Therapeutic relationships in community mental health

1. Therapeutic Relationships in vocational rehabilitation: the interaction of two relationships for people with severe mental illness Jocelyn Catty, Marsha Koletsi, Sarah White, Thomas Becker, Angelo Fioritti,RanaKalkan, ChristophLauber, PascaleLissouba, WulfRössler, TomaTomov, Jooske T. van Busschbach, DurkWiersma & Tom Burns for the EQOLISE Group

2. Therapeutic relationships in community mental health • New to study despite wealth in psychotherapy • Meeting care needs promotes good TR • Influenced by clients’ psychopathology • - but little evidence on whether TRs driven by client factors, predisposition towards services, or reflect unique relationship • Some client-rated outcomes reflect a general appraisal tendency – but TR not tested

3. TR Questions • Do TR ratings reflect clients’ predisposition? • If so, is this positive / negative appraisal of circumstances? • Or predisposition to form good relationships? • Does a good TR have a bearing only on the task in hand?

4. The EQOLISE Trial: Vocational Rehabilitation in Europe • International RCT (n=312), 6 European centres • Randomised to Individual Placement and Support (IPS) or usual Vocational Rehabilitation • Interviews at baseline, 6, 12 and 18 months • TR data (HAS) on: • TR with clinical keyworker • TR with vocational worker (client and prof-rated)

5. EQOLISE Findings • IPS doubled access to work (Burns et al, 2007) • Working / vocational outcomes also predicted by • TR with vocational worker (client & prof-rated) • Previous work history • IPS fidelity (Catty et al, 2008) • TR with clinical keyworker did not predict vocational outcomes

6. Question 1: is TR task-specific? • Explore associations between clients’ relationships with a) their clinical keyworkers and b) their vocational workers and their clinical and social functioning outcomes;

7. Question 2: are TRs driven by client predisposition? • Explore associations between clients’ ratings of their relationships with their clinical keyworkers and their vocational workers

8. Predictors of clinical and social functioning • TR at each timepoint tested against clinical and social variables at subsequent timepoint: • Global symptoms and disability (GAF-S & GAF-D) • Positive & negative symptoms (PANSS) • Anxiety and depression (HADS-A & HADS-D) • Quality of life (LQOLP-EU) • Social disability (GSDS) • Remission • hospitalisation

9. Predictors of clinical & social functioning: analysis • Client-rated TR at each timepoint tested for association with each clinical & social functioning variable 6 months later • Professional-rated TR at each timepoint tested for association with each variable 6 months later • Linear regression model (logistic for binary variables) with random client effect

10. Associations between TR with clinical & vocational workers • Change in TR with vocational worker tested against change in TR with clinical keyworker • Multi-level model using data from each timepoint • Random client effect incorporated • Analysis repeated using fixed time effect (is TR changing?) and fixed TR-with vocational worker x time effect (is relationship between TRs changing)

11. Results: Clients (n=312) and TR data • 248 (83.3%) with schizophrenia • 188 (60.3%) male • TR with clinician at baseline on all but one • T1: client-rated TR with VW for 228 (87.4% of 261) – prof-rated for 206 (202 pairs) • T3: client-rated TR with VW for 176 (80.4% of 219) – prof-rated for163

12. Levels of therapeutic relationshp • TR with clinical keyworker: - mean TR 42.4 (out of 55) • TR with vocational worker: • Client-rated mean TR 40.4 • Prof-rated mean TR 41.4 • Little change in TR levels over time

13. TR with clinical keyworker as predictor of clinical / social functioning • Only association was with overall subjective quality of life (r=0.01, 95%CI 0.001, 0.01, p=0.013) • A 10-point higher TR rating was associated with a 0.1 point higher QoL rating (out of 7) 6 months later

14. TR with vocational worker as predictor of clinical / social functioning • Client-rated: no significant associations • Professional-rated: • Associated with global symptoms & disability, positive, negative & general symptoms, social disability, remission & depression (borderline) • For contemporaneous timepoints: • Associated with global symptoms & disability, positive, negative & general symptoms, social disability, remission & QoL – not depression

16. Results –TRs with clinical & vocational workers • Significant association between client-keyworker relationship & client-rated client-vocational-worker relationship (B=0.24, 95%CI 0.17, 0.31, p<=0.0001) – low magnitude • Time variable & TR x time interaction NS – neither TR nor the association between TR with keyworker & TR with vocational worker changed over time

17. Discriminating between tasks: impact on outcomes • Client-rated client-vocational worker relationship predicted getting a job – • But not clinical or social functioning outcomes • Client-keyworker relationship predicted only slightly higher subjective QoL • Vocational worker-rated relationship predicted range of clinical & vocational o/comes – but driven by how easy client was to relate to, not truly predictive

18. Discriminating between relationships • Relationship with clinical keyworker at baseline = one of few predictors of relationship with vocational worker at 6 mo • Ratings of 2 relationships correlated but low magnitude • No evidence that the development of a good TR with vocational worker detracts from previous good TR with clinical keyworker

19. Conclusions • Impact of TR may be on the shared task - task-specificity • Relationships with different professionals distinct from each other – only about half the variance explained