Research on the role of the therapeutic relationship in routine psychiatric care

Transcription

1 Research on the role of the therapeutic relationship in routine psychiatric care Rose McCabe Unit for Social & Community Psychiatry, Barts & the London School of Medicine

2 plan of talk I. the therapeutic relationship II. doctor-patient communication & meaning in treatment III. linking communication & relationship

3 I. the therapeutic relationship

4 service configuration and individual outcome Service configuration? probability Black box Clinical practice and Treatment processes Individual outcome?

5 the therapeutic relationship in psychotherapy the vehicle of success in psychoanalysis exactly as in other methods of treatment (Freud 1912) various terms, concepts & methods of assessment non-specific large global factor predicts outcome

6 psychiatric settings statutory role flexible setting variable time-scale (life long treatment?) treatment often aimed at stability rather than change multidisciplinary teamwork (AO) most important factor in good psychiatric care (Johansson & Eklund 2000) neglected in research

7 therapeutic relationship & outcome linked to outcome: effect size r= (Martin et al 2000, 18/77 studies of SMI) in depression, TR accounted for 21% variance in improvement compared with 2% for treatment differences (Krupnick et al 1996) for each unit of increased tr, remission 3 times more likely in schizophrenia (Frank & Gunderson 1990) less likely to drop out of treatment more likely to accept medication better functional outcomes TR accounted for 11% variance in outcome at 2 years positive outcomes: symptom severity, treatment adherence, hospitalisation, social functioning, quality of life

8 findings: patient ratings symptoms explain 12-28% variance in patient ratings of therapeutic relationship (McCabe & Priebe 2003) hostility, thought disorder EQOLISE: international RCT (n=312) of supported employment (IPS), 18 month follow-up (Burns et al, in press) TR (rated by patient & worker) with vocational worker at 6 mo predicts employment

9 findings: therapist ratings social functioning related to therapist ratings in psychiatry: therapist ratings predict outcome high EE relationships: more likely to criticise patient s personality low EE: believing patient s problems a result of illness high EE: attributing problems to patient s personality

10 findings: general patients rate the TR higher than clinicians low (or no) correlation b/n clinician & patient ratings in psychotic illness moderate correlation in non-psychotic illness older age better relationship

11 MEASURES OF THE THERAPEUTIC RELATIONSHIP Measure Author Rater Rating form Studies Barrett-Lennard Barrett-Lennard, 1962 Client Questionnaire 1 Relationship Inventory California Psychotherapy Marmar & Gaston, 1. Client 1. Questionnaire 3 Scale Therapist 3. Expert 2. Questionnaire 3.Videotapes Helping Alliance Counting Luborsky et al., 1983 Rater Transcripts 2 Signs (1 training) Helping Alliance Scale Priebe & Gruyters, Client Questionnaire Psychotherapy Status Stanton et al., 1984 Clinician Questionnaire 2 Report Scale to Assess the Allen et al., 1984 Expert rater Rating scale 2 Therapeutic Alliance (Transcripts) Therapeutic Alliance Scale Marziali et al., 1981 Expert rater Audiotapes 2 Therapeutic Alliance Marmar et al., Client 1. Questionnaire 1 Rating System 2. Therapist 3. Expert 2. Questionnaire 3. Audio/video Therapeutic Alliance Clarkin et al., 1987 Expert rater Questionnaire 2 Rating Scale (chart material) Therapist-Client Bennun et al., Client Questionnaire 1 Relationship Scale 2. Therapist Therapist-Patient Scale for Stark et al., Client Questionnaire 2 Schizophrenic Patients 2. Therapist Vanderbilt Therapeutic Hartley & Strupp, Expert rater Questionnaire 1 Alliance Scale Working Alliance Inventory 1983 Horvath & Greenberg, Client 2. Therapist 3. Rater (Audiotapes) 1. Questionnaire 2. Questionnaire 3. Videotapes 5

12 STAR Scale To Assess therapeutic Relationships developed over 4 yrs a patient and a clinician version each with 12 items in each scale, 3 distinct factors are assessed: positive collaboration (6 items) positive clinician input (3 items), and non-supportive clinician input/emotional difficulties (3 items) good psychometric properties

13 II. doctor-patient communication

14 relationship and interaction interaction: behavioural exchange between patient and clinician that is observable and may be described in objective terms relationship: psychological construct held by individuals participating in the TR on each other and their interaction

15 a positive diagnosis 200 patients attending GPs with symptoms but no abnormal signs randomly assigned to a positive or a neutral consultation positive: firm diagnosis & told they would be better in a few days neutral: I cannot be certain what is the matter with you 2 weeks later: 64% of + said they were better compared to 39% of - (p<.001) with or without prescription Thomas (1987)

