Patients' opinions of psychiatric care: a Swedish study.

Over the past few decades, health care as a whole and psychiatry specifically have evolved as a result of various societal influences. Quality assurance, evidence-based treatment and patients' satisfaction with care are all examples of such trends. In Sweden, the patients' satisfaction with care has become the concern both of researchers and of mental health care administrators. This may be a result of changed social norms and of the relatively recent apprehension of patients' wish to participate in their own health care.

There is a documented, although weak, relationship between satisfaction with care and treatment outcome (Priebe & Gruyters, 1995; Ries et al, 1999). However, although in surveys patients routinely record high levels of satisfaction with mental health services, non-compliance with treatment continues to be a major problem (Ries et al, 1999; Webb et al, 1999). There also seem to be problems with the concept of patient satisfaction and its assessment. Satisfaction is a vague term that can be operationalised in several ways and from different perspectives. It is unclear how satisfaction should be measured and studies have focused on very different aspects of it, such as the physical environment, waiting time, administrative routines, information, access to staff, attitudes of staff, and the relationship between staff and patients. Furthermore, different rating or survey instruments are often used, which makes the generalisation of findings problematic.

The Swedish study

The variability in the measures of satisfaction, the weak relationships between satisfaction and treatment outcome, and the paradoxical finding of satisfaction coupled with widespread non-compliance with treatment were the motives for a study conducted by Johansson & Eklund (2003). They investigated patients’ subjective perspectives on what they considered to be good psychiatric care. It seemed important to understand more specifically the causes of high or low satisfaction. A qualitative research approach was used, based on in-depth interviews. The study was conducted in two typical Swedish psychiatric settings, one for out-patients (who had depressive or neurotic or personality disorders) and one for in-patients (who had various psychoses). These settings were selected to reflect the different types of care for different kinds of patients, provided by a variety of staff.

Satisfaction is a vague term that can be operationalised in several ways and from different perspectives. It is unclear how satisfaction should be measured and studies have focused on very different aspects of it.

The need for understanding relationships

Although all patients and staff were selected to form a heterogeneous sample, the results clearly revealed one common main theme in what constitutes good psychiatric care, namely the establishment of a helping relationship, such that the patients felt understood by the staff. The ideal relationship was characterised by warmth, empathy and understanding, by a lack of pressure of time, and by the patient having a feeling of being provided for. The staff had to be able to enter into the patient’s feelings and to understand his or her unique communication, problems and situation. Some sub-categories in establishing the helping relationship emerged.

Giving enough time

Giving enough time was important in two ways. First, patients needed enough time to open up and disclose their inner life and to express their situation. Second, it was important that the staff did not intervene too fast. This was true for medical and pharmacological as well as for psychotherapeutic interventions. Notable was that, according to the patients’ perception, the staff were convinced that they needed to be efficient, but the patients did not share this belief. Instead, they wanted more time with staff. This is an important discrepancy, as there is a tendency towards fewer and shorter encounters between patients and staff in Swedish psychiatric practice, as there is internationally (Olfson et al, 1999).

Values, preconceptions and understandings

This factor concerned the idea that staff should not be governed by their own values, ideas and preconceptions of psychiatric patients, but should listen to the individual and base their actions on the patient’s unique situation. Also, the patients believed that it was important for the staff to have approximately the same explanation and understanding of the patients’ problems as they had themselves. This meant that the patients could discuss and influence their treatment, which in turn would allow the patients to keep some of their autonomy and independence.

Notable was that, according to the patients’ perception, the staff were convinced that they needed to be efficient, but the patients did not share this belief. Instead, they wanted more time with staff.

Supportive psychosocial climate

Another important factor for the development of a helping relationship was that a supportive psychosocial climate should be present. Warmth, support, interest and engagement should characterise the relationships between patients and staff. This could be counteracted by, for example, staff avoiding eye contact, not remembering the patient’s name, or reading the medical record while the patient was talking about his or her problems. The patients emphasised that they would not like to experience the staff as uninterested or unconcerned.

Ambivalence

The in-patient group expressed some ambivalence regarding the helping relationship. Some were disappointed with their contacts and longed for a much deeper relationship than the one they had with staff. At the same time, they expressed a fear of or rejected such relationships, preferring instead more distant contact. This ambivalence is probably due to the diagnosis (i.e. psychosis) and might be interpreted as a wish to be seen and a longing for complete contact, and at the same time a fear of closeness and of being rejected.

A high-quality therapeutic relationship is essential between all providers and patients: it is the essence of satisfaction with care and it determines the outcome of psychiatric treatment.

Meaningfulness

The in-patient group also experienced meaningfulness as a sub-category of the helping relationship. They expressed a wish to be perceived as meaningful themselves and that what they communicated was regarded as meaningful and understandable. Another aspect of meaningfulness related to what patients experienced while they were in hospital – that is, they wished to understand the meaning of different events and contexts.

Discussion

Whether the patients were satisfied or dissatisfied with the care they received, they all suggested that the quality of the relationships between the patient and individual members of staff (e.g. therapist), and being understood by the staff, were central to the quality of the care.

In the field of psychotherapy there is a long tradition of research concerning the determinants of outcome. It has been shown that psychotherapy in general is effective – and that there is little difference between various techniques or theoretical orientations (Wampold, 2001). As a consequence, the research has focused on what aspects of therapy are responsible for the outcome. A common research approach is to divide the factors that influence outcome into those specific to a particular therapeutic technique and non-specific or common factors (Lambert & Barley, 2002). The common factor that has generated the greatest interest in research is the therapeutic alliance, because its effect has been shown to be similar across various forms of treatments and it has consistently been shown that its quality is related to outcome (Horvath & Bedi, 2002).

The common factor that has generated the greatest interest in research is the therapeutic alliance, because its effect has been shown to be similar across various forms of treatments and it has consistently been shown that its quality is related to outcome.

The results from our study, where the focus was on patients’ satisfaction with care and not on the therapeutic alliance, revealed a connection between the constituents of good care and the phenomenon of the helping alliance. The findings pointed to the importance of the therapeutic relationship within general psychiatric care. Results from other Swedish studies of patients’ satisfaction with care (Bjoerkman et al, 1995; Samuelsson et al, 2000), as well as from studies from other parts of the world (Priebe & Gruyters, 1993; Olusina et al, 2002), point in the same direction. Moreover, research in general mental health services has shown that the quality of the therapeutic relationship has an effect on the outcome of treatment (Eklund, 1996; Priebe & Gruyters, 1993).

As it is well known from psychotherapy and general psychiatric research that the helping alliance is an important determinant of outcome, a conclusion must be that, in order to improve mental health services and therapeutic outcome, staff should incorporate psychotherapeutic principles in their work. A high-quality therapeutic relationship is essential between all providers and patients: it is the essence of satisfaction with care and it determines the outcome of psychiatric treatment.