Proceso concurrente, ¿votos divididos?

There are two prime motivations for the present study. The first arises from findings

that positive ratings of the therapeutic alliance are associated with positive

assessments of outcome in the case management of clients with psychosis (Preibe &

Gmyters, 1993; Neale & Rosenheck, 1995). As case management is the

“cornerstone” (Shepherd, 1990) of mental health care of the seriously mentally ill, an

investigation into factors that influence the working alliance, and thus maybe

indirectly influence positive outcome, is clinically useful.

The second motivation is that research into compliance with treatment, especially

medication, is important with this client group. Non-compliance has been frequently

cited as a factor in relapse and subsequent hospitalisation (Green, 1988; Hoge et al.,

1990). Apart from the distress associated with relapse and hospitalisation, the latter

also accounts for a disproportionate amount of the cost of caring for clients with

psychosis (Hirsh & Bristow, 1993). Thus strategies aimed at increasing compliance

are a priority for mental health professionals, and an investigation of factors which

The principle of clinical governance has it that interventions should have

demonstrated clinical and cost effectiveness (Department of Health, 1997), and this

study represents an attempt to examine variables which may influence both the

efficacy and the costs of treatment of clients with schizophrenia, namely alliance and

adherence.

5.2 Themes

The next concern is to identify the themes of theoretical interest in the literature

which underpin the two clinically important factors of alliance and compliance

mentioned above.

5.21 Alliance and compliance

The first theme is the link between alliance and compliance. The study by Krupnick

et al. (1996), showing that the alliance predicted outcome in the pharmacotherapy of

depression, did not control for compliance. Thus it would seem important to

examine the relationship between alliance and compliance. The study by Frank &

Gunderson (1990) investigated compliance and alliance among psychotic clients, but

in a different setting which most clients in this country do not encounter, namely

individual psychotherapy. Perhaps more importantly, the study did not include client

ratings of the alliance alongside those of clinicians.

5.22 Congruence of beliefs

The second theme raised in the literature is a possible relationship between

congruence of explanatory models, the alliance and compliance. It was suggested

difficulties in establishing congruence. There seems to be some evidence of a link

between compliance and congruence of causal beliefs (Foulks et ah, 1986), although

this study did not actually measure clinician beliefs. A link with the alliance was

suggested in the above study, but not investigated. The review of the literature in the

preceding chapter suggested that the dimensions of aetiology and pathology were

particularly controversial in the case of schizophrenia, and could perhaps be

considered together. Congruence regarding treatment is also considered.

5.23 Insight

It was also suggested in the introductory chapters that the concept of insight may be

related to some of the above dimensions. This concept has been linked with

compliance (Fenton et al., 1997) and in this study possible links with alliance will

also be investigated.

5.24 Aspects of the alliance

Another theme of interest is the development of the aspects of the working alliance.

The literature suggested that the development of the working alliance would take

longer with this client group (Bordin, 1994) and there was a suggestion of six months

as the time frame envisaged as being necessary (Frank & Gunderson, 1990).

5.35 Concordance

Finally, it has been stated that central to the development of the working alliance is

agreement between the client and clinician. This agreement has been termed

concordance (Horvath and Greenberg, 1989), a term which has also come to be used

this context refers to the notion that both client and clinician have valid views on the

nature and treatment of a problem, and that by a process of negotiation agreement on

treatment can be reached, which would lead to a therapeutic alliance, and increased

adherence (Bradley, 1999). The concept of concordance is thus one that may draw

together the themes discussed above, as the variables linked together in the definition

offered by Bradley (ibid.) are adherence, therapeutic alliance and negotiation over

treatment in the context of clients’ and clinicians’ health beliefs. In particular, there

would seem to be some parallels between the constructs of concordance and the

working alliance, in that both place some emphasis on the views of both the client

and the clinician, and the process of negotiation to reach agreement. However, the

concept of concordance may be particularly useful, as it can be defined to include

both cognitive and behavioural components. This would allow for the term to be

used to cover both adherence to treatment and the agreement central to the working

alliance. The concept of concordance could then be a construct which would account

for the finding of an association between alliance and adherence (e.g. Frank &

Gunderson, 1990), and thus be a conceptual link between adherence and alliance.

Equally, concordance offers a conceptual link between congruence of beliefs and

compliance, as suggested by Foulks et al. (1986).

Thus the three concepts of alliance, compliance and congruence could be linked by

the overarching construct of concordance. Consequently, an important theme of this

study is the investigation of the validity of the construct of concordance, using a

definition based on Bradley (1999). Concordance can be defined as a sense of

agreement and mutuality between client and clinician, in the cognitive, behavioural

of the construct will be examined by considering the covariance of the variables of

alliance, compliance and congruence. If the construct of concordance as defined is

valid, and if the measures of alliance, compliance and belief discrepancy are valid,

then one could predict that the three latter variables would vary together.