationships in psychiatry: the basis of therapy or therapy in itself?

All healthcare is delivered in relationships between professionals and patients, and this relationship is particularly central to mental healthcare. Although fewer studies have been conducted in community psychiatry than in psychological treatments, there is increasing evidence that the therapeutic relationship predicts outcome across various psychiatric settings. The clinician-patient relationship and communication may indirectly improve outcome, e.g. mediated through better treatment adherence. Yet, evidence suggests that these interpersonal processes also have a direct therapeutic effect. Thus, depending on the conceptual model of therapeutic processes they may be seen as therapy in itself. Clinicians receive little specific instruction and supervision in communication skills, and research on the issue is scarce. Whilst there are conceptual and methodological challenges to such research, the aim should be to identify therapeutically effective elements of relationships and communication that can be tested in experimental studies. Although still rare, interventions to improve clinician-patient communication in routine mental healthcare show favourable results. A further step may be adapting established psychological treatment models, such as cognitive behaviour or solution focused therapy, to make routine clinical interactions more therapeutic and evidence based. This would be in the interest of clinicians, in optimizing their therapeutic potential, and patients alike.

Psychiatric patients’ views on why their involuntary hospitalisation was right or wrong: a qualitative study

PurposeTo explore involuntary patients’ retrospective views on why their hospitalisation was right or wrong.MethodsInvoluntary patients were recruited from 22 hospitals in England and interviewed in-depth. The study drew on grounded theory and thematic analysis.ResultsMost of the patients felt mentally unwell before admission and out of control during their treatment. Despite these common experiences, three groups of patients with distinct views on their involuntary hospitalisation were identified: those who believed that it was right, those who thought it was wrong and those with ambivalent views. Those with retrospectively positive views believed that hospitalisation ensured that they received treatment, averted further harm and offered them the opportunity to recover in a safe place. They felt that coercion was necessary, as they could not recognise that they needed help when acutely unwell. Those who believed that involuntary admission was wrong thought that their problems could have been managed through less coercive interventions, and experienced hospitalisation as an unjust infringement of their autonomy, posing a permanent threat to their independence. Patients with ambivalent views believed that they needed acute treatment and that hospitalisation averted further harm. Nonetheless, they thought that their problems might have been managed through less coercive community interventions or a shorter voluntary hospitalisation.ConclusionsThe study illustrates why some patients view their involuntary hospitalisation positively, whereas others believe it was wrong. This knowledge could inform the development of interventions to improve patients’ views and treatment experiences.

Are therapeutic relationships in psychiatry explained by patients’ symptoms? Factors influencing patient ratings

OBJECTIVE To investigate the therapeutic relationship and how it is influenced by sociodemographic and clinical factors. METHOD This study analysed self-ratings of the therapeutic relationship in 90 first-admitted, 72 long-term hospitalised and 41 out-patients with schizophrenia along with 249 alcoholic and 42 depressive in-patients and their association with sociodemographic and clinical variables. In all the patients, the therapeutic relationship was assessed using a simple scale based on three items. RESULTS The therapeutic relationship differed significantly across groups. It was rated most positively by alcoholic patients and least positively by long-term hospitalised schizophrenia patients. Increased observer-rated psychopathology was significantly associated with a poorer therapeutic relationship in all groups except the hospitalised schizophrenia patients. In this group, increased self-rated symptoms were associated with a poorer relationship. In multiple regression analyses, 3-28% of the relationship variance was explained by psychopathology. CONCLUSIONS; Patient ratings of the therapeutic relationship were partially explained by psychopathology, leaving the greater part of the variance to be explained by factors other than sociodemographic and clinical characteristics.

Theoretical frameworks for understanding and investigating the therapeutic relationship in psychiatry

Background: Mental health care is delivered through a relationship between a clinician and a patient. Although this therapeutic relationship is of central importance for mental health care, it appears to be relatively neglected in psychiatric research. Empirical research has for the most part adopted concepts and methods developed in psychotherapy and general medical practice. Hence, unpacking the presuppositions that have informed research on the therapeutic relationship to date may be a useful first step in developing this field. Method: A review of the literature was carried out. Results: Six central theories are identified as framing the definitions and methods on this topic: role theory, psychoanalysis, social constructionism, systems theory, social psychology and cognitive behaviourism. To date, role theory, psychoanalysis and systems theory appear to be the frameworks most often applied in research in this field. Each perspective offers a unique emphasis in the analysis of the therapeutic relationship, which is reflected in the empirical work from each perspective discussed herein. Conclusions: None of the theories identified have been fully specified and comprehensively investigated in psychiatric settings. However, more than one approach may be used for thinking about relationships, depending on the treatment situation. Further specification and testing of the theories in psychiatric practice – taking account of the specific context – is warranted to underpin more pragmatic research. A stronger link between fundamental psychological and sociological research and applied health care research would advance our understanding of which elements of positive therapeutic relationships are instrumental in improving patient outcome and ultimately contribute to improving mental health care.

Is Nonverbal Communication Disrupted in Interactions Involving Patients With Schizophrenia

Background: Nonverbal communication is a critical feature of successful social interaction and interpersonal rapport. Social exclusion is a feature of schizophrenia. This experimental study investigated if the undisclosed presence of a patient with schizophrenia in interaction changes nonverbal communication (ie, speaker gesture and listener nodding). Method: 3D motion-capture techniques recorded 20 patient (1 patient, 2 healthy participants) and 20 control (3 healthy participants) interactions. Participants rated their experience of rapport with each interacting partner. Patients’ symptoms, social cognition, and executive functioning were assessed. Four hypotheses were tested: (1) Compared to controls, patients display less speaking gestures and listener nods. (2) Patients’ increased symptom severity and poorer social cognition are associated with patients’ reduced gesture and nods. (3) Patients’ partners compensate for patients’ reduced nonverbal behavior by gesturing more when speaking and nodding more when listening. (4) Patients’ reduced nonverbal behavior, increased symptom severity, and poorer social cognition are associated with others experiencing poorer rapport with the patient. Results: Patients gestured less when speaking. Patients with more negative symptoms nodded less as listeners, while their partners appeared to compensate by gesturing more as speakers. Patients with more negative symptoms also gestured more when speaking, which, alongside increased negative symptoms and poorer social cognition, was associated with others experiencing poorer patient rapport. Conclusions: Patients’ symptoms are associated with the nonverbal behavior of patients and their partners. Patients’ increased negative symptoms and gesture use are associated with poorer interpersonal rapport. This study provides specific evidence about how negative symptoms impact patients’ social interactions.

Good communication in psychiatry – a conceptual review

BACKGROUND The communication between clinician and patient is the basis of psychiatric treatment. However, there has been little practical attention to training in it, and no specific theory of what constitutes good communication in psychiatry has been developed. This review aims to identify principles that guide good communication. METHODS A conceptual review of guiding principles for how clinicians should communicate with patients to achieve clinical objectives in psychiatry. RESULTS Five guiding principles for clinicians were identified: a focus on the patients concerns; positive regard and personal respect; appropriate involvement of patients in decision making; genuineness with a personal touch; and the use of a psychological treatment model. CONCLUSIONS The principles are mostly generic, but their implementation can be particularly challenging in psychiatry. They may guide further empirical research on effective communication in psychiatry and be utilised using different personal skills of clinicians.