1. UNDERSTANDING THE PROCESS OF SUPPORTED RECOVERY SARAH DE WATTIGNAR DOCTORATE OF CLINICAL PSYCHOLOGY UNIVERSITY OF AUCKLAND SUPERVSIORS: JOHN READ AND CLAIRE CARTWRIGHT

2. Contents Background Aims Method Results Quantitative and Qualitative The Therapeutic Relationship Summary Clinical Implications Conclusions

3. Background Early Intervention Service (EIS) evaluation EIS informed by the Recovery Model Service user involvement paramount SoCRATES (Bentall et al, in press) Therapeutic Alliance Evaluation of an EIS (Theuma et al, 2007) Therapeutic Relationship

4. Aims Qualitative exploratory study Subjective experience of service users EIS for psychosis Service satisfaction The process of recovery Helpful aspects Unhelpful aspects

5. Method Consultation Total sample N = 129 Recruitment (mail and telephone) Narrative interviews N = 20 Likert items (8) Thematic analysis using Nvivo software

6. Results Quantitative Demographic and clinical characteristics Likert items Non-parametric statistics Qualitative Life Prior to Service Engagement Factors Positively Influencing Recovery Factors Negatively Influencing Recovery The Process of Recovery

7. Sample

8. Likert Items

9. Quantitative Overall Satisfaction x Relationship Spearman’s rho = 0.85, p < 0.01 Relationship x Respect Spearman’s rho = 0.81, p < 0.01 Overall Satisfaction x Duration of Engagement Spearman’s rho = 0.75, p < 0.01 Overall Satisfaction x Respect Spearman’s rho = 0.67, p < 0.01

10. Qualitative Life Prior to Service Engagement Factors Positively Influencing Recovery Factors Negatively Influencing Recovery The Process of Supported Recovery

11. Positive Factors The Therapeutic Relationship (20/152) Medication (20/56) Components of Therapy (19/92) External Resources (15/52) Social Support and Connectedness (11/24) Family Involvement (10/24) Client Factors (9/19) Employment (7/10)

12. Negative Factors Medication (16/41) Components of Therapy (12/65) The Therapeutic Relationship (12/47) Family Under- and Over-Involvement (11/23) External Resources (8/22) Hopelessness (8/16) Self-Stigma (8/16) Unemployment (7/9) Disruptions in Care (6/23) Inpatient Care (6/10)

13. The Therapeutic Relationship Clients’ Perceptions of Clinicians (9/18) The Personable Approach of Clinicians’ (16/47) Provision of a Client-Focused Service (15/40) The Treatment Partnership (17/35) Clinician Expertise (5/9)

14. Psychotic Experiences Josh I was not well. I just thought I was on a TV show basically. And so I was extremely paranoid at the time. And I was in a pretty bad place. Jeremy I suffered a psychotic episode. I became really hypersensitive to the media, on TV and thought that people were talking about me and stuff, and I thought there was a government conspiracy.

15. TR: Personable Approach Josh The psychologist came to my house. Introduced himself. I can’t remember exactly what he said, I was quite ill, he just introduced himself, said this is what we do in our team, and that was the first time that I met him, and he’s quite a personable guy, I didn’t feel threatened or anything by him. And he introduced it in such a way that it sounded like the team would be good for me too.

16. Jeremy I wasn’t provided with a lot of information when I first saw them, I remember they took me down to the clinic and I had an interview, I didn’t know what I was supposed to be talking about with the doctor, and she just sat there and wrote down everything that I said, and I didn’t really know what it was all about. It was a little bit weird and there wasn’t a lot of information as to why I was doing this and how it was going to help me and what the process was.

17. TR: Treatment Partnership Josh I think one thing I noticed was that they would shake your hand. These guys would touch me and shake your hand, and it was like cool, that’s great. And then you’d leave and they’d shake your hand, and it was like we’re going to fix this problem, and it conveyed a sense of purpose about it. Like we’re in this together. More like a collaborative approach. It was good like that.

18. Jeremy Giving me time and space to come out of it by myself was possibly quite helpful, but at the same time it was a little bit too stand offish, and not really explaining what was going on.

19. Family Involvement Josh Family was good, very definitely helpful. I think the best thing about that was they were able to have their little say, their input and they could be on the same page as me. It wasn’t second hand information. I wouldn’t go home and tell them, Chinese whispers, they were getting it first hand, and that was pretty important. So they didn’t just have my word, they could take the word of the doctors. And if they had any questions they were answered immediately.

