Adult Psychiatric Patients Research Articles

Medication Non-adherence and Use of Traditional Treatment Among Adult Psychiatric Patients in Jimma Town Treated at Jimma University Teaching Hospital Psychiatric Clinic. Community Based Cross-sectional Study, 2016

Background: Medication non-adherence is common problem across all branches of medicine including psychiatry especially in severe mental illness. Many people with mental illness are known to use both modern and traditional treatment for their illness. However, the level of medication non-adherence among this group of patients is not yet explored. This study was conducted to assess the magnitude of non-adherence and traditional treatment as well as associated factors with non-adherence. Methods: Community based cross sectional study was conducted from April June, 2016 in Jimma town. Data was collected using interviewer administered questionnaire and from patients’ medical record. The four-item Morisky medication adherence scale was used to assess degree of medication non adherence. Pre-test was done on patients who had follow-up at Jimma University teaching Hospital psychiatric clinic and outside the study area. Data was analyzed using SPSS version 20 for windows and descriptive statistics and binary logistic regression statistical methods were applied. P-Value of less than 0.05 was considered statistically significant association in the final model. Results: Out of 300 patients, 61.7% males and 38.3% were females. The prevalence rate of medication nonadherence was 39.3% and 198 (66%) of the participants were traditional treatment users. Using religious types of traditional treatment [AOR=3.763, 95% C.I (1.459, 9.707)], longer duration of treatment (>10 years) [AOR=0.375, 95% C.I (0.155, 0.908)], no history of treatment default [AOR=0.375, 95% C.I (0.155, 0.908)] and no relapse history [AOR=0.365, 95% C.I (0.190, 0.702)] were independently associated variables with medication non-adherence. Conclusion: This study showed that high magnitude of non-adherence and majority of the participants were users of traditional treatments which significantly affects medication adherence. Therefore, mental health professionals should focus on methods how to work cooperatively with traditional treatment giver to decrease non adherence and improve counseling service for patients about being non adherent and its effect on clinical outcome.

The Effect of Reading Interventions among Poor Readers at a Forensic Psychiatric Clinic

The aim of the present study was to investigate the effect of a short period, 15 sessions, of reading interventions in a sample of adult forensic psychiatric patients: 61 patients with decoding difficulties – 44 in the experimental group and 17 in the comparison group – with an average age of 31.6 participated. Of these, 36% were female, and 29% had an immigrant background. The participants carried out a battery of reading tests. The results in the experimental group showed a medium effect size (d = .36 to .76) on all reading tests between pre- and post-test. The comparison group, however, showed no gain at all between the test occasions. The results indicate that a proportionally low reading intervention effort produces improvement in reading. This study discusses the importance of including reading assessment and offering remediation in order to reach optimal future social adjustment for patients in forensic clinics.

False Memories in the Laboratory and in Life: Commentary on Brewin and Andrews (2016)

SummaryReviewing laboratory experiments, Brewin and Andrews (this issue) conclude that memory implantation techniques induce full‐blown false autobiographical memories in only 15% of subjects. Does this imply that guided imagery and related methods are unlikely to generate false memories of childhood sexual abuse in adult psychiatric patients? Not necessarily. Although these methods alone may seldom produce false memories, additional factors common in clinical settings are likely to amplify their capacity to do so in psychiatric patients (e.g., belief that repressed memories of trauma can cause symptoms; belief that these methods can recover repressed memories; high scores on dissociation measures). Copyright © 2016 John Wiley & Sons, Ltd.

The Modular Assessment of Risk for Imminent Suicide (MARIS): A proof of concept for a multi-informant tool for evaluation of short-term suicide risk

