The alliance concept in psychiatric care

Prof. Stefan Priebe

Barts & the London School of Medicine

Queen Mary, University of London

Therapeutic alliance

ClinicianIndividual

Family and/orpartner

Other social and professional relationships

Service

Health care system

Patient

The therapeutic alliance 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

• predicts outcome

Psychiatric settings vs. psychotherapy

• Statutory role• Flexible setting• Variable time-scale and possibly life long

treatment• Different and changing treatment goals,

often aimed at stability rather than change • Multidisciplinary teamwork• Various treatment methods

Alliance in psychiatry

• In patient surveys consistently reported as the most important component of care

• In some quantitative studies predictor of adherence and outcomes

• In qualitative research identified as central factor for engagement

Study in Assertive Outreach patients

• Why and how did patients first disengage with services?

• Why and how did they later engage with AO teams?

• In-depth interviews

• Analysis using elements of Thematic Analysis and Grounded Theory

Findings on disengagement

Three main themes were identified:1) Desire to be an independent and able person2) Lack of active participation and poor therapeutic relationship3) Loss of control due to medication and its effects

Lack of active participation and poor relationship

• Breakdown of relationship with psychiatrists, with CPNs, in hospital or a combination

• Often positive description of individual clinicians (“I ‘ve never had a bad key worker”)

• Not being listened to and respected

• Not involved in decision making

Lack of active participation and poor relationship (I)

“I just felt I was fobbed off …..it was definitely a case with some psychiatrists of Them and Us. And you couldn’t talk on the level at all, so in the end you didn’t say very much ….. I used to think who does it benefit and thought not me.”

“They are trying to take over your life, treating you like a kid.”

Lack of active participation and poor relationship (II)

“I felt they never listened to me and they were just making choices for me, and if they listened to me a bit more then I might have felt a bit more like I was. I just felt my life was out of control, and I didn’t have a say in what I was doing.”“They didn’t want to hear what you had to say…talking about something they want to talk about, which was very insulting.”

Findings on engagement

Three main themes were identified:1) Social support and engagement without focus on medication2) Time and commitment 3) Partnership model of therapeutic relationship

Partnership model of therapeutic relationship

• Active role in decision making

• All staff, including psychiatrists, are perceived to take on board the patient’s experiences and views

• Appreciation of non-judgemental attitude, eg concerning drug abuse

Partnership model of therapeutic relationship (I)

“He seems more concerned about me..when I suggested that I wanted to stop my depot for a while, he actually let me and he did actually come across as if he was concerned about me hallucinating again. And he wasn’t too pushy…He wanted me to be more involved in my own health, in looking after my own health rather than him.”

Partnership model of therapeutic relationship (II)

“The team and I have been through a lot. They have seen me in a good position and the team have seen me in bad conditions, so they have an idea, a much better idea and understanding of my moods and how to react to things. So we have a good working relationship.”

Feeling after a meeting with key worker and hospitalisations in following 20 months

0.224

0.564

0

0.1

0.2

0.3

0.4

0.5

0.6

Hospitalisation Index p<0.01

Better

Unchanged/worse

Initial assessment

Feeling after meeting

Figure 1 RECRUITMENT AND FOLLOW-UP FLOWCHART

Interviewed at BASELINE

N =778

ONE YEAR FOLLOW-UP N=396

Contacted N=1050 CONTACTED AND INFORMED

CONSENT NOT GIVEN N=272

LOST TO FOLLOW-UP

N=382

TOTAL SAMPLE

N=1570

NOT PRESENT TO BE CONTACTED N=71

NOT CONTACTED FOR OTHER REASONS

N=136

Present and tried to contact N=1186

Missed because researcher was not informed in time due to organisational

reasons N=313

Data

• 778 interviewed patients were a) 2 years older, b) less often male (57% vs 66%) and c) more often white (77% vs 69%) than non-interviewed patients

• Within 1 year 234 patients (15%) were re-sectioned (and 169 voluntary admissions, 11%)

• 40% felt the index sectioning was justified

Predictors of re-sectioning

• In total sample, patients from black African or Caribbean background had higher rates

• The rate ration comparing Black to White was 1.37

• In the interviewed sample, living alone, being on benefits and initial satisfaction with treatment were significant predictors

