1999 - Therapeutic Relationships And Quality Of Life - Association Of Two Subjective Constructs In Schizophrenia Patients

InteftationalJoLrul of So.ial Psrchi4ttr(1999)Vol.45 No.4 276-283.

TIIERAPEI]TIC RELATIONSHIPSAND QUALITY OF LIFE: ASSOCIATIONOF TWO SUBJECTIVECONSTRUCTS IN SCHIZOPHREMA PATIENTS ROSEMARIEMCCABE,UTE,II-RIKE RODER-WANNER. K{RIN HOFFMANN & STEFAN PRIEBE

SUMMAF} qualityol life is an imponantcritedonin outcomeevatuation Subjeclive that has beenwelfresearched in psychiatry. By compason, the therapeutic retationship whichmay also be subjeclively assessedhas been €tativetynegtected as an oulcomecrilerionalthoughit has predictive powerin retationto outcome.This exploratory studyinvestigaled quatityof tifeandlhefapeutic subjective retationships (N 90)andlolg.term(N=1681schizopf,en.a in Inslaomrssion patierrs, eaih at iwo poinlsol rime.The lottow-up periodwas 9 monthsfor the fiGt-admission sampleand 1.5 yearslor the tongtermsampte.A signtficant retaiionship was toundbelveenglobaiassessments of qualityol tifeandtherapeutic rctationships In long-lelm,bul nolin firsl-admission patients. Thisfindingwasconsistent al both assessmenrs! suggesting thattherapeutic retationships maybecomemorecenlral to qualilyol lile in long-termcare situationsand that patientsviewsof lhis relationship are increasingly embedded in theiroverattappraisat ot tite.

INTRODUCTION Quality of Life (QoL) has beconc a popular consrrucr in rhe field of psychiarry and an impoiari outcome criterion in evaluativeresearch.This is in line $ilh policy which slares that improvenent in QoL is one of rbe major aims of rnenrathealrhcare.Although objeclile indicatorsofQol are reponed. subjecriveindicaton ?re central ro its assessment. Tbe construcr has been well-researchedin psychial,tr,over the pas( iwo decades.During rhis rime, vaDouslnstuments have been developedfor measuringQoL, mosr of which addresssatisfaction with life in generaland with varioustife domains(e.g.,Lehman. t9S3; Otjver. 1991; Lower, 1999; Hansson,1999). By contrast. the therapeulic relationship' appears ro be neglecred in psychialrjc research even though i( is central 1()the practiceof psychiarry.In Reud's terms,ir is ..rhe vehicle of successin therapy" and it has beenexlensivelystudiedin psycholhe.alJy€ver since Freud higblighled the speciil rclarionshipbetweenthe clienr and therapisi.A posirjve therapeutic relaiionship has been consistenrly found to predicl increased treatmenl adherenceand a bener outcone acrossdifferenr forms of psychorherap)(Horvath & Syrnonds.l99l: Horaarh & Greenberg,1994;Alexander& Coffey, 1997).Nume.ouspapershave beenpublishedwhich

