The Relationship Between Race, Patient Activation, and Working Alliance: Implications for Patient Engagement in Mental Health Care

  • Johanne Eliacin
  • Jessica M. Coffing
  • Marianne S. Matthias
  • Diana J. Burgess
  • Matthew J. Bair
  • Angela L. Rollins
Original Report

Abstract

This study explored the relationship between race and two key aspects of patient engagement—patient activation and working alliance—among a sample of African-American and White veterans (N = 152) seeking medication management for mental health conditions. After adjusting for demographics, race was significantly associated with patient activation, working alliance, and medication adherence scores. Patient activation was also associated with working alliance. These results provide support for the consideration of race and ethnicity in facilitating patient engagement and patient activation in mental healthcare. Minority patients may benefit from targeted efforts to improve their active engagement in mental healthcare.

Keywords

Patient activation Patient engagement Mental health African-Americans 

References

  1. Alegria, M., Carson, N., Flores, M., Li, X., Shi, P., Lessios, A.S., & Shrout, P.E. (2014). Activation, self-management, engagement, and retention in behavioral health care: A randomized clinical trial of the DECIDE intervention. JAMA Psychiatry, 71(5), 557–565. doi:10.1001/jamapsychiatry.2013.4519.CrossRefPubMedPubMedCentralGoogle Scholar
  2. Alegria, M., Chatterji, P., Wells, K., Cao, Z., Chen, C.N., Takeuchi, D., & Meng, X.L. (2008). Disparity in depression treatment among racial and ethnic minority populations in the United States. Psychiatric Services, 59(11), 1264–1272. doi:10.1176/appi.ps.59.11.1264.CrossRefPubMedPubMedCentralGoogle Scholar
  3. Alegria, M., Roter, D.L., Valentine, A., Chen, C.N., Li, X., Lin, J., & Shrout, P.E. (2013). Patient-clinician ethnic concordance and communication in mental health intake visits. Patient Education and Counselling, 93(2), 188–196. doi:10.1016/j.pec.2013.07.001.CrossRefGoogle Scholar
  4. Atdjian, S., & Vega, W.A. (2005). Disparities in mental health treatment in U.S. racial and ethnic minority groups: Implications for psychiatrists. Psychiatric Services, 56(12), 12. doi:10.1176/appi.ps.0.1600.CrossRefGoogle Scholar
  5. Bordin, E. (1979). The generalizability of the psychoanalytic concept of working alliance. Psychotherapy, 16, 252–260. doi:10.1037/h0085885.CrossRefGoogle Scholar
  6. Castonguay, L.G., Constantino, M.J., & Holtforth, M.G. (2006). The working alliance: Where are we and where should we go? Psychotherapy, 43(3), 271–279. doi:10.1037/0033-3204.43.3.271.CrossRefPubMedGoogle Scholar
  7. Center for Advancing Health. (2010). A new definition of patient engagement: What is engagement and why is it important? Washington, DC: Center for Advancing Health. Retrieved from http://www.cfah.org/engagement/.
  8. Chubak, J., Anderson, M.L., Saunders, K.W., Hubbard, R.A., Tuzzio, L., Liss, D.T., & Reid, R.J. (2012). Predictors of 1-year change in patient activation in older adults with diabetes mellitus and heart disease. Journal of the American Geriatrics Society, 60(7), 1316–1321. doi:10.1111/j.1532-5415.2012.04008.x.CrossRefPubMedGoogle Scholar
  9. Constantine, M.G. (2007). Racial microaggressions againt African-American clients in cross-racial counseling relationships. Journal of Counseling Psychology, 54(1), 1–16. doi:10.1037/0022-0167.54.1.1.CrossRefGoogle Scholar
  10. Cook, T.B., Reeves, G.M., Teufel, J., & Postolache, T.T. (2015). Persistence of racial disparities in prescription of first-generation antipsychotics in the USA. Pharmacoepidemiology and Drug Safety, 24(11), 1197–1206. doi:10.1002/pds.3819.CrossRefPubMedGoogle Scholar
  11. Cooper, L.A., Roter, D.L., Carson, K.A., Beach, M.C., Sabin, J.A., Greenwald, A.G., & Inui, T.S. (2012). The associations of clinicians’ implicit attitudes about race with medical visit communication and patient ratings of interpersonal care. American Journal of Public Health, 102(5), 979–987. doi:10.2105/ajph.2011.300558.CrossRefPubMedPubMedCentralGoogle Scholar
  12. Davis, T.A., Ancis, J.R., & Ashby, J.S. (2015). Therapist effects, working alliance, and African American women substance users. Cultural Diversity and Ethnic Minority Psychology, 21(1), 126–135. doi:10.1037/a0036944.CrossRefPubMedGoogle Scholar