BackgroundTo date, no diagnostic tool has demonstrated clinical value for the assessment of short-term suicide risk among high-risk individuals. To this end we have developed the Modular Assessment of Risk for Imminent Suicide (MARIS), a modular patient and clinician informed risk evaluation instrument. Here we assess its predictive validity for suicidal behavior (SB) in psychiatric patients following discharge from an inpatient unit. MethodsThe MARIS and a psychological test battery were administered to 136 adult psychiatric patients hospitalized for high risk of suicide. Eighty-six participants had complete data at discharge and 59 (69.8%) were reached for follow-up. Logistic regressions were used to assess the predictive validity of the MARIS for SB over the 4–8weeks following hospital discharge and its incremental predictive validity over standard risk factors. ResultsPatients who exhibited SB in the period between initial assessment and follow-up had significantly higher MARIS scores. ROC analysis indicated good sensitivity and specificity of MARIS in identifying risk (OR=19). Further, MARIS total score significantly improved predictive validity by the standard risk factors when added to a model comprising global depression severity, hopelessness, and lifetime number of suicide attempts, and was the only factor that approached independent significance. ConclusionThe MARIS appears to be a practical and effective tool for detecting short-term suicide risk following hospital discharge, supporting the validity of modular multi-informant approach to suicide risk evaluation. Replication of these findings and further investigation of the applications of such an approach are warranted.

Prediction of suicidal behavior in high risk psychiatric patients using an assessment of acute suicidal state: The suicide crisis inventory.

We have developed the Suicide Crisis Inventory (SCI) to evaluate the intensity of the Suicidal Crisis Syndrome, an acute state hypothesized to precede suicide attempt. The psychometric properties of the SCI, including predictive validity for suicidal behavior (SB), were assessed. Adult psychiatric patients (n = 201) hospitalized for high suicide risk were assessed. Logistic regression models assessed the SCI's predictive validity for SB in the 4-8 weeks following hospital discharge and its incremental predictive validity over traditional risk factors (n = 137, 64% f/u rate). Internal structure, reliability, convergent and discriminant validity, and state versus trait properties were also assessed. The SCI had excellent internal consistency (Cronbach's α 0.970). The SCI total score at discharge predicted short-term SB with 64% sensitivity 88% specificity (OR = 13, P = .003) at its optimal cut score. In a test of its incremental predictive validity, SCI total score at discharge improved prediction of SB over traditional risk factors (Chi-squared 5.597, P = .024, model P = .001), with AOR 2.02 (P = .030). The SCI admission versus discharge test-retest reliability and score distributions showed it to be an acute state measure. The SCI was predictive of future SB in high-risk psychiatric inpatients during the crucial weeks following their hospital discharge. Further validation in diverse patient populations is needed.

A Step Toward a Better Understanding of the Relationship Between Victimization and Emotional Distress: Indirect Effect of Adult Attachment and Interaction With Household Dysfunction.

A history of victimization has been linked to the latter development of emotional distress. However, not all victims develop emotional distress in response to victimization, emphasizing the need to identify mediators that can guide intervention, as well as moderators to more targeted preventive actions. Within a developmental psychology framework, we aimed to test two models: (a) the role of adult attachment as a mediator in the relationship between victimization and emotional distress, and (b) the role of household dysfunctions as moderators in the relationship between victimization and emotional distress, in psychiatric patients. Participants were 120 adult psychiatric patients, between ages 20 and 79 years (M = -47.22, SD = 13.102) that responded to questions assessing household dysfunction in the family of origin, victimization, and adult attachment. Results revealed that adult attachment was a significant mediator in the association between victimization and emotional distress. Parental mental disorder and total household adversity were significant moderators for that same association. These results provide important clues for intervention. The focus on promoting secure adult relationships may contribute not only to the psychosocial adjustment of psychiatric patients but also to a healthier family functioning. Reducing the household dysfunction may provide a protective environment for the development of children, promoting a positive psychosocial adjustment, also preventing the intergenerational transmission of violence, insecure attachment, and emotional distress.

Prevalence of Childhood Victimization Experiences in Psychiatric Patients: a Systematic Review

Studies have found high prevalence rates of childhood victimization within psychiatric patients, with a solid association between its occurrence and adult mental disorders. However, several limitations persist in this field of investigation, leading to a fragmentation of the knowledge concerning the prevalence of childhood victimization in adult psychiatric patients and limiting the acting range of the mental health community. In order to better understand the current status of the investigation in the field, we undertook a systematic review aimed at identifying studies that assessed the prevalence of childhood victimization experiences in adult psychiatric patients Our results showed that emotional abuse had the highest prevalence range, varying from 20.8 % to 94.3 %. Some studies used non validated measures to assess childhood victimization, while other studies lacked a definition of childhood victimization. We need more methodologically sound studies, with clear definitions of childhood victimization, in order to allow comparison across studies and to gain a clear picture of the prevalence rates of childhood victimization within psychiatric patients.

