Working alliance, interpersonal trust and perceived coercion in mental health review hearings

Abstract

Background: There is some evidence that when mental health commitment hearings are held in accordance with therapeutic jurisprudence principles they are perceived as less coercive, and more just in their procedures leading to improved treatment adherence and fewer hospital readmissions. This suggests an effect of the hearing on therapeutic relationships. We compared working alliance and interpersonal trust in clinicians and forensic patients, whose continued detentions were reviewed by two different legal review bodies according to their legal category.

Methods: The hearings were rated as positive or negative by patients and treating psychiatrists using the MacArthur scales for perceived coercion, perceived procedural justice (legal and medical) and for the impact of the hearing. We rated Global assessment of Function (GAF), Positive and Negative Symptom Scale (PANSS), Working Alliance Inventory (WAI) and Interpersonal Trust in Physician (ITP) scales six months before the hearing and repeated the WAI and ITP two weeks before and two weeks after the hearing, for 75 of 83 patients in a forensic medium and high secure hospital.

Results: Psychiatrists agreed with patients regarding the rating of hearings. Patients rated civil hearings (MHTs) more negatively than hearings under insanity legislation (MHRBs). Those reviewed by MHTs had lower scores for WAI and ITP. However, post-hearing WAI and ITP scores were not different from baseline and pre-hearing scores. Using the receiver operating characteristic, baseline WAI and ITP scores predicted how patients would rate the hearings, as did baseline GAF and PANSS scores.

Conclusions: There was no evidence that positively perceived hearings improved WAI or ITP, but some evidence showed that negatively perceived hearings worsened them. Concentrating on functional recovery and symptom remission remains the best strategy for improved therapeutic relationships.

Figures

Figure 1

Patients' appraisals of two types of hearings. Patients' ratings of hearings as coercive, procedural justice regarding the role of legal chair and their own solicitor and procedural justice regarding their psychiatrist, and the impact of the hearing.

Figure 2

Consultant psychiatrists' appraisals of two types of hearings. Consultant psychiatrists' ratings of hearings as coercive, procedural justice regarding the role of legal chair and their own solicitor and procedural justice regarding their psychiatrist, and the impact of the hearing.

Figure 3

WAI and ITP before and after hearings. Note that the arrows indicate the time of the hearings.

Figure 4

MHT and MHRB groups compared. Results are for the ITP when patients rated their consultant psychiatrists.

Figure 5

Patients' perceptions of the hearing and WAI patient ratings of psychiatrist before and after the hearing. Note that the arrows indicate the time of the hearings.

Figure 6

Patients' perceptions of the hearing and patient ratings of ITP re their psychiatrist before and after the hearing. Note that the arrows indicate the time of the hearings.

Figure 7

ROC curves for patient-rated ITP re their psychiatrist at T1 and the patient's positive or negative perceptions of the hearing.

Figure 8

ROC curves for patient-rated WAI re their psychiatrist at T1 and the patient's positive or negative perceptions of the hearing.

Figure 9

ROC curves for PANSS total score at T1 and the patient's positive or negative perceptions of the hearing.