  13. Deen, D., Lu, W.H., Rothstein, D., Santana, L., & Gold, M.R. (2011). Asking questions: The effect of a brief intervention in community health centers on patient activation. Patient Education and Counseling, 84(2), 257–260. doi:10.1016/j.pec.2010.07.026.CrossRefPubMedGoogle Scholar
  14. DHHS. (2001). Mental Health, culture, race and ethnicity—a supplement to mental health: A report of the surgeon general. Rockville: US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Centre for Mental Health Services.Google Scholar
  15. Dixon, L.B., Holoshitz, Y., & Nossel, I. (2016). Treatment engagement of individuals experiencing mental illness: Review and update. World Psychiatry, 15(1), 13–20. doi:10.1002/wps.20306.CrossRefPubMedPubMedCentralGoogle Scholar
  16. Eliacin, J., Rollins, A.L., Salyers, M.S., Burgess, D.J., & Matthias, M.S. (2016a). Engaging African-American veterans in mental health care: Patients’ perspectives. Journal of Nervous and Mental Disease, 204(4), 254–260. doi:10.1097/NMD.0000000000000479.CrossRefPubMedGoogle Scholar
  17. Eliacin, J., Rollins, A.L., Burgess, D.J., Salyers, M.P., & Matthias, M.S. (2016b). Patient activation and visit preparation in African American veterans receiving mental health care. Cultural Diversity and Ethnic Minority Psychology, 22(4), 580–587. doi:10.1037/cdp0000086.CrossRefPubMedGoogle Scholar
  18. Fialko, L., Garety, P.A., Kuipers, E., Dunn, G., Bebbington, P.E., Fowler, D., & Freeman, D. (2008). A large-scale validation study of the Medication Adherence Rating Scale (MARS). Schizophrenia Research, 100(1), 53–59. doi:10.1016/j.schres.2007.10.029.CrossRefPubMedGoogle Scholar
  19. Fogarty, C.T., Sharma, S., Chetty, V.K., & Culpepper, L. (2008). Mental health conditions are associated with increased health care utilization among urban family medicine patients. The Journal of American Board and Family Medicine, 21(5), 398–407. doi:10.3122/jabfm.2008.05.070082.CrossRefGoogle Scholar
  20. Fortuna, L.R., Alegria, M., & Gao, S. (2010). Retention in depression treatment among ethnic and racial minority groups in the United States. Depression and Anxiety, 27(5), 485–494. doi:10.1002/da.20685.CrossRefPubMedPubMedCentralGoogle Scholar
  21. Goldsmith, L., Lewis, S.W., Dunn, G., Bentall, R.P. (2015). Psychological treatments for early psychosis can be beneficial or harmful, depending on the therapeutic alliance: An instrumental variable analysis. Psychological Medicine, 45(1), 2365–2373. doi:10.1017/S003329171500032X.CrossRefPubMedPubMedCentralGoogle Scholar
  22. Gordon, H.S., Street, R.L. Jr., Sharf, B.F., & Souchek, J. (2006). Racial differences in doctors’ information-giving and patients’ participation. Cancer, 107(6), 1313–1320. doi:10.1002/cncr.22122.CrossRefPubMedGoogle Scholar
  23. Haslett, W.R., McHugo, G.J., Bond, G.R., & Drake, R.E. (2014). Use of software for tablet computers to promote engagement with supported employment: Results from an RCT. Psychiatric Services, 65(7), 954–956. doi:10.1176/appi.ps.201300275.CrossRefPubMedGoogle Scholar
  24. Hibbard, J.H., Stockard, J., Mahoney, E.R., & Tusler, M. (2004). Development of the patient activation measure (PAM): Conceptualizing and measuring activation in patients and consumers. Health Services Research, 39(4p1), 1005–1026. doi:10.1111/j.1475-6773.2004.00269.x.CrossRefPubMedPubMedCentralGoogle Scholar
  25. Hibbard, J.H., Mahoney, E.R., Stockard, J., & Tusler, M. (2005). Development and testing of a short form of the patient activation measure. Health Services Research, 40(6p1), 1918–1930. doi:10.1111/j.1475-6773.2005.00438.x.CrossRefPubMedPubMedCentralGoogle Scholar
  26. Hibbard, J.H., Greene, J., Becker, E.R., Roblin, D., Painter, M.W., Perez, D.J., & Tusler, M. (2008). Racial/ethnic disparities and consumer activation in health. Health Affairs, 27(5), 1442–1453. doi:10.1377/hlthaff.27.5.1442.CrossRefPubMedGoogle Scholar
  27. Horvath, A.O., & Symonds, B.D. (1991). Relation between working alliance and outcomes in psychotherapy: A meta-analysis. Journal of Counseling Psychology, 38(2), 139–149. doi:10.1037/0022-0167.38.2.139.CrossRefGoogle Scholar
  28. Kimerling, R., Pavao, J., & Wong, A. (2016). Patient activation and mental health care experiences among women veterans. Administration and Policy in Mental Health and Mental Services Research, 43(4), 506–513. doi:10.1007/s10488-015-0653-x.CrossRefGoogle Scholar
