An investigation into the factors associated with the quality of the therapeutic relationship between staff and people with severe and enduring mental health problems.

Abstract

This thesis investigates the factors associated with the quality of the therapeutic relationship between staff and people with severe and enduring mental health problems. It is presented as three papers: a literature review, a report of the empirical research study and a critical reflection of the research process.In the first paper, the author provides a narrative review of studies that have investigated the factors associated with the quality of the therapeutic relationship between psychiatric staff and people with severe and enduring mental health problems. A total of 28 research studies met the inclusion criteria and were included in the final review. The studies varied considerably in terms of their design and methodology, as well as the different instruments used to measure the quality of the therapeutic relationship. The findings were then organised in terms of measures of the therapeutic relationship and factors that may be associated with relationship quality. These findings were then further broken down into patient factors that may affect the therapeutic relationship and staff factors from both inpatient and outpatient settings. The key findings were that patient factors included demographics, psychopathology, insight, functioning and behaviour. Staff factors included demographics, education and training and working environment. However, it is not clear if each factor contributed independently, in combination or if indeed third factor variables were involved. There little doubt that the quality of the therapeutic relationship is an important component in the wider therapeutic process. What still requires further investigation is the individual ingredients that are necessary to ensure the patient and staff member are able to build and maintain a constructive therapeutic relationship that meets both their needs. The empirical research paper examined the extent to which attributions, personal and environmental factors were associated to the quality of the therapeutic relationship. It was hypothesised that the quality of the therapeutic relationship would be associated with attributions of control. We assessed the quality of the staff patient relationship using the Working Alliance Inventory; Attributions of Control were measured using the Five Minute Speech Sample. Patient symptoms, functioning and behaviour were also investigated, as were service engagement, ward environment and staff stress. We found that staff who rated the therapeutic relationship as more favorable made fewer ratings of attributions of control, although this did not affect patient ratings of the relationship. Service engagement and ward atmosphere were associated with the quality of the therapeutic relationship; patient behaviour and staff stress were not. Patient symptoms, functioning and staff burnout revealed mixed findings. Our findings highlight the potentially important role of attributions of control on the quality of staff and patient therapeutic relationships. The final paper provides a critical reflection of the research process. It begins by outlining the rationale for the development of the literature review and the empirical paper, and continues to discuss some of the methodological considerations of the research paper. Implications for therapeutic practice are then suggested, followed by wider service related issues. Finally recommendations are made for future research.

Date of Award	1 Aug 2013
Original language	English
Awarding Institution	The University of Manchester
Supervisor	Katherine Berry (Supervisor)