Mental health problems are on the increase, yet mental health care is a low priority worldwide. A recent report on mental health in the USA in 2015 stated that nearly 20 per cent of adults in the USA suffer from mental illness. In South Africa up to 80 per cent of individuals with common mental disorders do not receive treatment. There are also questions about the efficacy of treatment for mental disorders. For example, there is no evidence that treatment outcomes in depression are better than they were a quarter of a century ago. Consistent findings of research indicate, however, that a good therapeutic alliance can improve the outcome of treatment. But do physicians engage with their patients and build good therapeutic relationships? This question is especially pertinent in a psychiatric training institution, such as Weskoppies Hospital, the main psychiatric training hospital of the University of Pretoria. This study was undertaken to explore experiences and therapeutic relationships of patients in Weskoppies Hospital, to develop a model and substantive theory of therapeutic relationships and to comment on registrar training.
An explorative-descriptive qualitative collective instrumental case study was done. Thirty in-depth semi-structured interviews were conducted with 15 inpatients of Weskoppies Hospital. Purposive sampling was used to ensure maximum variation and richness of information. Transcribed recordings were organised using the computer programme ATLAS.ti. Grounded theory methods were used for the data analysis.
Only three patients described a good to very good therapeutic relationship with their registrars. Two other patients, although positive about certain qualities of their registrars, still had reservations about their interactions. Eleven patients had spent lengthy periods in closed wards. None of the three patients who described a good relationship with their registrars had been subjected to any coercive measures. Registrars rotate four-monthly, most have a symptom-based, biological approach and are used to seeing their patients only once a week due to a high workload. Encounters between staff and patients were mostly superficial; fellow patients became very important to most patients.
The findings point to a lack of containment. Therefore, a model and substantive theory of therapeutic relationships in a psychiatric hospital was developed in which the concept of containment was placed at the centre. Containment should ideally be provided through a personal, professional relationship with the registrar/psychiatrist or with another team member. This, however, needs to be embedded in a containing environment, since whatever happens in a hospital cannot be seen in isolation, but is part of a complex inter-related system and has to be seen from a systems point of view.
This model and substantive theory may contribute to a better understanding of the complexity of the situation in a psychiatric hospital. The findings show that a greater focus on therapeutic relationships is needed in the training of registrars. Providing a personal form of containment may lessen the need for coercive measures. Strict guidelines are furthermore needed to limit and control the use of coercive measures.