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)

8. 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

9. 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

10. 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

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