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Aims: To review the methods and findings from studies of the therapeutic relationship (TR) in the treatment of severe mental illness. Method: A literature search was conducted to identify all studies that used an operationalised measurement of the TR in the treatment of severe mental illness. Results: Fifteen scales–the majority of which were developed for psychotherapy–and the expressed emotion index have been used. Most scales have acceptable internal, inter-rater and test–retest reliability. As none of the scales has been used in more than five studies, no single scale is widely established in psychiatric research. A more positive relationship consistently predicts a better short-and long-term outcome. It appears that a large global factor accounts for the greatest proportion of the variance in the therapeutic relationship. Conclusions: The therapeutic relationship is a reliable predictor of patient outcome in mainstream psychiatric care. Valid assessments may need to take account of different, specific aspects of the relationship in psychiatric settings such as greater heterogeneity of treatment components and goals, increased variability of setting and the statutory responsibility of the clinician. Methodological progress may require conceptual work to ensure valid assessments of this central element of treatment.

Subjective quality of life is an important criterion in outcome evaluation that has been well-researched in psychiatry. By comparison, the therapeutic relationship which may also be subjectively assessed has been relatively neglected as an outcome criterion although it has predictive power in relation to outcome. This exploratory study investigated subjective quality of life and therapeutic relationships in first-admission (N = 90) and long-term (N=168) schizophrenia patients, each at two points of time. The follow-up period was 9 months for the first-admission sample and 1.5 years for the long-term sample. A significant relationship was found between global assessments of quality of life and therapeutic relationships in long-term, but not in first-admission patients. This finding was consistent at both assessments, suggesting that therapeutic relationships may become more central to quality of life in long-term care situations and that patients' views of this relationship are increasingly embedded in their overall appraisal of life.

AbstractAssociations between mental health and poverty are increasingly well established. Yet in neoliberally oriented contexts in which distress engendered through the everyday hardships of poverty is increasingly pathologised and medicalised, important questions are raised over the assumptions inherent within mental health policy and its implementation. Using the UK as a focus, this paper reviews and maps out key questions that require investigation in order to better understand the complex inter-relations between poverty and distress; explores how current paradigms might influence notions of individual responsibility and agency as well as health seeking behaviours; and examines the role of, and cultural and systemic expectations and constraints placed upon GPs as they respond to distress amongst patients from low-income communities. In so doing, we argue for recognition of the moral narratives that underpin both mental health care and processes of welfare reform, and call for an expansion of conventional notions of evidence-based healthcare to incorporate the understandings, experiences and priorities of people from low-income groups. We call for more detailed questioning and analysis of the interactions that lead to mental health diagnosis and treatment and better understanding of the relevance and effectiveness of current treatment options. As a central tenet of this, we argue for more flexible and nuanced healthcare responses that better reflect the dynamic and multi-faceted nature of poverty-related distress.