Skip to main content

Advertisement

SpringerLink
Log in

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

  • Original Report
  • Published:
Administration and Policy in Mental Health and Mental Health Services Research Aims and scope Submit manuscript

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.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

References

  • 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.

    Article  PubMed  PubMed Central  Google Scholar 

  • 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.

    Article  PubMed  PubMed Central  Google Scholar 

  • 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.

    Article  Google Scholar 

  • 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.

    Article  Google Scholar 

  • Bordin, E. (1979). The generalizability of the psychoanalytic concept of working alliance. Psychotherapy, 16, 252–260. doi:10.1037/h0085885.

    Article  Google Scholar 

  • 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.

    Article  PubMed  Google Scholar 

  • 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/.

  • 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.

    Article  PubMed  Google Scholar 

  • 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.

    Article  Google Scholar 

  • 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.

    Article  CAS  PubMed  Google Scholar 

  • 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.

    Article  PubMed  PubMed Central  Google Scholar 

  • 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.

    Article  PubMed  Google Scholar 

  • 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.

    Article  PubMed  Google Scholar 

  • 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 

  • 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.

    Article  PubMed  PubMed Central  Google Scholar 

  • 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.

    Article  PubMed  Google Scholar 

  • 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.

    Article  PubMed  Google Scholar 

  • 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.

    Article  PubMed  Google Scholar 

  • 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.

    Article  Google Scholar 

  • 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.

    Article  PubMed  PubMed Central  Google Scholar 

  • 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.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  • 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.

    Article  PubMed  Google Scholar 

  • 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.

    Article  PubMed  Google Scholar 

  • 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.

    Article  PubMed  PubMed Central  Google Scholar 

  • 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.

    Article  PubMed  PubMed Central  Google Scholar 

  • 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.

    Article  PubMed  Google Scholar 

  • 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.

    Article  Google Scholar 

  • 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.

    Article  Google Scholar 

  • 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.

    PubMed  Google Scholar 

  • 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.

    Article  PubMed  PubMed Central  Google Scholar 

  • 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.

    Article  PubMed  Google Scholar 

  • 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.

    PubMed  Google Scholar 

  • 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.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  • 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.

    Article  PubMed  PubMed Central  Google Scholar 

  • 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.

    Article  PubMed  PubMed Central  Google Scholar 

  • 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.

    PubMed  PubMed Central  Google Scholar 

  • 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 

  • 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.

    Article  PubMed  PubMed Central  Google Scholar 

  • 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.

    Article  PubMed  Google Scholar 

  • 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.

    Article  Google Scholar 

  • 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.

    Article  CAS  PubMed  Google Scholar 

  • 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.

    Article  PubMed  PubMed Central  Google Scholar 

  • 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.

    Article  Google Scholar 

Download references

Acknowledgements

The authors thank Linda Collins, Erica Evans, Jessica McGlynn, and Zamal Frank for their assistance with data collection.

Funding

The projects reported here were supported by the Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Pilot Grant (PPO 13-395), VA Health Services Research and Development (HSR&D) Center for Innovation (CIN 13-416), and Center for Health Information and Communication Locally Initiated Project fund.

Author information

Authors and Affiliations

  1. Center for Health Information and Communication, CHIC, Health Services Research & Development, Richard L. Roudebush VA Medical Center, 1481 West 10th Street, Indianapolis, IN, 46202, USA

    Johanne Eliacin, Jessica M. Coffing, Marianne S. Matthias, Matthew J. Bair & Angela L. Rollins

  2. Department of Psychology, Indiana University Purdue University at Indianapolis, Indianapolis, IN, 46202, USA

    Johanne Eliacin & Angela L. Rollins

  3. Center for Health Services Research, Regenstrief Institute, Inc., Indianapolis, IN, 46202, USA

    Johanne Eliacin, Marianne S. Matthias, Matthew J. Bair & Angela L. Rollins

  4. ACT Center of Indiana, Indianapolis, IN, 46202, USA

    Johanne Eliacin & Angela L. Rollins

  5. Communication Studies, Indiana University Purdue University at Indianapolis, Indianapolis, IN, 46202, USA

    Marianne S. Matthias

  6. Center for Chronic Disease Outcomes Research (CCDOR), Minneapolis VA Health Care System, Minnesota, MN, 55417, USA

    Diana J. Burgess

  7. Department of Medicine, University of Minnesota, Minnesota, MN, 55455, USA

    Diana J. Burgess

  8. Indiana University School of Medicine, Indianapolis, IN, 46202, USA

    Marianne S. Matthias & Matthew J. Bair

  9. Indiana University Center for Health Services and Outcomes Research, Indianapolis, IN, 46202, USA

    Matthew J. Bair

Authors
  1. Johanne Eliacin
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Jessica M. Coffing
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Marianne S. Matthias
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Diana J. Burgess
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Matthew J. Bair
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Angela L. Rollins
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Johanne Eliacin.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Eliacin, J., Coffing, J.M., Matthias, M.S. et al. The Relationship Between Race, Patient Activation, and Working Alliance: Implications for Patient Engagement in Mental Health Care. Adm Policy Ment Health 45, 186–192 (2018). https://doi.org/10.1007/s10488-016-0779-5

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10488-016-0779-5

Keywords

Search

Navigation