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atlest to rhe significance of rhe therapcotic relationship as a principal p'redicbr and 'n? cental non+pecific clement in psychotherapy(for a review see Horvath & Luborsky' 1993)' ln;sychilrric ca.e, a similar linding has been replicatedamong adultswith s€verenental illnesi across a nurnber of differcnt settings: in complex bospital lreatnent (Brdker et al' l q q 5 r .i n d a y h o \ p i r d rl e u l m ( n l , P n e b e& C r u y t e r ' . l o ' J 4 ,r n d i n a c o m m J t u qc a r e\ e t l i n E {Fra;k & G;nderson,1990;Priebe& Gruyters,1993:Gehrs& Goering l99'l: Solomon?'al 1995r Gaston €r al. 1998). As in psychotherapv the therapeutic relationship displavs prediclive validily in a psychialric context and appeds lo be a very effective element of ireatment *t'ictr is mosl tikely used as a means of delivering other treament components (e.g.,pharnacotherapy,seeWeiss el41 1997). iroweve.. ttrere ar" no estultistred ..rirods for assessing tle the'apeutic relationship in psychiatric seltings. Psychiarry ha^s,for the most pan, emploved neasure's dev€loped for psychothenpy, bur rnodelsof psychothempydo not applv to dyadic telationshipsin psv;hiatry which are difiercnl fiom, and more complex tha.. those in conventionalpsvcbotherajy setrings. Measures thri have been consFucted expticitlv for use in a psvcluatric context(i.e.,fout are extremelyrcductionisticand shon, withou! anv r€ validation(Clarkin etdl. 1987: Stark ctdl. 1992i Priebe & Gruvters. 1993; Klittenberg, 1998) Despitethese methodological limitalions, global assessmentsof the therapeutic relationship have demonstrated preJictive lali lity among those wilh severe mental illness. While research thus tar on the role of the tberapeutic relationship has been conducted more from tbe persp€ctive of the health professional(panicularly irs ulility in predicting individul outcomc)'lhe therapeuttc rela&rnship is also of considerableimponance on an individuil level, i c , as subjectiYelv assessed by the pauent. As far as we are awre. the therapeuticrelationshiph$ nol b€en systematicallystudied in relalion to QoL. Whcreas qudlity of lif€ has been emploved primdrilv as 'm outcone variable. the therapeulicrelationshipis viewed more as a mediating iaclor raher tnan an outcomecriterion in its own righi. Thus, $e questionsthat led to the presentstudy wer€: palients? L how de ihe therapeulicrelalionsbipand QoL related in schizophJenia beca'lse thesituations long_t€rm treatment and in shorllerm difterent IL is lhe relationship therapeutic relationship is supposed to be different (i.e.. in relation to goals and pace of treatment. adoption of a shon or long'term perspective)? The present study was an exploratory one tha! inYestigrled one's p€rceptionof the therapeutic re)ationship and whether il wa5 associated with satisfaclion with other relationships in one's life and ovenll satisfactionwilh life SamDl€ Two gioups of subjecls meetiDg ICD 10 criteria for a diagnosis of schizophreniawere cornp-",t. ne fir.t udrnission sample was a group of 90 schizopkenia patients admilted ro a psichirtric hospitalfor the ftst tine in heir life. 51 of whom were followed up 9 months afterdischarge(Rdder-Wanner& Pnebe. 1998a& b) The long-tenn sanple was a suogroup of lhe BerI;Deinstitutionalisation studv (Priebeet al 1996i Hoffmann er al 1997; Kaiser pr dl. 1998):the key inclusion crirerionfor this gloup was a continuoushospitalisationof a1 lelsr 6 nonths. Th; averagecumulativeduration of hospitrlisationsof this samplewas 9 8 at baselinewhile in hospital ( a 10.3) years.176patientsin the long-ierm group were assessed answenro all questions clear, unequivocal patienis 168 were assessed, wtro ils ilt t1"." sale

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THERAPEIMC RELATIONSTIIPSAND QOL

of interesthere (i.e-, in relation to QoL and thcrapeuticrelarionships).113 of this long-tem group werefollowed up on averageone-and-a-halfyears late., 98 of whom gaveunequivocal answersto all questionsofinlerest and were in someform of rreatmenrso that ihe questions about the therapeuticrelarionshipapplied.4l ofthese had beendischargedby the follow-up

METHOD Subjecdvequality of Life was assessed using the cerman version of rhe Lancashireeuality of Life Profile which was developedby Oiiver (O]i!er. 1991; Oliver .r al. I 99?i priebe €r al. I995). The queslionDaire permits an evaluationof rhepaiients objeclivecircurn(ances,rheir subjective satisfaclion wjth nine specinc life domains and their general lile saiisfaction. Subjectiveratirgs are taken on 7-point scaiesfor sarisfactionwith life as a whole and with eighrlife domains(1 = couldn'lbe worsei 7 = couldn i be betier).The meansof satisfaction with life as a whole and the eight domainswere rakenas indicaiors for subjecrivequalil], of A modified versjon of the Helping Alliance Scale (HAS: Priebe & Gruyters, 1993) was usedwhich focussedon the therapeuticrelatiorship(s)peninenl in one's rrearmentsjtuation. Three itens which pertain to therapeuticrelariorships( Do you believe you are receiving the nght aeahent/care for you?", "Does your therapis/casenanager,/keyworkerundcr stand you and is h€/she engaged jn your treatmenvcare?" and "Do t ou feel respecred and well regarded?")were summedto !'ield d indicatorofone's relnrionshipwirh one s pnmary therapist.typically a keyworker. Each item \ras raredon an ll-point visual analoguescale. wher€ 0 - not at all and 10 = yes entirely. Psychopathologylas obsener rated using rhe l8-item version of the B.ief psychiarric R a u n r S c a l er B P R S :O v e r a l l& c u r h a m . l o h ) , .