Type and timing of adverse childhood experiences differentially affect severity of PTSD, dissociative and depressive symptoms in adult inpatients.

BackgroundA dose-dependent effect of Adverse Childhood Experiences (ACE) on the course and severity of psychiatric disorders has been frequently reported. Recent evidence indicates additional impact of type and timing of distinct ACE on symptom severity experienced in adulthood, in support of stress-sensitive periods in (brain) development. The present study seeks to clarify the impact of ACE on symptoms that are often comorbid across various diagnostic groups: symptoms of posttraumatic stress disorder (PTSD), shutdown dissociation and depression. A key aim was to determine and compare the importance of dose-dependent versus type and timing specific prediction of ACE on symptom levels.MethodsExposure to ten types of maltreatment up to age 18 were retrospectively assessed in N = 129 psychiatric inpatients using the Maltreatment and Abuse Chronology of Exposure (MACE). Symptoms of PTSD, shutdown dissociation, and depression were related to type and timing of ACE. The predictive power of peak types and timings was compared to that of global MACE measures of duration, multiplicity and overall severity.ResultsA dose-dependent effect (MACE duration, multiplicity and overall severity) on severity of all symptoms confirmed earlier findings. Conditioned random forest regression verified that PTSD symptoms were best predicted by overall ACE severity, whereas type and timing specific effects showed stronger prediction for symptoms of dissociation and depression. In particular, physical neglect at age 5 and emotional neglect at ages 4–5 were related to increased symptoms of dissociation, whereas the emotional neglect at age 8–9 enhanced symptoms of depression.ConclusionIn support of the sensitive period of exposure model, present results indicate augmented vulnerability by type x timing of ACE, in particular emphasizing pre-school (age 4–5) and pre-adolescent (8–9) periods as sensitive for the impact of physical and emotional neglect. PTSD, the most severe stress-related disorder, varies with the amount of adverse experiences irrespective of age of experience. Considering type and timing of ACE improves understanding of vulnerability, and should inform diagnostics of psychopathology like PTSD, dissociation and depression in adult psychiatric patients.

Interventions to Reduce Compulsory Psychiatric Admissions: A Systematic Review and Meta-analysis.

Compulsory admissions, defined as admissions against the will of the patient (according to local judicial procedures), have a strong effect on psychiatric patients. In several Western countries, the rate of such admissions is tending to rise. Its reduction is urgently needed. To establish which interventions effectively reduce compulsory admissions in adult psychiatric patients in outpatient settings. A systematic computerized literature search was performed using EMBASE, MEDLINE, Web of Science, PsycINFO, CINAHL, PubMed (not yet indexed for MEDLINE), Cochrane Central, and Google Scholar. Every database was searched from its inception until April 30, 2015. Randomized clinical trials (RCTs) that studied any kind of intervention designed to reduce compulsory admission rates in adult psychiatric patients (age range, 18-65 years) in outpatient settings were eligible. Eligibility was independently assessed by 2 of us. Two of us independently extracted relevant data. The Cochrane Collaboration's tool was used for assessing risk of bias. Overall risk reduction (random-effects estimate) was calculated in the following 4 subgroups of interventions: advance statements, community treatment orders, compliance enhancement, and integrated treatment. Relative risk (RR) was calculated on the basis of the number of patients who had been compulsorily admitted. Our meta-analyses included 13 RCTs comprising 2970 psychiatric patients. The meta-analysis of the RCTs on advance statements showed a significant 23% (RR, 0.77; 95% CI, 0.60-0.98; I2 = 2.2%) (n = 1102) risk reduction in compulsory admissions. In contrast, the RCTs on community treatment orders (RR, 0.95; 95% CI, 0.81-1.10; I2 = 0.0%) (n = 742), compliance enhancement (RR, 0.52; 95% CI, 0.11-2.37; I2 = 55.7%) (n = 250), and integrated treatment (RR, 0.71; 95% CI, 0.49-1.02; I2 = 49.0%) (n = 876) showed no significant risk reduction in compulsory admissions. The meta-analysis of the RCTs on advance statements showed a statistically significant and clinically relevant 23% reduction in compulsory admissions in adult psychiatric patients, whereas the meta-analyses of the RCTs on community treatment orders, compliance enhancement, and integrated treatment showed no evidence of such a reduction. To date, only 13 RCTs have used compulsory admissions as their primary or secondary outcome measure. This demonstrates the need for more research in this field.

