Therapeutic alliance and long-term hospital treatment outcome

Interpersonal Change Following Intensive Inpatient Treatment

OBJECTIVE

Persons admitted for inpatient psychiatric care often present with interpersonal difficulties that disrupt adaptive social relations and complicate the provision of treatment. Whereas domains of psychosocial functioning in this population demonstrate clear growth in response to intervention, the impact of treatment on more complex patterns of interpersonal behavior has been largely overlooked within the existing literature. Interpersonal profiles characteristic of psychiatric inpatients were identified in the current study to determine rates of transition to adaptive functioning following hospitalization.

METHODS

Personality disturbance was assessed in 513 psychiatric inpatients using the Inventory of Interpersonal Problems. Scores were analyzed within a series of latent profile models to isolate unique interpersonal profiles at admission and at discharge. Longitudinal modeling was then employed to determine rates of transition from dysfunctional to adaptive profiles. Relationships with background characteristics, clinical presentation, and treatment response were explored.

RESULTS

Normative, Submissive, and Hostile/Withdrawn profiles emerged at both admission and discharge. Patients in the Normative profile demonstrated relatively moderate symptoms. Submissive and Hostile/Withdrawn profiles were related to known risk factors and elevated psychopathology. Approximately half of the patients who had been identified as Submissive or Hostile/Withdrawn transitioned to the Normative profile by discharge. Transition status evidenced modest associations with background characteristics and clinical presentation. Treatment engagement and reduction of clinical symptoms were strongly associated with adaptive transition.

CONCLUSION

Maladaptive interpersonal profiles characteristic of psychiatric inpatients demonstrated categorical change following inpatient hospitalization. Enhanced therapeutic engagement and overall reductions in psychiatric symptoms appear to increase potential for interpersonal change.

Implications for the prevention of aggressive behavior within psychiatric hospitals drawn from interpersonal communication theory

Although interpersonal style is a defining feature of personality and personality disorder and is commonly identified as an important influence on aggressive behavior, treatment completion, and the development of an effective therapeutic alliance, it is rarely considered in practice guidelines for preventing, engaging, and managing patients at risk of aggression. In this article, the authors consider three potential applications of interpersonal theory to the care and management of patients at risk of aggression during hospitalization: (a) preventing aggression through theoretically grounded limit setting and de-escalation techniques, (b) developing and using interventions to alter problematic interpersonal styles, and (c) understanding therapeutic ruptures and difficulties establishing a therapeutic alliance. Interpersonal theory is proposed to offer a unifying framework that may assist development of intervention and management strategies that can help to reduce the occurrence of aggression in institutional settings.

A systematic review of the international published literature relating to quality of institutional care for people with longer term mental health problems

BACKGROUND

A proportion of people with mental health problems require longer term care in a psychiatric or social care institution. However, there are no internationally agreed quality standards for institutional care and no method to assess common care standards across countries. We aimed to identify the key components of institutional care for people with longer term mental health problems and the effectiveness of these components.

METHODS

We undertook a systematic review of the literature using comprehensive search terms in 11 electronic databases and identified 12,182 titles. We viewed 550 abstracts, reviewed 223 papers and included 110 of these. A "critical interpretative synthesis" of the evidence was used to identify domains of institutional care that are key to service users' recovery.

RESULTS

We identified eight domains of institutional care that were key to service users' recovery: living conditions; interventions for schizophrenia; physical health; restraint and seclusion; staff training and support; therapeutic relationship; autonomy and service user involvement; and clinical governance. Evidence was strongest for specific interventions for the treatment of schizophrenia (family psychoeducation, cognitive behavioural therapy (CBT) and vocational rehabilitation).

CONCLUSION

Institutions should, ideally, be community based, operate a flexible regime, maintain a low density of residents and maximise residents' privacy. For service users with a diagnosis of schizophrenia, specific interventions (CBT, family interventions involving psychoeducation, and supported employment) should be provided through integrated programmes. Restraint and seclusion should be avoided wherever possible and staff should have adequate training in de-escalation techniques. Regular staff supervision should be provided and this should support service user involvement in decision making and positive therapeutic relationships between staff and service users. There should be clear lines of clinical governance that ensure adherence to evidence-based guidelines and attention should be paid to service users' physical health through regular screening.

Institutional therapeutic alliance and its relationship with outcomes in a psychiatric day hospital program

The article shows the results of a longitudinal study aimed to explore the institutional therapeutic alliance (ITA) that is the alliance formed by a patient and all the therapeutic staff. Fifty five patients who have psychiatric disorders in partial hospitalization were evaluated at admission (global functional level, social support, symptomatic condition, and treatment expectancies), at discharge, and after 3 months. ITA was assessed after 1 week of treatment and at discharge, from patient's and staff's perspectives. Preliminary findings suggest that the ITA represents a specific phenomenon different from the classical therapeutic alliance (patienttherapist), which would be particularly relevant for the treatment of patients who are severely disturbed.

