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Articles   |    
Leverage, the Treatment Relationship, and Treatment Participation
Dale E. McNiel, Ph.D.; Barbara Gormley, Ph.D.; Renée L. Binder, M.D.
Psychiatric Services 2013; doi: 10.1176/appi.ps.201200368
View Author and Article Information

Dr. McNiel and Dr. Binder are affiliated with the Department of Psychiatry, University of California, San Francisco, 401 Parnassus Ave., San Francisco, CA 94143 (e-mail: dalem@lppi.ucsf.edu).
Dr. Gormley is with the Department of Psychology and Counseling, Governors State University, University Park, Illinois.

Copyright © 2013 by the American Psychiatric Association

Abstract

Objective  Although many psychiatric patients experience various forms of pressure or leverage to participate in community treatment, the association between such experiences and treatment participation is controversial. This study evaluated the hypothesis that aspects of the treatment relationship, such as the working alliance, psychological reactance, and perceived coercion, could be important in understanding treatment adherence and satisfaction in a group of patients at risk of experiencing leverage.

Methods  A total of 198 outpatients at two community mental health centers completed structured interviews including measures of the treatment relationship, treatment participation, experience of leverage, and clinical functioning. Regression analyses were used to assess associations between the treatment relationship and treatment adherence and satisfaction while concomitantly considering experiences of leverage, demographic characteristics, and clinical functioning.

Results  Approximately four in ten participants reported experiencing some form of leverage to adhere to treatment during the previous six months, such as pressures related to the criminal justice system, money, housing, and outpatient commitment. Patients who perceived greater coercion to participate in treatment were more likely to report taking their medications as prescribed. Higher satisfaction with treatment was associated with lower perceived coercion, a better working alliance, and lower levels of psychological reactance.

Conclusions  Benefits in medication adherence associated with interventions that patients perceive as coercive may come at a cost of decreased satisfaction with treatment. Aspects of the treatment relationship hold promise for individualizing treatment planning in a way that addresses satisfaction as well as adherence.

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Table 1Summary of regression models of treatment participation by 198 patients at two community mental health centersa
Table Footer Note

a Multivariable regression models examined the association of each measure of treatment participation and the relationship measures while concomitantly considering experiences of any leverage and control variables. Models of adherence to medication and appointments used ordered logistic regression, and the model of treatment satisfaction used multiple regression analysis; df=1 for all tests shown

Table Footer Note

b –2 log likelihood without covariates=438.35; –2 log likelihood with covariates=377.04; Wald χ2=52.57, df=13, p<.001

Table Footer Note

c –2 log likelihood without covariates=331.47; –2 log likelihood with covariates=297.31; Wald χ2=28.60, df=13, p<.01

Table Footer Note

d Adjusted R2=.248, F=5.58, df=13 and 168, p<.001

Table Footer Note

*p<.05, **p<.01

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