Jocelyn Catty, Sarah White, Sarah Clement, Naomi Cowan, Gemma Ellis, Connie Geyer,

Pascale Lissouba, Zoe Poole and Tom Burns for the ECHO Group

Background:therapeutic relationship

Predictor of range of outcomes in general adult mental health services

Variance in ratings as yet unaccounted forLack of evidence about multiple professional TRsClient-rated TR associated with QoL (McCabe et al

1999)Client-rated outcome measures (needs, QoL &

symptoms) linked to appraisal (Hansson et al, 2007)- though treatment satisfaction the exceptionTR, continuity & proportion of care needs met

loaded onto one factor, Relationship & Continuity

Continuity of Care: ECHO278 long-term users of community mental health

teams (CMHTs), on enhanced CPA180 with psychotic disorders – 3 year follow-up98 with non-psychotic disorders – 2 year follow-

upInterviews at yearly intervals – global

functioning, symptoms, QoL, care needs, empowerment, continuity of care, TR (STAR – McGuire-Snieckus et al, 2007)

Client-keyworker TR assessed by both parties, client-psychiatrist TR assessed by client

QuestionsWhat predicts client-keyworker TR?What predicts client-psychiatrist TR?Are clients’ TR ratings driven by a

tendency for positive or negative appraisal?

Do they rate TRs with different professionals differently (do they discriminate)?

What drives any difference?

ObjectivesDetermine client & professional characteristics

associated with TR

Determine contrasts between TRs with keyworkers and TR with psychiatrists & explore variables associated with any contrasts

The ECHO Cohort52% female, 72.7% White, 53.2% living with

others, 82.4% in unsupervised accommodation16.4 years mean duration of illness, mean age

42.5Psychotic cohort: 67.6% schizophreniaNon-psychotic cohort: 53.1% depression, 16.3%

anxiety, 14.3% PD250 (89.9%) interviewed at 1 year follow-up141 (78.3% of 180) interviewed at 2 year follow-

up

Predictors of TREach TR rating used as outcome of multi-level

modelling, preceded by univariate analysesSocio-demographic & clinical & social functioning

variables tested as potential predictorsBetter client-rated client-keyworker TR predicted

byempowerment, continuity, non-psychotic diagnosis

Better professional-rated client-kw TR predicted bypsychotic diagnosis, discipline (CPNs)

Better client-psychiatrist TR predicted bycontinuity, Asian ethnicity (& time)

STAR-kw (client-rated)

Beta 95%CI F P

GAF 0.01 -0.06, 0.10 0.22 0.64

Empowerment 0.12 0.03, 0.21 7.17 0.01

MANSA 0.26 -0.74, 1.25 0.26 0.61

CONTINU-UM 5.75 4.63, 6.88 102.38 <0.001

CAN Total needs 0.03 -0.25, 0.32 0.05 0.82

Diagnosis Mean 95%CI F P

Psychotic 35.61 34.54, 36.68 13.89 <0.001

Non-psychotic 38.98 37.68, 40.28

STAR-prof (keyworker-rated)

Beta 95%CI F P

GAF 0.05 -0.02, 0.11 2.11 0.15

Empowerment -0.01 -0.08, 0.06 0.08 0.78

MANSA 0.14 -0.67, 0.95 0.12 0.73

CONTINU-UM 0.39 -0.51, 1.29 0.74 0.39

CAN Total needs -0.14 -0.36, 0.08 1.63 0.21

Diagnosis Mean 95%CI F P

Psychotic 41.55 40.43, 42.66 3.94 0.05

Non-psychotic 39.95 38.84, 41.07

Keyworker discipline

CPN 42.27 41.30, 43.25 3.84 0.01

OT 39.52 37.59, 41.45

Social Worker 40.03 38.82, 41.25

Other 41.18 39.47, 42.89

Transition in previous year

Yes 40.26 39.30, 41.23 3.03 0.09

No 41.24 40.29, 42.19

STAR-psych (client-rated)

Beta 95%CI F p

GAF 0.04 -0.09, 0.16 0.37 0.54

Empowerment 0.05 -0.10, 0.20 0.41 0.52

MANSA 0.52 -1.08, 2.12 0.42 0.52

CONTINU-UM 4.57 2.89, 6.25 29.24 <0.001

CAN Total needs -0.19 -0.64, 0.27 0.67 0.41

Ethic Group Mean 95%CI F P

White 32.60 31.17, 34.03 2.56 0.06

Asian 36.97 32.42, 41.51

Black 35.61 31.76, 39.46

Other 37.11 32.26, 41.96

Time-point

1 33.97 31.90, 36.05 11.42 <0.001

2 37.17 34.89, 39.45

TRs with different professionalsClient-keyworker TR was tested for association

with client-psychiatrist TR (both client-rated) using paired t-tests, both at T1

To determine predictors of any preference, a TR preference score was calculated (+ = pref for kw)

Demographic & illness variables tested for association with TR preference in a linear regression

TR preferenceStatistically significant preference for

keyworkers (replicated at follow-up)Preference for keyworker over

psychiatrist predicted univariately by lower empowerment, lower continuity, non-psychotic diagnosis, being female

But none significant in linear regression model

Evidence for appraisal - FORAssociation between TR, empowerment

and continuity may suggest an underlying tendency for positive appraisal is driving the ratings

However, QoL and needs did not predict TR

Continuity of care measure may have approximated a service satisfaction measure, which may be conceptually closest to TR

Evidence for appraisal - AGAINST

There was a difference in ratings of the 2 relationships (keyworker and psychiatrist)

Lack of evidence for socio-demographic & illness predictors of preference may provide some evidence of the importance of the interpersonal process