  29. Kotwicki, R.J., Balzer, A.M., & Harvey, P.D. (2016). Measuring and facilitating client engagement with financial incentives: Implications for improving clinical outcomes in a mental health setting. Community Mental Health Journal. doi:10.1007/s10597-016-0053-z.PubMedGoogle Scholar
  30. Lubetkin, E.I., Zabor, E.C., Brennessel, D., Kemeny, M.M., & Hay, J.L. (2014). Beyond demographics: differences in patient activation across new immigrant, diverse language subgroups. Journal of Community Health, 39(1), 40–49. doi:10.1007/s10900-013-9738-1.CrossRefPubMedPubMedCentralGoogle Scholar
  31. Maranda, M.J., Deen, D., Elshafey, S., Herrera, M., & Gold, M.R. (2014). Response to a patient activation intervention among Spanish-speaking patients at a community health center in New York City. Journal of Health Care for the Poor and Underserved, 25(2), 591–604. doi:10.1353/hpu.2014.0110.CrossRefPubMedGoogle Scholar
  32. Matthias, M.S., Fukui, S., Kukla, M., Eliacin, J., Bonfils, K., Firmin, R., Oles, S., Adam, E.L., Collins, L.A., & Salyers, M.P. (2014). Consumer and relationship factors associated with shared decision-making in mental health consultations. Psychiatric Services. doi:10.1176/appi.ps.201300563.PubMedGoogle Scholar
  33. McCabe, R., Bullenkamp, J., Hansson, L., Lauber, C., Martinez-Leal, R., Rössler, W., Salize, H.J., Svensson, B., Torres-Gonzalez, F., van den Brink, R., Wiersma, D., & Priebe, S. (2012). The therapeutic relationship and adherence to antipsychotic medication in schizophrenia. PLoS ONE, 7(4), e36080. doi:10.1371/journal.pone.0036080.CrossRefPubMedPubMedCentralGoogle Scholar
  34. McGinnis, K.A., Fine, M.J., Sharma, R.K., Skanderson, M., Wagner, J. H., Rodriguez-Barradas, M.C., & Justice, A.C. (2003). Understanding racial disparities in HIV using data from the veterans aging cohort 3-site study and VA administrative data. American Journal of Public Health, 93(10), 1728–1733. doi:10.2105/AJPH.93.10.1728.CrossRefPubMedPubMedCentralGoogle Scholar
  35. McGuire, T.G., & Miranda, J. (2008). New evidence regarding racial and ethnic disparities in mental health: Policy implications. Health Affairs, 27(2), 393–403. doi:10.1377/hlthaff.27.2.393.CrossRefPubMedPubMedCentralGoogle Scholar
  36. Montes, J.M., Maurino, J., de Dios, C., & Medina, E. (2013). Suboptimal treatment adherene in bipolar disorder: Impact on clinical outcomes and functioning. Patient Preference and Adherence, 7, 89–94. DOI:10.2147/PPA.S39290.PubMedPubMedCentralGoogle Scholar
  37. Munder, T., Wilmers, F., Leonhart, R., Linster, H.W., & Barth, J. (2010). Working Alliance Inventory-Short Revised (WAI-SR): Psychometric properties in outpatients and inpatients. Clinical Psychology & Psychotherapy, 17(3), 231–239. doi:10.1002/cpp.658.Google Scholar
  38. Patel, S.R., & Bakken, S. (2010). Preferences for participation in decision making among ethnically diverse patients with anxiety and depression. Community Mental Health Journal, 46(5), 466–473. doi:10.1007/s10597-010-9323-3.CrossRefPubMedPubMedCentralGoogle Scholar
  39. Sharf, J., Primavera, L.H., Diener, M.J. (2010). Dropout and therapeutic alliance: A meta-analysis of adult individual psychotherapy. Psychotherapy, 47(4), 637–645. doi:10.1037/a0021175.CrossRefPubMedGoogle Scholar
  40. Street, R.L. Jr., Gordon, H., & Haidet, P. (2007). Physicians’ communication and perceptions of patients: Is it how they look, how they talk, or is it just the doctor? Social Science & Medicine, 65(3), 586–598. doi:10.1016/j.socscimed.2007.03.036.CrossRefGoogle Scholar
  41. Thompson, K., Kulkarni, J., & Sergejew, A.A. (2000). Reliability and validity of a new medication adherence rating scale (MARS) for the psychoses. Schizophrenia Research, 42(3), 241–247.CrossRefPubMedGoogle Scholar
  42. Thompson, L., & McCabe, R. (2012). The effect of clinician-patient alliance and communication on treatment adherence in mental health care: A systematic review. BioMed Central psychiatry, 12, 87. doi:10.1186/1471-244x-12-87.CrossRefPubMedPubMedCentralGoogle Scholar
  43. Williams, D.R., & Mohammed, S.A. (2013). Racism and Health I: Pathways and scientific evidence. American Behavioral Scientist, 57(8), 1152–1173. doi:10.1177/0002764213487340.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York (outside the USA) 2016