Factors associated with involuntary readmissions within one year

Adjusted rate ratio1

95% CI P

Living alone (Yes v No)

0.59 0.35 0.99 0.045

Benefits

(Yes v No)1.83 1.13 2.95 0.014

Satisfaction with treatment (CAT,

range 0-10)

0.93 0.86 1.00 0.039

1Adjusted for age, gender and ethnic group

Factors associated with perceived justification of involuntary admission at one year

Adjusted rate ratio1

95% CI P

Living alone (Yes v No)

1.95 1.07 3.55 0.029

Satisfaction with treatment (CAT, range

1.27 1.16 1.39 <0.001

0-10)Social functioning (GAF, range 0-100)

0.95 0.93 0.98 0.001

11 Adjusted for age, gender and ethnic group and other variables in the model

Summary of findings (I)

• Black patients have slightly higher readmission rates (in line with general rates on sectioning)

• Being on benefits as indicator of poor socio-economic status is linked with re-sectioning

• Living alone increases re-sectioning rate (no social support), but is also linked with justification of sectioning (higher appreciation of hospital care)

• Low functioning at baseline is associated with justification of sectioning (experience of impact of acute illness on functioning)

Summary of findings (II)

• Lower initial satisfaction with treatment is associated with higher re-sectioning rates and less positive views of sectioning at one year

• Patients’ assessment of treatment matters, even if assessed at initial stages when patients still have high symptom levels

Theoretical Frameworks

• Role Theory

• Psychoanalysis

• Social Constructionism

• Systems Theory

• Social Psychology

• Cognitive Behaviourism

Role Theory

• Separate and mutually validating roles

• Paternalistic relationship

• Consumer relationship

• Collaborative relationship

• Focus on consistent aspects in a given situation

Psychoanalysis

• Individual history informing the present

• Transference and counter-transference in relationship

• Focus on consistent aspects in participating individuals

Social Constructionism

• Therapeutic relationship as a socially constructed institution

• Therapeutic relationship as a mutually constructed reality

• Focus on constructs determined by context

Systems Theory

• Relationships as part of a complex system of relations

• The dyadic patient-clinician-relationship as nucleus

• Possible consideration of wider systems related to patient and clinician

• Focus on differences and relationships within systems

Social Psychology

• The therapeutic relationship defined by social exchange

• The therapeutic relationship defined by social influence and expectations

• Focus on situational and contextual factors

Cognitive Behaviourism

• The therapeutic relationship in terms of mutual conditioning and reinforcement

• Relevant factors related to previous learning history and current reinforcement/models

• Focus on learning principles and underlying cognitions

Methods of assessment

• Methods developed for and in psychotherapy

• Empirically derived ‘non-specific’ methods

• Measures constructed for psychiatric settings

• Typically ad hoc measures

• Minimal established reliability and validity in psychiatric settings

Development of STAR

• Scale To Assess Therapeutic Relationships (in Community Mental Health Care)

• All items of existing scales tested for applicability• Qualitative interviews with clinicians and patients

for additional aspects• All reasonable items applied • Results subjected to factor analysis• Test-retest reliability established for reduced

version

STAR

• 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

STAR-C

• I get along well with my patient (1)• My patient and I share a good

rapport (1)• I listen to my patient (2)• I feel my patient rejects me as a

clinician (3)• I believe my patient and I share a

good relationship (1)• I feel inferior to my patient (3)• My patient and I share similar

expectations regarding progress in treatment (1)

• I feel that I am supportive of my patient (2)

• It is difficult for me to empathise with or relate to my patient’s problems (3)

• My patient and I are open with one another (1)

• I am able to take my patient’s perspective (2)

• My patient and I share a trusting relationship (1)

STAR-P

• My C speaks with me about my personal goals and thoughts about treatment (2)

• My C and I are open with one another (1)

• My C and I share a trusting relationship (1)

• I believe my C withholds the truth from me (3)

• My C and I are honest with one another (1)

• My C and I work towards mutually agreed goals (1)

• My C is stern with me when I speak about things that are important to me (3)

• My C and I have established an understanding of the kind of changes that would be good for me (1)

• My C is impatient with me (3)• My C seems to like me regardless of

what I do or say (2) • We agree on what is important for me to

work on (1)• I believe my C has an understanding of

what my experiences have meant to me (2)

Current situation

• Are mental health professionals trained in establishing good alliances?