20. Jeremy There wasn’t a lot of information going through to my mum, so I’d say that part was a little bit lapse about it. My preference would have been for them to work closer with someone that I trusted like a family member or something, because I would have to relay to my family members what was going on, and I don’t know, it was a tough thing to do, because they didn’t really understand.

21. TR: Client-Focused Service Josh I found their manner quite good, conducive to me, particularly helping me address the unreality of my situation. They started to get to know me quite well, in the sense that they knew what I was up to, we had a few yarns and how the parents were and stuff like that, so it was quite a good feeling. They remembered who I was, I wasn’t like a number in a file, they knew the person, and they treated me like a person. I never felt like a patient really.

22. Jeremy I felt like their attitude was, oh no, here we go again, and I could pick up on that. And even though it was that, that’s really what was happening, oh no, here we go again, I was almost, not insulted, but just felt that no one believed me and yeah, that part made me not want to have too much involvement with them.

23. TR: Treatment Partnership Josh The psychiatrist was an extremely personable guy, and he was pretty straight up as well from what I remember. I remember him saying, we were talking about the weight gain again, and I remember him saying oh we’ve already talked about this, have you got this sorted out. And I remember that, because that was pretty fair enough at the time too. It was an honest relationship. (Josh)

24. Jeremy If someone had more personal contact, rather than just the medication, cause their priority was to get me medicated, and my priority was to talk about what was happening and what wasn’t, and we’d go off in different directions, where they were trying to get me to take medication, and I was trying to sit down and talk to them and ask them why all this stuff was happening to me. They had their priorities and I believed that I had mine, and they clashed a little bit.

25. Components of Therapy Josh I think just the reality checks were most helpful for me. I felt that these guys, they never overtly said that nothing’s going on, which I did notice, but they were more confrontational about the whole thing really. I don’t know if it would work for everyone, but for me it was good. I had my Dad in one ear, and the doctors in the other ear, and even if I didn’t fully believe them, it meant that I would act like I believed them and I would just be more able to interact with other people without spurting bullshit.

26. Jeremy Honestly I would believe that if someone had taken the time to sit me down and say how can all these things be happening and why would it happen to you and it’s not happening and there’s no one spying on you, I felt like that could have been managed a little bit better. Because I felt like I’d sit down and say to them I’m being spied on or people are monitoring me, and they’d just look at me as if, I wasn’t all there, and I found that to be not that helpful.

27. Un-Therapeutic Relationship Personable Approach of Clinicians: Mismatch Degree of Warmth, Humour etc. Degree of Formality Gender The Treatment Partnership Lack of collaboration Lack of disclosure Symptom of Psychosis Disruption in Care

28. Summary Participants entered the service, many with negative expectations and having to overcome stigma The quality of the Therapeutic Relationship had flow-on effects for many other factors influencing recovery Different aspects of the Therapeutic Relationship were more salient than others for participants Personable Approach of Clinicians Treatment Partnership

29. Clinical Implications Adapting the Therapeutic Relationship for better outcome: Session Rating Scales (Miller et al, 2000) Relationship Goals and Topics Approach and Method Overall Tailoring Psychotherapy to the Person (Norcross et al, 2011)

30. Conclusions High levels of satisfaction was associated with a longer Duration of Care, the Therapeutic Relationship and Respect Therapeutic Relationship takes time to develop More difficult to develop a Therapeutic Relationship with some clients than others Clinicians can develop a wide repertoire of relational styles through open dialogue with clients

31. The End Miller, A. D., Duncan, B. L., & Johnson, L. (2002). Session Rating Scale. Scott D. Miller PhD. Retrieved 16 August 2011. http://www.scottdmiller.com/ Norcross, J. C., Krebs, P. M., & Prochaska, J. O. (2011). Stages of change. Journal of Clinical Psychology, 67(2), 143-154. Norcross, J. C., & Lambert, M. J. (2011). Psychotherapy relationships that work II. Psychotherapy, 48(1), 4-8. Norcross, J. C., & Wampold, B. E. (2011). Evidence-based therapy relationships: Research conclusions and clinical practices. Psychotherapy, 48(1), 98-102. Norcross, J. C., & Wampold, B. E. (2011). What works for whom: Tailoring psychotherapy to the person. Journal of Clinical Psychology, 67(2), 127-132.