Authors and Affiliations

  • Johanne Eliacin
    • 1
    • 2
    • 3
    • 4
  • Jessica M. Coffing
    • 1
  • Marianne S. Matthias
    • 1
    • 3
    • 5
    • 8
  • Diana J. Burgess
    • 6
    • 7
  • Matthew J. Bair
    • 1
    • 3
    • 8
    • 9
  • Angela L. Rollins
    • 1
    • 2
    • 3
    • 4
  1. 1.Center for Health Information and Communication, CHIC, Health Services Research & DevelopmentRichard L. Roudebush VA Medical CenterIndianapolisUSA
  2. 2.Department of PsychologyIndiana University Purdue University at IndianapolisIndianapolisUSA
  3. 3.Center for Health Services ResearchRegenstrief Institute, Inc.IndianapolisUSA
  4. 4.ACT Center of IndianaIndianapolisUSA
  5. 5.Communication StudiesIndiana University Purdue University at IndianapolisIndianapolisUSA
  6. 6.Center for Chronic Disease Outcomes Research (CCDOR)Minneapolis VA Health Care SystemMinnesotaUSA
  7. 7.Department of MedicineUniversity of MinnesotaMinnesotaUSA
  8. 8.Indiana University School of MedicineIndianapolisUSA
  9. 9.Indiana University Center for Health Services and Outcomes ResearchIndianapolisUSA

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