Stigma and discrimination in mentally disordered offender patients – a comparison with a non-forensic population

High levels of stigma and discrimination are reported by individuals with mental health problems. Aim: To assess self-reported levels of stigma and discrimination in forensic psychiatric patients, with psychotic illness, compared with general adult psychiatric patients with psychosis. Hypothesis: Individuals with a history of violent offending, as well as severe mental illness, report more stigma and discrimination, than non offender patients, as a result of them being perceived as dangerous and unpredictable. Method: Experiences of stigma and discrimination were compared in 32 forensic and 32 non-forensic general psychiatric patients, with schizophrenia or schizoaffective disorder, using the Stigma and Discrimination Scale (DISC). Results: Stigma and discrimination were widely reported by all patients, particularly affecting relationships with family, intimate relationships and friendships. No significant difference emerged between the forensic and non-forensic patients, in experienced or anticipated stigma. Conclusions: We suggest that the lower level of psycho pathology, longer inpatient stays and intensive rehabilitation for forensic patients may reduce the extent to which these patients experience stigma and discrimination.

Pharmacogenetic testing for the guidance of psychiatric treatment: a multicenter retrospective analysis.

We investigated the association between clinical outcome and the recommendations of a pharmacogenetic test (Neuropharmagen) in patients with a variety of psychiatric conditions whose previous treatment regimen had failed. This retrospective, naturalistic, multicenter study included adult psychiatric patients (depression, psychosis, anxiety, bipolar, etc.) who had been seen at 3 private clinics. All patients had received pharmacogenetic testing (Neuropharmagen) and were classified depending on whether or not their post-test treatment regimen followed the test recommendations. Clinical severity was assessed with the Clinical Global Impression of Severity (CGI-S) at baseline (pre-test) and 3-month follow-up, and adverse events were recorded. 182 patients were available for analysis. After multivariate adjustment, patients whose treatment followed the test recommendations had odds of improvement about 4 times greater than patients whose treatment did not follow the recommendations (adjusted OR=3.86, 95%CI 1.36-10.95; p=0.011). Importantly, psychiatric diagnosis did not significantly affect the odds of improvement. Also, in the subpopulation with baseline CGI-S score >3 (N=170), the rate of stabilization at follow-up (defined as CGI-S≤3) was significantly higher in patients whose treatment followed the pharmacogenetic recommendations (p=0.033). There was no apparent difference in the incidence of adverse events (6 patients in each group). Non-drug naïve patients whose treatment followed the recommendations of pharmacogenetic testing were more likely to improve their condition than patients whose treatment did not. These results are consistent with previous clinical research on depressed patients, and this study also suggests that this benefit can be extended to psychiatric conditions other than depression.

Association between C-reactive protein and suicidal behavior in an adult inpatient population

ObjectivesTo examine the relationship of inflammation and suicidal behavior in hospitalized adult psychiatric patients. MethodWe retrospectively examined serum high sensitivity C-reactive protein (hsCRP) levels in inpatients at a tertiary-level university hospital (N = 184). The inpatients comprised three cohorts: 1) patients admitted following a suicide attempt, 2) patients with suicidal ideation, and 3) inpatient psychiatric controls. Additionally, we gathered demographic data, clinical data, smoking status, white blood cell count, and fasting lipid panel. ResultsAs CRP level increased, the probability of patients belonging to the suicide attempt group increased as compared to both the probabilities of being in inpatient psychiatric control and or suicide ideation groups [OR = 2.09, CI = (1.29, 3.38) and OR = 1.75, CI = (1.15, 2.66) respectively]. We also observed a significant effect of depression in that depressed patients were more likely to have a suicide attempt when compared to patients with no depression or with mania [OR = 10.38, CI = (1.97, 54.70)]. ConclusionsThere seems to be an inflammation gradient, measured by CRP levels, from recent suicide attempters, suicidal ideators and psychiatric controls. We replicated the association between a pro-inflammatory state and suicidal behavior in a sample of “real world” severely ill psychiatric inpatients.

