The relationship of therapeutic alliance to quality of life for people with serious mental illness: A pilot study based on lived experience
Raquelle Mesholam-Gately (1,2,3), Emily Parsons (4), Christian Rosa-Baez (5), Nathan Schwirian (5), Linda Larson (5), Peter Durning (5), Dan Johnston (5), Vera A. Muñiz-Saurré (5), Charles Stromeyer (5), Matcheri Keshavan (1,2,3)
1. Massachusetts Psychosis Network for Early Treatment (MAPNET), Beth Israel Deaconess Medical Center, Boston, MA
2. Massachusetts Mental Health Center Public Psychiatry Division of the Beth Israel Deaconess Medical Center, Boston, MA
3. Department of Psychiatry, Harvard Medical School, Boston MA
4. OASIS Program, University of North Carolina at Chapel Hill, Chapel Hill, NC
5. Peer Advisory, Advocacy & Research Council, Massachusetts Mental Health Center Public Psychiatry Division of the Beth Israel Deaconess Medical Center, Boston, MA
Abstract
Background: The therapeutic alliance in mental health care is associated with better symptomatic and functional outcomes, as well as increased treatment adherence and satisfaction with care. There are, however, few instruments measuring therapeutic alliance for those with serious mental illness (SMI) that have specifically been developed in collaboration with researchers and people with lived experience. Guided by lived experience expertise, his study examined the relationship between therapeutic alliance and quality of life in SMI.
Methods: This project represented a partnership between researchers, clinicians and those with lived experience of SMI in the Peer Advisory, Advocacy & Research Council (PAARC; formerly Consumer Advisory Board) at the Psychosis Research Program of the Massachusetts Mental Health Center (MMHC) Public Psychiatry Division of Beth Israel Deaconess Medical Center, Boston, MA. People with SMI (N=76) between the ages of 20-76 receiving outpatient care at the MMHC and other MA DMH mental health facilities in the Boston area provided data for this project. Participants were asked to complete a 1 hour interview with researchers and PAARC members. Interviews involved questionnaires developed by the research team about the therapeutic allaince (Treatment Relationship Inventory; TRI) and subjective quality of life (a modified version of the World Health Organization Quality of Life Assessment; mWHO-QOL). Internal reliability of the TRI, including its subscales, was calculated with Chronbach’s alpha. Associations between survey ratings were measured with Spearman’s correlations. Nonparametric partial correlations were conducted to consider the potential confounding influence of select sample characteristics on the survey associations.
Results: The TRI was found to be highly reliable for all 30 items comprising the total score (α = .94), as well as for each of the subscales. Total average scores for the TRI and mWHO-QOL were significantly and positively correlated (rs=.41, p<.001). Subsections within the TRI (clinician relationship, emotional climate, interpersonal continuity, mutual trust) and the total average score for the mWHO-QOL were also significantly correlated (range of rs=.31 to .40; all ps <.01). Subsections within the mWHO-QOL (physical, cognitive, emotional) and the total average score for the TRI were similarly significantly correlated (range of rs=.24 to .36; all ps <.05). Most specific subsections between the instruments also showed significant correlations. Controlling for age, gender and treatment background characteristics via separate nonparametric partial correlation analyses did not change the significant association between TRI and mWHO-QOL total average scores. Comparable significant findings were shown when just analyzing an adolescent and young adult subset of the sample (N=16; aged 20-34).
Conclusions: These findings suggest that a strong therapeutic alliance is related to better quality of life in people with SMI. Additionally, certain aspects of the therapeutic alliance and quality of life have a stronger association than others. Further research can help to elucidate the predictive nature of therapeutic alliance on quality of life in early phases of illness, particularly psychosis, and inform more effective approaches to early intervention by targeting aspects of therapeutic alliance early in treatment. Moreover, applying these novel scales, and with it the expertise of lived experience, in future assessments of therapeutic alliance will provide further insights into the impact of collaborative approaches to conceptualizing, developing and providing recovery-oriented mental health services.