Abstract
The quality of the therapeutic relationship between psychiatric patients and their attending physicians plays a key role in treatment success. We hypothesize that mandatory treatment is negatively associated with the quality of the therapeutic relationship. In a cross-sectional study design, data on psychopathological symptom load (as captured with the Brief Psychiatric Rating Scale) and on the quality of the therapeutic relationship (as measured with the Scale to Assess the Therapeutic Relationship) were collected from 113 adult male psychiatric patients and 35 attending physicians. Patients belonged to one of three groups: self-referred or involuntarily admitted patients from general psychiatry wards or patients from medium secure forensic psychiatric units. On average, self-referred patients rated the quality of the therapeutic relationship significantly more positive than did involuntarily admitted patients in general psychiatry wards. Forensic psychiatric patients, on average, gave an intermediate rating of the quality of the therapeutic relationship. There was no association between patients’ ratings and physicians’ ratings of the quality of the therapeutic relationship. Patients’ ratings of the quality of the therapeutic relationship were inversely related to symptom severity in general and hostility in particular. Ratings of the quality of the therapeutic relationship are not associated with patients’ legal status but rather with patients’ symptoms of hostility.
Highlights
The therapeutic relationship (TR) has recently been described as an important process factor in psychiatry and psychotherapy
We assessed the relationship between patients’ and clinicians’ evaluations of the quality of the TR by structural equation modelling (SEM), which allows for an error-free estimation of the strength of association between patient and clinician ratings. This cross-sectional study comprised a sample of male patients diagnosed with schizophrenia or schizophrenia-like disorders. (In general psychiatry, the diagnosis was made by each participant’s responsible senior physician; in forensic psychiatry, the diagnosis was made based on a senior physician’s expert opinion.) Between September 2011 and September 2012, 113 male inpatients were recruited in three settings in Switzerland (Fig 1): (1) self-referred inpatients in a general psychiatry department at the University Hospital of Psychiatry Zurich (n = 42), (2) inpatients under involuntary admission in civil psychiatry
The patients under a mandatory treatment order in general psychiatry—not the forensic psychiatric patients—on average rated the quality of the TR as significantly worse than did the self-referred patients from general psychiatry
Summary
The therapeutic relationship (TR) has recently been described as an important process factor in psychiatry and psychotherapy. The Impact of Legal Coercion on the Therapeutic Relationship have shown an association between the quality of the TR and lower dropout rates, better medication adherence, fewer readmissions, and improved symptom levels for patients suffering from schizophrenia [9,10,11]. Previous authors have described the lack of agreement on the tasks and goals of therapy as a major contributing factor to the breakdown in the TR [13]. These aspects become even more relevant in forensic psychiatry where the legal basis leads to highly restricted treatment settings. Therapists in forensic psychiatry cannot focus exclusively on the patients’ therapeutic needs and demands
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