RESULTS Demographicdatafor the two sampleswas collated(seeTable 1). The long,term samplewas sigdficandy older than rhe first-adnission sample (t: 10.7, p < 0.001) while rhere werc s i g n r l i c a n dm y o r ef e m r l e . r n r h ef i r \ r . a d m i s \ r osna m p t e , l ? = 1 9 . 0 . p< 0 0 0 2 t .M e a nB p R S tolal scoreat initial assessment was comparableacrossrbe two groupsbur was sipificantty lowe. ir the tusr-admissiongroup at follow-up (1 = 6.6, p < 0.001). Mean subjecrjvequality of life scoreswere also comparedacrossthe two groups:there was no significaDtdifference beiween tbe groups al eirher poinr of dme. Pearso, coneiations were calcularedto examinethe relalionshipbetweenthe rheraDeuric r e l a l i o n ' h r pa n d r h e r e l e \ d r l i r e d o m d r n \ s d l i \ f a c u o nw i d r r r i e n d .a n d I t e a s d s h o r ; , a n d overall satisfactionscore of dE LQLP. Following re.ommendationsby Kaiser er al. 099?l and Piebe et al. (1999), partial conelations were obtained ro conlrol for rhe influence of psychopatbology. In the first-adrnitted group, as may be seer from Table 2, only one colrelalion was significanr thal betweenlife as a wbole and the therapeuiicrelationshipal baseljne.lf we

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219

R. MCCABEET AL. T.bl.l Chamcr€nstio of tht 6a1.dftision FiHl-admisrion smple (N=90)

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focus on the QoL sum score.itmay be seenthat therewas no significantassociationbetween the therapeuticrelationshipand QoL in this sanple at eitber assessmenl. In the long-tenn group, quite a differen! patt€m emerged. As may be seen from Table 3. there were sig ficant correlations between tberapeutic relationships and the 2 domalns and |he overall score at blselin€. At follow-up. aI of the conelationsremainedsubstantial and stathtically significant.Tuming our attention !o the QoL sum score. the reladonship between the theraoeuticrehtionshiD and overall satisfactionshowed an increasefrorn the inidal to |he follow-up assessnent(the lbllow-up period \ras one and a half years).Panial conelanons controllins for psychopathologyate shown in bracketsin Trble L The colTeladons eitherremain€dthe sameor were slightly lower but remainedstatisticallysignilicad. A facbr analysiswas also conductedusing the QoL domain scoresand the surn scoreof therapeuticrelatiooships.wltle the lherapeuticrelationshjpwas a separatefactor at two poims in the lirst-admissiongroup, this wa5 'ot a consistentresull in the long-term group.

DISCUSSION The nain finding of this sludy was a signiticant associationbetween global assessmen$ of qualiiy of life and the herapeutic relationship in long-lerm schizophreniapatients. indicaling lhat there .re generalised faclors influencing appraisats of both constructs. This was an exploratorystudyand ir is not lnown to what exlent thesefindingscan be generalised !o other samples.It is perhapsusefulto keep in rnjnd so'ne methodologicrl limitntionsof this Ttbk 2 $€mp€uli. rclrrionshipd md etisfacCo.rclaiioro lEieen tion *iLh lr'€nd!,lite 6 r shole and ore..ll €Lisfacton itr pldctrtr fiBt.dd,ftd

Friends 0.13 0.09

Lil€ as a whole

Sm score 0.12

L 230

TIIERAPEI]TIC RELATTONSHIPSAND QOL Tlble 3 th€.ap€uli. relationshipa rnd bet*&n CoffelatioN *ith bends, lift s a whole rnd oremll stisfaction satis{s.lion in lona'1€rm patien6 .nd (in bEclerg p.y.hopathologlt alte. conlrotlin8lor

ld Arsessme.r

0.40*+ (0.13!.)

