Published online Jun 19, 2022. doi: 10.5498/wjp.v12.i6.814
Peer-review started: July 13, 2021
First decision: October 4, 2021
Revised: October 8, 2021
Accepted: May 22, 2022
Article in press: May 22, 2022
Published online: June 19, 2022
Processing time: 335 Days and 15.7 Hours
Treatment alliance has an impact on several key patient outcomes in all psychiatric disorders, including bipolar disorder (BD). It has been suggested that the construct of treatment alliance is different among patients from routine psychiatric settings compared to psychotherapeutic settings; however, research on the composition of treatment alliance in psychiatric disorders, such as BD, is relatively limited. The findings of this study might provide clinicians with insights into the kind of treatment relationships their patients seek from them. It appears that patients appreciate a collaborative and supportive relationship that promotes mutual trust and enhances perceived satisfaction. Therefore, treatment alliances that incorporate these components are more likely to help patients with BD.
There is evidence to suggest that the concept of treatment alliance may differ among patients with psychiatric disorders seeking treatment in routine clinical settings. This study attempted to determine whether a broader construct of treatment alliance was prevalent among outpatients with BD. However, this was a preliminary exploratory study of treatment-alliance in BD that had some methodological limitations. The results emphasize the need for further, methodologically advanced research into the construct of treatment alliance in BD given its likely impact on adherence and other treatment outcomes.
Based on the existing evidence regarding treatment alliance, it was hypothesized that a broader construct of the alliance was more likely to exist among such patients. Therefore, in addition to collaborative aspects, other contributions to the construct of treatment alliance explored among patients of this study were perceived trust in clinicians, perceived clinicians’ support, and treatment satisfaction.
This was a cross-sectional study, conducted in the psychiatric unit of a multi-specialty hospital in north India over 12 mo (September 2018 to September 2019). A consecutive sample of 160 remitted adult outpatients with BD on mood stabilizers for at least a year were selected. The principal instrument to assess treatment alliance was the Working Alliance Inventory-client version (WAI-Client). Other potential constituents of the alliance explored were perceived trust in clinicians assessed by the Trust in Physicians (TRIP) scale, perceived support from clinicians assessed by the Psychosocial Care by Physicians (PCP) scale, and perceived treatment satisfaction assessed by the Patient Satisfaction Questionnaire (PSQ). Associations between scores on all scales were determined by correlational and multiple regression analyses. Exploratory factor analysis of combined items of all scales was conducted using a principal components analysis.
Scores on all the three WAI-Client subscales were significantly correlated with each other (r = 0.66-0.81; P < 0.0001). The total TRIP scores were associated with the total WAI-Client scores (r = 0.28; P < 0.01). The total TRIP scores and the total PCP scores were also significantly associated with the WAI-Client scores on the task subscale (r = 0.28-0.29; P < 0.01). The total TRIP scores were significantly associated with the total PSQ scores (r = 0.45; P < 0.0001). Factor analysis yielded two independent and coherent factors, which explained 69% of the variance in data. Factor-1 (“alliance and support”), which explained about 41% of the variance, was comprised of a combined WAI-Client goal-task-bond component as well as the PCP support items. Factor-2 (“trust and satisfaction”), which explained about 28% of the variance, consisted of all the TRIP trust and the PSQ treatment satisfaction items.
A broader construct of treatment alliance in BD was found. Apart from collaborative components, this construct included patients’ perceptions regarding trust in clinicians, support from clinicians, and treatment satisfaction.
More focused research is needed to determine the components of treatment alliance in BD. Future research should also determine the relative importance of the different components of alliance and their impact on key patient outcomes.