16 analysing consultations: conversation analysis detailed micro-analysis of talk-in-interaction in order to: to identify and describe the specific interactional consequences which follow from given verbal practices (Drew et al 2001) what people do, not what they say they do how participants in an interaction negotiate meaning on a turn-by-turn basis

17 .hhh Audible inhalation hhh Audible exhalation : Extended sound ising intonation Falling intonation Emphasising (word or part of word underlined) Talk is quieter than the surrounding talk < > Talk is faster than the surrounding talk HELLO Talk is louder than the surrounding talk = Latched utterance, no interval between utterances [ ] Beginning and end of overlap ( ) Transcriptionist doubt *** Smiling (.) Pause of less than 0.2 seconds (0.0) Silence measured in seconds and tenths of seconds

18 normal transcript mother: okay three months time doctor: so patient: why don t people believe me doctor when I say I m God? why don t they believe me cause everyone knows I am.

19 making sense of psychotic experience patient presents concerns patient attempts to make sense of their anomalous experience avoidance, or absence of attempts, to establish intelligibility becomes an issue of belief/disbelief explicit conflict about the underlying problem meaning is disputed McCabe et al. (2002)

20 why is meaning important (in psychosis)? all models of psychotherapy prioritise feeling understood with psychosis, the person is vulnerable to losing meaning creating meaning from strange experiences may be particularly important (Hinshelwood, 1999) McCabe & Priebe (2003)

21 meaning in treatment nonspecific effects account for at least 1/3 successful treatment outcomes positive health outcomes, including mortality specific effect of medication accounts for 1/4 successful treatment outcomes consensus that non-specific effects are attributable to symbolic aspects of treatment the same intervention has different effects depending on its meaning for patients & clinician

22 III. linking communication & the therapeutic relationship

23 communication relationship therapeutic relationship is linked to outcome relationships are constructed in and displayed in interactions what is it about the quality of communication that influences outcome? methodologically: how to link detailed descriptive findings about qualitative communication processes with quantitative indices of outcome?

24 communication outcome communication outcome relationship outcome communication relationship outcome

25 study design record 105 psychiatrist-patient consultations people attending outpatients with a diagnosis of schizophrenia interview psychiatrists & patients at baseline: consultations recorded patients & psychiatrists rate the therapeutic relationship patients rate their satisfaction with the communication observers rate symptoms & patient centredness at 6 month follow-up: patients & psychiatrists rate the therapeutic relationship observers rate symptoms, relapses psychiatrists rate compliance, engagement with services

26 communication relationship outcome communication effort invested in establishing mutual intelligibility observer rated patient centredness relationship patient and psychiatrist rated outcome psychiatrist and observer rated

27 constructing meaning in talk in each next turn at talk, a hearer displays their understanding of the prior talk display what s/he understood the prior talk to be doing primary site of intersubjectivity if there is no problem, move on if not interpreted properly, fix it before moving on repair is a specific conversational mechanism used to deal with problems of understanding critical to any successful interaction

28 repair protocol transcribe all consultations code all consultations using a standardised repair protocol every line of every consultation coded strength: highlights what patients & clinicians themselves treat as problematic an index for each interaction of (1) effort invested in producing meaning & (2) effort invested in addressing misunderstanding effort invested in establishing mutual intelligibility hypothesis: the greater the effort invested in addressing problems of meaning, the better the outcome Healey et al. (in press)

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30 study organisation multi-centre collaborators: Stefan Priebe, Vanessa Pinfold, Richard laugharne, David Dodwell run on the mhrn south london west east anglia funding from mrc

31 data collection 99 participants recruited at baseline 26 psychiatrists (21 male) 51 at follow-up

32 preliminary results 1 psychiatrists do less repair when patients are more symptomatic (esp. positive symptoms) more repair linked to greater patient centredness psychiatrist psychosocial beliefs associated with a more patient-centred approach involving the patient more in decision making higher patient rated satisfaction with communication

33 results 2 patients who are more satisfied with communication rate the therapeutic relationship more positively higher patient satisfaction associated with higher psychiatrist rated therapeutic relationship satisfaction with communication at baseline linked to engagement with services (collaboration) at follow-up

34 preliminary analyses overlapping constructs using subjective ratings multivariate analysis mapping relationships (inc. predictive power) between communication, the therapeutic relationship (2 perspectives), engagement with services, symptoms

35 conclusions doctors repair less when patients are more psychotic but more psychotic patients do not repair less patients who are more satisfied with the communication have better therapeutic relationships psychiatrists psychosocial beliefs influence their communication: more patient centred & patients more satisfied satisfaction with communication at baseline linked to engagement with services at follow-up

36 thank you to all of the participants Mary Lavelle, Emy Snell, Ljubica Ivanovic, Pat Healey and MHRN support from Sonia Malik, Jane Addison, Lindsay Weetman