Old and new reasons for specialization

Mental illness is one of the largest areas of activity in the health service, with mental disorders of the elderly an important part of it. This substantial ageing of the population is a new phenomenon, occurring over the last century. It has given prominence to mental illness in old age. There is a growing interest in making decisions about how many and which services to provide to the older community.The expertise of old age psychiatry services lies in the care and treatment of people with complex mixtures of psychological, cognitive, functional, behavioral, physical and social problems usually relating to ageing. Current evidence suggests specialist old age services are best equipped to diagnose and treat mental illness in our ageing population. However, the specialists should be integrated optimally into a service system to the benefit of the elderly. It will be crucial to improve access of older patients to the services. The service system and the partners in the system differ to those for younger adult psychiatric patients. Thus, not only knowledge and skills underline the necessity of specialization but also the increasingly complex health service structures of modern societies.Disclosure of interestThe author has not supplied his declaration of competing interest.

Predicting hospital aggression in secure psychiatric care.

BackgroundRisk assessment instruments have become a preferred means for predicting future aggression, claiming to predict long-term aggression risk.AimsTo investigate the predictive value over 12 months and 4 years of two commonly applied instruments (Historical, Clinical and Risk Management - 20 (HCR-20) and Violence Risk Appraisal Guide (VRAG)).MethodParticipants were adult male psychiatric patients detained in a high secure hospital. All had a diagnosis of personality disorder. The focus was on aggression in hospital.ResultsThe actuarial risk assessment (VRAG) was generally performing better than the structured risk assessment (HCR-20), although neither approach performed particularly well overall. Any value in their predictive potential appeared focused on the longer time period under study (4 years) and was specific to certain types of aggression.ConclusionsThe value of these instruments for assessing aggression in hospital among patients with personality disorder in a high secure psychiatric setting is considered.Declaration of interestJ.L.I., C.A.M. and J.K. are employed by the trust where the data were collected.Copyright and usage© The Royal College of Psychiatrists 2016. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) licence.

Self-administered acupressure for treating adult psychiatric patients with constipation: a randomized controlled trial.

BackgroundConstipation has a high prevalence rate (>30 %) in psychiatric patients with psychotropic drugs. Common pharmacological and non-pharmacological interventions for constipation might have longer-term negative and adverse effects that would outweigh their short-term efficacy in symptom reduction. This randomized controlled trial aims to investigate the effect of self-administered acupressure for the management of constipation, in hospitalized psychiatric patients.MethodsSeventy-eight patients were recruited in matched pairs in terms of gender, age and laxative use from five acute psychiatric wards in Hong Kong. Each of these matched pairs of patients was randomly assigned to either a self-administered acupressure (n = 39) or a sham group (n = 39), using computer-generated random numbers. After baseline measurement, the intervention and sham group received the same training in self-administered acupressure and supervised practice once per day for 10 days, except light pressure on non-acupoints was taught to the sham group. The acupoints chosen for acupressure included Zhongwan (RN12), right and left Tianshu (ST25), right and left Quchi (LI11). Participants’ symptoms and quality of life regarding constipation were measured at baseline and immediately and 2 weeks after completion of the interventions with constipation assessment scale and patient assessment of constipation quality of life questionnaire, respectively.ResultsAfter 2 weeks follow-up, participants who had received self-administered acupressure indicated significantly greater improvements in both symptom severity (P = 0.0003) and quality of life (P = 0.0004) when compared with the sham group.ConclusionThe psychiatric patients with constipation who practiced self-administered acupressure for 10 days improved their symptom severity and perceived quality of life immediately and 2 weeks after completion of the intervention in comparison with the sham group.Trial registration: The trial was registered with the ClinicalTrials.gov (Reg. No: NCT02187640)Electronic supplementary materialThe online version of this article (doi:10.1186/s13020-015-0064-7) contains supplementary material, which is available to authorized users.