[Treatment progress scale for violent psychosis patients]

OBJECTIVES

The dangerousness of psychiatric patients is related to many well-documented factors in literature. To better document the course of dangerousness in most violent psychotic patients with severe and persistent diseases, we have developed a Treatment Progress Scale (TPS).

METHOD

The TPS was developed based on the literature research and the expertise of a multidisciplinary team.

RESULTS

The instrument has good interrater reliability and has shown to be easy to use, after being implemented for 5 years in a treatment unit at Philippe-Pinel Institute. The instrument provides a systematic assessment of important clinical parameters validating treatment observance and patient evolution over months. It also builds on the daily observations made by different members of the multidisciplinary team, the common language of patients and staff, the transparency of our work with patients, and the clear identification of most treatment targets. It also brings a valued complement to the dangerousness assessment.

CONCLUSIONS

The TPS is a relevant instrument for the violent psychotic inpatient specific population. It provides a better identification of treatment progress and helps to specify dangerousness from an evolution perspective. Variations may be developed to assess outpatients and patients in a general setting.

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

OBJECTIVE

The study aimed to determine the conceptual basis of measures of the patient-professional relationship used in routine mental health services research by reviewing their face, content and construct validity.

METHOD

A comprehensive literature search identified measures of the relationship used in mental health services research. The conceptual basis of each identified measure was identified by a review of measures' authors assessments of face, content and construct validity plus item analysis of the measures themselves.

RESULTS

The search identified 15 measures. The seven developed in psychotherapy were likely to be better validated conceptually; most were based on therapeutic alliance models. Measures developed specifically for mental health services were based on a wider range of models including global assessments of the relationship.

CONCLUSION

Most of the better validated measures originate in psychotherapy, but there is limited evidence for their validity in general mental health services. Four measures are recommended.

Do baseline client characteristics predict the therapeutic alliance in the treatment of schizophrenia?

This study examined clinical predictors of client and therapist alliance ratings early in therapy, the relationship between client and therapist alliance ratings, and the psychometric properties of the Working Alliance Inventory in individuals with schizophrenia receiving manual-based treatment. Assessment of clinical symptoms and social functioning were conducted at baseline, and alliance ratings were obtained at 5 weeks. The Working Alliance Inventory had high internal consistency, but there were low correlations between client and therapist ratings. Results also indicated that social functioning and the activation and autistic preoccupation factors on the Positive and Negative Syndrome Scale were significant predictors of therapists' alliance ratings. There were no significant relationships between clinical predictors and clients' therapeutic alliance ratings. The findings indicate that client interpersonal factors are significant predictors of the therapist-rated alliance in the treatment of schizophrenia. Low correlations between clients' and therapists' ratings of the alliance should be examined in future research.

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.

Contemporary issues in the psychiatric residential treatment of disturbed adolescents

This article reviewed the current challenges to the provision of residential treatment for disturbed adolescents, described the Menninger Clinic's model for short-term residential treatment that has been developed over the last 10 years to meet these challenges, and provided a case example to exemplify the role of such newly developed concepts as "mentalizing" in the provision of psychiatric treatment. Stimulated by the alarm of the costs of health care in general, residential treatment is highly scrutinized by private third-party payers and public funding sources. The impact of this movement to reduce health care costs aggressively is that lengths of stay for residential treatment of children and adolescents have been shortened and continuity of care is difficult to maintain. Since the mid-1980s,when lengths of stay began to shorten, the Menninger Clinic has worked to develop an intensive program with a length of stay of 2 to 4 months. The essential ingredients needed to ensure that treatment is effective and that treatment gains are sustained were described. Finally, a case was used to illustrate current views of understanding some of the processes that engage patients and stimulate changes in several variables.

Patients’ opinion on what constitutes good psychiatric care

The present study investigates patients' opinion on what constitutes good psychiatric care. It was a qualitative study using an open-ended in-depth interview centering on the patient's experiences of receiving psychiatric care. The subjects were selected to ensure maximum variation and heterogeneity. A model of deliberate sampling for heterogeneity and a modified, stratified sampling method were used. One outpatient and one inpatient sample were selected. The description and analysis of data were based on a variable-oriented, cross-case technique. The analysis was made separately for the two sub-samples. The main result for both samples was the emergence of one main category: the quality of the helping encounter. The quality of the relationship between patient and therapist/staff, and being understood by the therapist/staff, formed the most central aspects of good care. For the inpatient group the analyses also pointed to stability and structure and relief of pressure as main categories. Though the focus of the study was on satisfaction with general psychiatric care, the results revealed a construct initially identified within the field of psychotherapy, namely the 'helping alliance', as the most crucial factor. The results also gave some further indications of what bring about a good therapeutic relationship; and prominent in this study, and not very often reported in the context of helping alliance, was that ambivalence, time and meaning were important constituents of the relationship. The findings emphasize the importance and quality of the therapeutic relationship and point to the incorporation of psychotherapeutic principles in all provider-patient relationships in general psychiatric care.

