Recovery and decision-making involvement in people with severe mental illness from six countries: a prospective observational study.

BACKGROUND: Clinical decision-making is the vehicle of health care provision, and level of involvement predicts implementation and satisfaction. The aim of this study was to investigate the impact of decision-making experience on recovery. METHODS: Data derived from an observational cohort study "Clinical decision making and outcome in routine care for people with severe mental illness" (CEDAR). Adults (aged 18-60) meeting standardised criteria for severe mental illness were recruited from caseloads of outpatient and community mental health services in six European countries. After consenting, they were assessed using standardised measures of decision-making, clinical outcome and stage of recovery at baseline and 1 year later. Latent class analysis was used to identify course of recovery, and proportional odds models to investigate predictors of recovery stage and change. RESULTS: Participants (n = 581) clustered into three stages of recovery at baseline: Moratorium (N = 115; 19.8%), Awareness/Preparation (N = 145; 25.0%) and Rebuilding/Growth (N = 321; 55.2%). Higher stage was cross-sectionally associated with being male, married, living alone or with parents, and having better patient-rated therapeutic alliance and fewer symptoms. The model accounted for 40% of the variance in stage of recovery. An increased chance of worse outcome (change over 1 year to lower stage of recovery) was found for patients with active involvement compared with either shared (OR = 1.84, 95% CI 1.15-2.94) or passive (OR = 1.71, 95% CI = 1.00-2.95) involvement. Overall, both process (therapeutic relationship) and outcome (symptomatology) are cross-sectionally associated with stage of recovery. CONCLUSIONS: Patient-rated decision-making involvement and change in stage of recovery are associated. Joint consideration of decision practise within the recovery process between patient and clinician is supposed to be a useful strategy to improve clinical practice (ISRCTN registry: ISRCTN75841675. Retrospectively registered 15 September 2010).

Courses of helping alliance in the treatment of people with severe mental illness in Europe: a latent class analytic approach.

PURPOSE: The helping alliance (HA) between patient and therapist has been studied in detail in psychotherapy research, but less is known about the HA in long-term community mental health care. The aim of this study was to identify typical courses of the HA and their predictors in a sample of people with severe mental illness across Europe over a measurement period of one year. METHODS: Self-ratings of the HA by 588 people with severe mental illness who participated in a multicentre European study (CEDAR; ISRCTN75841675) were examined using latent class analysis. RESULTS: Four main patterns of alliance were identified: (1) high and stable (HS, 45.6 %), (2) high and increasing (HI, 36.9 %), (3) high and decreasing (HD, 11.3 %) and (4) low and increasing (LI, 6.1 %). Predictors of class membership were duration of illness, ethnicity, and education, receipt of state benefits, recovery, and quality of life. CONCLUSIONS: Results support findings from psychotherapy research about a predominantly stable course of the helping alliance in patients with severe mental illness over time. Implications for research and practice indicate to turn the attention to subgroups with noticeable courses.