Psychiatric Stigma in Treatment-Seeking Adults with Personality Problems: Evidence from a Sample of 214 Patients.

Stigmatization is a major burden in adult psychiatric patients with Axis-I diagnoses, as shown consistently in most studies. Significantly fewer studies on the emergence of psychiatric stigma in adult patients with personality disorders (PDs) exist, although the resulting evidence is conclusive. Some authors consider patients with PDs at risk for severe stigmatization because of intense difficulties during interpersonal contact, even in a psychotherapeutic relationship. The aim of this study was primarily the assessment of pre-existing stigma in patients referred for intensive treatment for PDs. The study enrolled 214 patients admitted to the adult department of a highly specialized mental health care institute offering psychotherapy for patients with severe and complex personality pathology. All patients underwent a standard assessment with self-report questionnaires and a semi-structured interview to measure Axis II PDs. The stigma consciousness questionnaire and the perceived devaluation-discrimination questionnaire, both validated instruments, were used to measure perceived and actual experiences of stigma. Independent sample t-tests were used to investigate differences in the mean total stigma scores for patients both with and without a PD. One-way ANOVAs were performed to assess the differences between having a borderline PD, another PD, or no PD diagnosis. Multiple regression main effect analyses were conducted in order to explore the impact of the different PD diagnosis on the level of stigma. The mean scores across all patient groups were consistent with rather low stigma. No differences were found for patients with or without a PD diagnosis. Level of stigma in general was not associated with an accumulating number of PDs. Given the remarkable results, we would strongly recommend further investigations in the field to better understand the phenomenon of stigma in all its aspects.

Improvement in Medical Practice: Performance in Practice: Improvement in Medical Practice: Clinical Modules for Screening and for the Assessment and Treatment of Adults With Substance Use Disorders

Improvement in Medical Practice: Performance in Practice: Improvement in Medical Practice: Clinical Modules for Screening and for the Assessment and Treatment of Adults With Substance Use Disorders

FACTORIAL VALIDITY OF THE SHORT FORM OF THE CHILDHOOD TRAUMA QUESTIONNAIRE (CTQ-SF) IN GERMAN PSYCHIATRIC PATIENTS, INMATES, AND UNIVERSITY STUDENTS.

For the purpose of retrospective assessment and characterization of childhood trauma in adults, the factorial validity of the short form of the Childhood Trauma Questionnaire (CTQ-SF) in Germany was evaluated by conducting confirmatory factor analyses for three samples including 1,524 adult psychiatric patients, 224 inmates, and 295 university students. In addition, sex-specific confirmatory factor analyses were performed within each sample. Because several authors have suggested a different factor structure than that originally proposed in the manual, two competing models focusing on the Physical neglect subscale were examined. In psychiatric patients and inmates, the fit indices were reasonable to good. Among the students, factor loadings were markedly lower, and fit indices were poor. Sex-specific analyses did not indicate sex differences. Comparing the original and the alternative models revealed better fit indices of the original factor structure. The present findings indicate that the German version of the CTQ-SF has factorial validity in psychiatric patients and inmates, but not in students.

Translating evidence from a systematic review to the development of an evidence-based fall prevention program in a tertiary psychiatric hospital

Falls have been a major safety concern in view of its high incidences and potential detrimental consequences. This article described a systematic review about effectiveness of interventions for the assessment and prevention of falls in adult psychiatric patients conducted previously. These patients possessed unique fall-related risk factors such as altered mental status, physiological symptoms, past history of falls, mobility and gait problems, concurrent medical conditions, and polypharmacy that might warrant specific tailored fall prevention interventions. Following the systematic review, a care bundle for fall prevention in a tertiary psychiatric hospital would be implemented, taking into account these risk factors and evidence relating to fall prevention.

The impact of legal coercion on the therapeutic relationship in adult schizophrenia patients.

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.