Mentalizing in the psychotherapy of a disturbed adolescent girl

The author traces some of the literature related to such concepts as the development of the therapeutic alliance and collaboration in the inpatient and residential psychiatric treatment of disturbed adolescents. The more recently developed concept of "mentalization" is discussed, especially with its relevance to the psychotherapy of difficult-to-treat adolescent patients. A case presentation highlights the establishment of relatedness and trust with such a patient. The case is described in terms of the mental activities of both therapist and patient that facilitated the psychotherapy process in a number of ways. Mentalization is seen as a useful concept, both in terms of understanding the process of psychotherapy, and as a fundamental attribute of the mental activities of the therapist and, likewise, fostered in the patient.

Relation of the therapeutic alliance with outcome and other variables: a meta-analytic review

To identify underlying patterns in the alliance literature, an empirical review of the many existing studies that relate alliance to outcome was conducted. After an exhaustive literature review, the data from 79 studies (58 published, 21 unpublished) were aggregated using meta-analytic procedures. The results of the meta-analysis indicate that the overall relation of therapeutic alliance with outcome is moderate, but consistent, regardless of many of the variables that have been posited to influence this relationship. For patient, therapist, and observer ratings, the various alliance scales have adequate reliability. Across most alliance scales, there seems to be no difference in the ability of raters to predict outcome. Moreover, the relation of alliance and outcome does not appear to be influenced by other moderator variables, such as the type of outcome measure used in the study, the type of outcome rater, the time of alliance assessment, the type of alliance rater, the type of treatment provided, or the publication status of the study.

Therapeutic alliance in cognitive therapy for schizophrenic and other long-term mentally ill patients: development and relationship to outcome in an in-patient treatment programme

A total of 26 schizophrenic and other long-term mentally ill patients receiving cognitive therapy sessions twice a week in the context of a comprehensive in-patient treatment programme were assessed every 5 weeks with regard to therapeutic alliance. The therapists rated the alliance according to the Psychotherapy Status Report and the patients rated it according to the Patient Collaboration Scale. The results showed either good or fair and stable therapeutic alliance for the majority of the patients throughout the treatment period. Few correlations were found between patient characteristics and initial alliance. The therapists' ratings showed a positive relationship between initial alliance and a favourable outcome of treatment at discharge.

Therapeutic alliance and transference: an exploratory study of their empirical relationship

Transference and the formation of a therapeutic alliance were studied in 126 patients from the Berlin psychotherapy project. The working hypothesis was that the internalized mother and father image would have an influence on the therapeutic alliance. The therapist rated the development of the therapeutic alliance at two points in time. When the parents' images and the therapist image were compared by using difference and similarity measures, four mother and four father types could be constructed of which some showed significant differences in the formation of therapeutic alliance. The introduction and the discussion are focused on the question as to what extent the psychoanalytic assumptions of transference can be useful in empirical therapy research for the construction of new variables and the explanation of social interactions between the two partners.

Stability of therapeutic alliance and its relationship to outcome in short-term inpatient psychiatric care

The relationship of therapeutic alliance to patient and treatment characteristics and to outcome, was studied in a sample of 106 patients consecutively admitted to a short-term psychiatric ward. The main finding was that a better therapeutic alliance at discharge was related to a greater improvement in symptoms during treatment. A multivariate model for prediction of outcome revealed a significant contribution from therapeutic alliance at discharge but not from alliance at admission or from changes in alliance during treatment. Improvement in alliance was seen in 41.5% of the patients, no change in 28.3% and a deterioration in 30.2%. Patients who improved their alliance did not differ from the others in background characteristics, but were more often subject to psychopharmacological treatment and were more often treated in a basic activation group. Patients with a stable poor alliance more often stated physically oriented target complaints at admission while patients with a stable satisfactory alliance more often presented interpersonally related complaints. It is concluded that further research in the field would benefit from a closer description of the change in the alliance and its relationship to treatment characteristics and outcome.

Psychotherapy research between process and effect: the need of new methodological approaches

The methodological problems and scanty results of psychotherapy research are noted and placed in a metascientific context. Efforts to attain ever greater specificity and standardization, guided by the idea of uniform methodology, are leading researchers steadily further away from the unique case. The underlying assumptions in current psychotherapy research are defined and the necessity of returning to case studies is indicated. Research methods need to be relevant and to make use of essential aspects of what is being researched (care of the research object). Psychotherapy research cannot avoid interpretations of meaning, and clinical methods should have a steering role. Case-study methods lead to specific problems of control and generalization. The scientific research strategy used in case studies is described and compared with the hermeneutic circle.

Assessment of therapeutic alliances in the psychiatric hospital milieu

The authors developed scales to assess long-term hospital patients' collaboration in milieu treatment and their working relationships with various staff members. A factor analysis of patients' ratings of their collaboration in several areas of treatment yielded three dimensions: Goal Orientation, Involvement, and Use of Structure. While each dimension of collaboration correlated positively with working relationships and progress, Goal Orientation was the most substantial contributor. Patients' and staff members' perceptions of their working relationships corresponded to a statistically significant-but modest-degree. Only nurses' ratings of progress related significantly to patients' ratings. The authors highlight divergent perceptions of the treatment process, and advocate that different perspectives be openly discussed and clarified in the service of improved collaboration.