Racial Differences in Therapeutic Alliance and Mental Health Recovery Orientation Among Veterans with SMI

Background: African Americans with serious mental illness (SMI) face significant challenges in obtaining quality mental health care and are at-risk for experiencing significant disparities in mental health care outcomes. Research suggests that African Americans are less likely to utilize mental health care compared to Whites. Patient-provider interactions may partly contribute to this disparity and have been noted to include less rapport building statements, negative implicit and explicit attitudes, lower positive affect and less patient-centeredness toward African American patients. Little is known about racial differences in the association between patient's perception of therapeutic alliance with mental health providers and patients' perceptions of their ability to recover from SMI. The purpose of the current study was to understand the effects of psychosis, race, and therapeutic alliance on mental health recovery orientation among veterans with SMI.

Methods: Participants were veterans who had a serious mental illness such as schizophrenia or bipolar disorder and were being treated in two veterans Affairs outpatient mental health clinics by a psychiatrist or nurse practitioner. Participants completed self-report measures including the BASIS-24, Mental Health Recovery Orientation Measure, and STAR therapeutic alliance assessment, which includes three subscales: positive collaboration, positive clinician input, and non-supportive clinician input. Regression analyses were used to determine main and joint effects of psychosis severity, race, and therapeutic alliance variables.

Results: The sample included 226 veterans (50% African American, 50% White). African American participants did not differ from White participants on most demographic measures such as gender, education, and overall BASIS-24 score. However, African American veterans were slightly older (p<.05), reported more psychotic symptoms (p<.05), higher mental health recovery orientation (p<.05), and perceived less non-supportive clinician input (p<.01) than Whites.

Results indicated there was no significant interaction among race and psychosis and positive clinician input or non-supportive clinician input. However, there was a significant three way interaction among psychosis, race, and positive collaboration (p<.01). Greater positive collaboration attenuates the negative effect of higher levels of psychosis on mental health recovery orientation for African Americans. Conversely, for Whites, positive collaboration had little effect on the negative relationship between psychosis severity and mental health recovery orientation.

Implications: Increased levels of psychosis may inhibit patients' perceptions of their ability to recover from a serious mental illness. However, for African American patients, positive collaboration with mental health providers may moderate the effects of symptomology. Community stigma surrounding mental health disorders in the African American community may amplify the importance of therapeutic alliance between African American patients with SMI and providers. Additionally, African American patients' initial low expectations and mistrust when engaging in patient-provider interactions may also be more starkly challenged in collaborative appointments, thus having a more pronounced impact of mental health recovery. It is possible that among White patients who do not experience these barriers to care, positive collaboration is less influential in developing increased mental health recovery orientation. Future studies should investigate therapeutic alliance and provider behaviors in clinical interactions as mechanisms of mental health recovery attitudes in African American and White patients with SMI.