D: yes of course of course, 3 months time, soM: okayP: why don't people believe me doctor when I say I'm God why don't they believe me cos everyone knows I am I think everyone knows I mean it's not nonsense it's trueD: what should I say now?P: I believe it anywayD: Well you you are free to believe it anyway but people are people are free to believe not to believe youP: MmD: you know what I mean alright this is your cardP: yeM: OkayD: this is you [name] this is eh eh for receptionP: next appointment ye

Medical consultation with patients with psychotic disorders

• Consultants explore psychotic experience only when checking medication effects

• Patients mention psychotic experience at pre-closing stages

• Consultants (and carers) respond with smiling and other avoiding behaviour

• Patients feel not understood

Current situation

• Are psychiatrists being trained in establishing good alliances?

• Do they receive regular supervision?

• Is the quality of alliances assessed in routine care?

• Is there extensive research on alliances?

Evidence based medicine on treatments in psychiatry

Treatment definition

Individual outcome

Why? How? Processes, experiences and relationships

probability

?

?

Why not more research?

• No financial or stakeholder interest?

• Difficulty to meet requirements of evidence based medicine?

• Contradiction in itself?

K. Jaspers:

…the ultimate thing in the doctor-patient relationship is existential communication, which goes far beyond anything that can be planned or methodically staged. The whole treatment is … defined within a community of two selves who live out the possibilities of Existence itself, as reasonable beings.

Why not more research?

• No financial or stakeholder interest?• Too resource intensive?• Difficulty to meet requirements of evidence

based medicine?• Contradiction in itself?• Assumption that there is good medical

communication and that is it?• Unclear concept?

Relationship/alliance and interaction/communication

• Relationship:Psychological construct held by participating individuals on each other and their interaction

• Interaction:Behavioural exchange between patient and clinician that is observable and may be described in objective terms

Alliance and communication

• Alliance as an overarching, powerful and appealing concept, but difficult to capture and influence

• Communication as an assessable phenomenon, but with unclear significance

• Does good communication lead to good alliance or vice versa or both?

Potential interventions in alliance

• Allocation of patients in line with anticipated alliance

• Change of clinician• Improvement of competence of clinician

through training and supervision• Flexibility of approach• Developing specific approaches and/or

interventions depending on alliance

Aim of good alliance/interaction

• Engagement?• Adherence?• Change of symptoms and behaviour?

Is the alliance the basis of effective treatment, or can it be effective treatment in itself?

Potential methods to achieve symptom/behavioural change in

psychiatric settings

• Poor man’s brief psychotherapy (e.g. dynamic or CBT)

• Client centered (Rogerian)

• Motivational interviewing

• Problem solving

• Solution oriented

DIALOG - Intervention

• Keyworker ask patients 11 questions about satisfaction with life domains and treatment and wishes for additional/different help

• Ratings are displayed on hand held computer and compared with previous ratings

• Randomised controlled trial in six European countries

Results

• Intervention leads to better subjective quality of life, fewer needs and higher treatment satisfaction

• Medium effect size in patients with more problematic baseline scores

Why?• Interaction is more:

structured?patient centered?forward looking and solution focused?

• As a consequence: better alliance?earlier and more appropriate interventions?different psychological interventions?

Challenge for research (I)

• Disentangle complex processes in qualitative and quantitative research

• Develop methods to evaluate distinctive steps (e.g. shared decision making)

• Model, optimise and test interventions

• Specify patient characteristics (e.g. preferences) and therapeutic situations benefiting from different interventions

Challenge for research (II)

• Explore how alliances may be associated with family and community relationships of patients

• Identify methods to improve behaviour of clinicians using personal strengths and/or increasing flexibility

Challenge for Psychiatry

• Emphasise therapeutic alliance to strengthen professional status/qualification

• Implement better training, on-going supervision and proper evaluation

• Develop psychiatry specific models for interventions to improve engagement, achieve adherence and induce symptom change

• Exploit the potentially wide impact of generic interventions in the alliance