033'* (0.33!)

(.0.21r)

(0.38**)

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study.Firstiy. asthiswas a cross-sectionalstudywith repeatedmeasures,lherewas no contrel orer eventsthat occuned in betweenthe lwo atsessmentsHoweler, the resuks seem sub stantialtaking into accounttha( the corrctalionswere consistcntlydifferenl at two pomts ol rime in the 1wo samples. Secondly,the netbod used to assessthe therapeuticrelationshipwas nol as elaborateas that employcdlo assessQoL. Although the numberofi|ems was similar in boib assessmenls. ftey w;re more lentatively applied with respect to the therapeutic relalionship. Inaddition. only thc patients' appraisatof QoL and the therapeuticrela{ionshipwere assessedan'i not the therdpisl-/observerperspectives. Intcresiingly, in psvchotherapv research the pcrspective of tbe p;tient has the strongest predictive power, foltowed bl the observer and lastl] the therapist. Il is not kno*n whether this finding also bolds in the'apeulic rntcmctronsrn From rhe findings reported herein, il would appear that the tbetapeutic relationship. aiier a while. is embeddedin an overall appraisalolone's whole iife situation.This was.l'owever' onty the casein the long te.m and not in the first'admissionsample lt i s conceilahle thal the therapeuticrelationshipbccomesan imponant part of dav'to day life for thosein long-letn care ;itualions and is not separateany morc as it appearsit is in a first-admi ssion sanple lt is plausible that the therapeuticrelationshipmoves inlo the quality of life arena and that x isviewe
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because,according1olhis theory,it is lessproblematicto have dissonanc€betweenatrituder in the shon-krm lhan in the long-term. Finllly, one could speculalethat the therapcuticrelationshipdevelopsin a similar way to otber relationshipsin one s lile (e.g.,with friendt. Underlying rhis explanarionis the notion that similar paliems ofbehaviour characterise differcnt relationships that one has, an ide! rhat has its roots in psychodynanxctheory. Although thcre may be sone divergencefrorn one's lypical posidon in a relatiorship when a new reladonsbipis fonned, ir rnay be that these rehlionships are subsequendy subject to the same patterns as previous other relationships. Enpirical researchfrom a systenic p€rspective(Priebe,1989;Priebe& Haug. 1992;Priebe & Pornmerien.1992) p.ovides some suppon for the idea that therapeuticpolential may be assessed, in pad, by exploring how the the.apeuticrelalionshipis similar to or differs from relationshipswith significut olhers,an areaof researchthar wananrsfurthe. atrenrion. In conclusbn, both qualiiy of life and the thenpeutic relalionship ue imponanl conslrucrs which may overlap dependingon the sampleand the trealmentsirualion,an associationthar is not auributableto the infiuenceof psychoparholosy.With referencero possiblepractical implicationsof ihese findings,it is possiblerhat,in long-r€nn samples.interventionsin QoL or changesin the therapeuticrelarionshipwill have an influenceon eachother.Moreoyer, it may be thar neitherwiil be as nexible al1eryearsofillness and trearmenlas fiey were earlier in ihe illnesstrajeclory.Conceivably,lf interventbns to improve th€ rherapculicrel.rtionship are inlroduced, one's perceptionof the therapeulicrelationshipmight nol change if it is viewed predonjnantly in fie context of one's life overall. The therapeudc relationship is probably linked to how menral heallh ser.r'ices are perceived.On a speculatjvenote,jf it is more flenble early on in lreahent (when a patienl f|st presents),rhrs would be the tilne to iniiuence i1 in a positive dnection. ff it is viewed negatively and this perception remains for many ye[s, it may be rnuch more difficult to changewhich clearly will affect therapeutic€ilbciiveDess.However, theseare na$ralistic studjes and the ways in which the therapeuticrelationsbip can be inltuenced are not yet

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THERAPEUIIC RELATIONSH1FSAND QOL

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