Therapeutic relationships with multiple professionals in community mental healthcare

1. Therapeutic relationships with multiple professionals in community mental healthcare Jocelyn Catty, Sarah White, Sarah Clement, Naomi Cowan, Gemma Ellis, Connie Geyer, Pascale Lissouba, Zoe Poole and Tom Burns for the ECHO Group

2. Background:therapeutic relationship • Predictor of range of outcomes in general adult mental health services • Variance in ratings as yet unaccounted for • Lack of evidence about multiple professional TRs • Client-rated TR associated with QoL (McCabe et al 1999) • Client-rated outcome measures (needs, QoL & symptoms) linked to appraisal (Hansson et al, 2007) • - though treatment satisfaction the exception • TR, continuity & proportion of care needs met loaded onto one factor, Relationship & Continuity

3. Continuity of Care: ECHO • 278 long-term users of community mental health teams (CMHTs), on enhanced CPA • 180 with psychotic disorders – 3 year follow-up • 98 with non-psychotic disorders – 2 year follow-up • Interviews at yearly intervals – global functioning, symptoms, QoL, care needs, empowerment, continuity of care, TR (STAR – McGuire-Snieckus et al, 2007) • Client-keyworker TR assessed by both parties, client-psychiatrist TR assessed by client

4. Questions • What predicts client-keyworker TR? • What predicts client-psychiatrist TR? • Are clients’ TR ratings driven by a tendency for positive or negative appraisal? • Do they rate TRs with different professionals differently (do they discriminate)? • What drives any difference?

5. Objectives • Determine client & professional characteristics associated with TR • Determine contrasts between TRs with keyworkers and TR with psychiatrists & explore variables associated with any contrasts

6. The ECHO Cohort • 52% female, 72.7% White, 53.2% living with others, 82.4% in unsupervised accommodation • 16.4 years mean duration of illness, mean age 42.5 • Psychotic cohort: 67.6% schizophrenia • Non-psychotic cohort: 53.1% depression, 16.3% anxiety, 14.3% PD • 250 (89.9%) interviewed at 1 year follow-up • 141 (78.3% of 180) interviewed at 2 year follow-up

7. Predictors of TR • Each TR rating used as outcome of multi-level modelling, preceded by univariate analyses • Socio-demographic & clinical & social functioning variables tested as potential predictors • Better client-rated client-keyworker TR predicted by • empowerment, continuity, non-psychotic diagnosis • Better professional-rated client-kw TR predicted by • psychotic diagnosis, discipline (CPNs) • Better client-psychiatrist TR predicted by • continuity, Asian ethnicity (& time)

11. TRs with different professionals • Client-keyworker TR was tested for association with client-psychiatrist TR (both client-rated) using paired t-tests, both at T1 • To determine predictors of any preference, a TR preference score was calculated (+ = pref for kw) • Demographic & illness variables tested for association with TR preference in a linear regression

12. TR preference • Statistically significant preference for keyworkers (replicated at follow-up) • Preference for keyworker over psychiatrist predicted univariately by lower empowerment, lower continuity, non-psychotic diagnosis, being female • But none significant in linear regression model

13. Evidence for appraisal - FOR • Association between TR, empowerment and continuity may suggest an underlying tendency for positive appraisal is driving the ratings • However, QoL and needs did not predict TR • Continuity of care measure may have approximated a service satisfaction measure, which may be conceptually closest to TR

14. Evidence for appraisal - AGAINST • There was a difference in ratings of the 2 relationships (keyworker and psychiatrist) • Lack of evidence for socio-demographic & illness predictors of preference may provide some evidence of the importance of the interpersonal process