Therapeutic Relationships in vocational rehabilitation: the interaction of two

relationships for people with severe mental illness

Jocelyn Catty, Marsha Koletsi, Sarah White, Thomas Becker, Angelo Fioritti, Rana Kalkan, Christoph Lauber,

Pascale Lissouba, Wulf Rössler, Toma Tomov, Jooske T. van Busschbach, Durk Wiersma & Tom Burns

for the EQOLISE Group

Therapeutic relationships in community mental health

• New to study despite wealth in psychotherapy• Meeting care needs promotes good TR• Influenced by clients’ psychopathology• - but little evidence on whether TRs driven by

client factors, predisposition towards services, or reflect unique relationship

• Some client-rated outcomes reflect a general appraisal tendency – but TR not tested

TR Questions

• Do TR ratings reflect clients’ predisposition?• If so, is this positive / negative appraisal of

circumstances?• Or predisposition to form good relationships?• Does a good TR have a bearing only on the

task in hand?

The EQOLISE Trial: Vocational Rehabilitation in Europe

• International RCT (n=312), 6 European centres• Randomised to Individual Placement and

Support (IPS) or usual Vocational Rehabilitation

• Interviews at baseline, 6, 12 and 18 months• TR data (HAS) on:

– TR with clinical keyworker– TR with vocational worker (client and prof-rated)

EQOLISE Findings

• IPS doubled access to work (Burns et al, 2007)

• Working / vocational outcomes also predicted by– TR with vocational worker (client & prof-rated)– Previous work history– IPS fidelity (Catty et al, 2008)

• TR with clinical keyworker did not predict vocational outcomes

Question 1: is TR task-specific?

• Explore associations between clients’ relationships with a) their clinical keyworkers and b) their vocational workers and their clinical and social functioning outcomes;

Question 2: are TRs driven by client predisposition?

• Explore associations between clients’ ratings of their relationships with their clinical keyworkers and their vocational workers

Predictors of clinical and social functioning

• TR at each timepoint tested against clinical and social variables at subsequent timepoint:– Global symptoms and disability (GAF-S & GAF-D)– Positive & negative symptoms (PANSS)– Anxiety and depression (HADS-A & HADS-D)– Quality of life (LQOLP-EU)– Social disability (GSDS)– Remission– hospitalisation

Predictors of clinical & social functioning: analysis

• Client-rated TR at each timepoint tested for association with each clinical & social functioning variable 6 months later

• Professional-rated TR at each timepoint tested for association with each variable 6 months later

• Linear regression model (logistic for binary variables) with random client effect

Associations between TR with clinical & vocational workers

• Change in TR with vocational worker tested against change in TR with clinical keyworker

• Multi-level model using data from each timepoint

• Random client effect incorporated• Analysis repeated using fixed time effect (is TR

changing?) and fixed TR-with vocational worker x time effect (is relationship between TRs changing)

Results: Clients (n=312) and TR data

• 248 (83.3%) with schizophrenia• 188 (60.3%) male• TR with clinician at baseline on all but one• T1: client-rated TR with VW for 228 (87.4% of

261) – prof-rated for 206 (202 pairs)• T3: client-rated TR with VW for 176 (80.4% of

219) – prof-rated for163

Levels of therapeutic relationshp

• TR with clinical keyworker:- mean TR 42.4 (out of 55)

• TR with vocational worker:– Client-rated mean TR 40.4– Prof-rated mean TR 41.4

• Little change in TR levels over time

TR with clinical keyworker as predictor of clinical / social functioning

• Only association was with overall subjective quality of life (r=0.01, 95%CI 0.001, 0.01, p=0.013)

• A 10-point higher TR rating was associated with a 0.1 point higher QoL rating (out of 7) 6 months later

TR with vocational worker as predictor of clinical / social functioning

• Client-rated: no significant associations• Professional-rated:

– Associated with global symptoms & disability, positive, negative & general symptoms, social disability, remission & depression (borderline)

• For contemporaneous timepoints:– Associated with global symptoms & disability,

positive, negative & general symptoms, social disability, remission & QoL – not depression

Vocational worker-rated TR as a predictor of clinical and social functioning

Variable Regression

Coefficient

95% C.I p-value

GAF-S 0.20 0.09 0.30 <0.001

GAF-D 0.25 0.14 0.36 <0.001

HADS-D -0.04 -0.08 0.003 0.069

PANSS positive -0.11 -0.15 -0.06 <0.001

PANSS negative -0.09 -0.14 -0.04 0.001

PANSS general -0.16 -0.24 -0.09 <0.001

GSDS total -0.08 -0.11 -0.04 <0.001

Odds Ratio 95% C. I. p-value

Remission 1.06 1.02 1.09 0.007

Results –TRs with clinical & vocational workers

• Significant association between client-keyworker relationship & client-rated client-vocational-worker relationship (B=0.24, 95%CI 0.17, 0.31, p<=0.0001) – low magnitude

• Time variable & TR x time interaction NS – neither TR nor the association between TR with keyworker & TR with vocational worker changed over time

Discriminating between tasks: impact on outcomes

• Client-rated client-vocational worker relationship predicted getting a job –

• But not clinical or social functioning outcomes• Client-keyworker relationship predicted only

slightly higher subjective QoL• Vocational worker-rated relationship predicted

range of clinical & vocational o/comes – but driven by how easy client was to relate to, not truly predictive

Discriminating between relationships

• Relationship with clinical keyworker at baseline = one of few predictors of relationship with vocational worker at 6 mo

• Ratings of 2 relationships correlated but low magnitude

• No evidence that the development of a good TR with vocational worker detracts from previous good TR with clinical keyworker

Conclusions

• Impact of TR may be on the shared task - task-specificity

• Relationships with different professionals distinct from each other – only about half the variance explained