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

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

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

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?

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

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

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)

STAR-kw (client-rated) Beta 95%CI F P GAF 0.01 -0.06, 0.10 0.22 0.64 Empowerment 0.12 0.03, 0.21 7.17 MANSA 0.26 -0.74, 1.25 0.61 CONTINU-UM 5.75 4.63, 6.88 102.38 <0.001 CAN Total needs 0.03 -0.25, 0.32 0.05 0.82 Diagnosis Mean Psychotic 35.61 34.54, 36.68 13.89 Non-psychotic 38.98 37.68, 40.28

STAR-prof (keyworker-rated) Beta 95%CI F P GAF 0.05 -0.02, 0.11 2.11 0.15 Empowerment -0.01 -0.08, 0.06 0.08 0.78 MANSA 0.14 -0.67, 0.95 0.12 0.73 CONTINU-UM 0.39 -0.51, 1.29 0.74 CAN Total needs -0.14 -0.36, 0.08 1.63 0.21 Diagnosis Mean Psychotic 41.55 40.43, 42.66 3.94 Non-psychotic 39.95 38.84, 41.07 Keyworker discipline CPN 42.27 41.30, 43.25 3.84 0.01 OT 39.52 37.59, 41.45 Social Worker 40.03 38.82, 41.25 Other 41.18 39.47, 42.89 Transition in previous year Yes 40.26 39.30, 41.23 3.03 0.09 No 41.24 40.29, 42.19

STAR-psych (client-rated) Beta 95%CI F p GAF 0.04 -0.09, 0.16 0.37 0.54 Empowerment 0.05 -0.10, 0.20 0.41 0.52 MANSA -1.08, 2.12 0.42 CONTINU-UM 4.57 2.89, 6.25 29.24 <0.001 CAN Total needs -0.19 -0.64, 0.27 0.67 Ethic Group Mean P White 32.60 31.17, 34.03 2.56 0.06 Asian 36.97 32.42, 41.51 Black 35.61 31.76, 39.46 Other 37.11 32.26, 41.96 Time-point 1 33.97 31.90, 36.05 11.42 2 37.17 34.89, 39.45

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

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

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

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