Research article
Open Access

Evaluation of therapeutic relationship skills training for mental health professionals: the Therapeutic Relationship Enabling Programme (TREP)

Faith Liao[1], David Murphy[1]

Institution: 1. University of Nottingham
Corresponding Author: Miss Faith Liao (faith.liao@nottingham.ac.uk)
Categories: Learning Outcomes/Competency, Students/Trainees, Technology, Clinical Skills, Research in Health Professions Education
Published Date: 28/05/2019

Abstract

Background: A 3-day workshop in Taiwan, developed in accordance with Carl Rogers’ person-centred theory, used an experiential-learning pedagogy and a helping learning technology mPath. This study aimed to evaluate the effectiveness of a short-term course for mental health professional students assessing to the acquisition of therapeutic relationship competencies.

 

Objective: To evaluate the training effects and investigate any changes in the level of therapeutic relationship competence of the participants before, at the end and two weeks after the intervention. 

 

Methods: A sample of 59 mental health professional students from 7 medical schools studying in nursing, occupational therapy, medicine, clinical psychology and other specialities with the completion of psychiatry-relevant courses. 26 of 59 mental health professional students volunteered to form the experimental group, and the controls were recruited using the snowball sampling technique. All of them completed the Barrett-Lennard Relationship Inventory OS-40 three times. Mean values and statistical significance tests were computed to compare the results.

 

Results: Within 3 days, the mental health professional students in the experimental group (N=26) completed the Therapeutic Relationship Enabling Programme (TREP) and showed a statistically significant level of change (Mean Difference= +9.5, p=0.002), which was in contrast to the outcome of the control group (N=33, Mean Difference= +0.18, p0.683), in the therapeutic relationship competences. The effecting growth curve of therapeutic relationship competence in the experimental group continually inclined two weeks after the intervention (Mean Difference= +19.423, p= 0.000) while the control group reflected a decline in therapeutic relationship competence (Mean Difference= -0.515, p= 0.812).

 

Conclusions: A person-centred-theory-based training workshop with the use of a specially designed technology enhanced Taiwanese mental health professional students’ learning on therapeutic relationship competences. A further investigation into learning person-centred therapeutic relationship qualities in the workshop as an innovative pedagogy and learning approach for medical education would be recommended.

 

Keywords: Communication skills; Competence Aqucisiton; Therapeutic Relationship; Medical Education; Education in Psychiatry; Curriculum Development/Evaluation; Person-Centred Experiential Approach; Quasi-Experiment; New technology

Introduction

Physicians are trained for the major purpose of preparing themselves to provide a fusion of medical science and social science in which emphasis is often placed upon the importance of developing empathy towards patients in medical practice. This is specifically the case when their task is to learn about the psychiatric context within their medical education. As literature from the American Association of Medical Colleges (AAMC), General Medical Council (GMC) in the United Kingdom and the Liaison Committee on Medical Education (LCME) in Canada and the United States shows, empathy enhancement is one of the essential goals for learning in medical education. This is to ensure medical students’ competency in developing and maintaining therapeutic relationships which can be relevant to patients’ prognosis (Stephien and Baernstein, 2006; Dale, Bhavsar and Bhugra, 2007; Shaprio, 2008; Bayne, 2011).

 

Psychiatry is an important branch of medicine. As such, medical trainings have seen increases to the total number of teaching hours assigned to psychiatry rotations, revising and expanding psychiatric teaching programs throughout the whole course, developing clinical placements in hospital wards starting in connection with other medical services, and developing the technique of psychiatric examination to parallel that of the physical diagnosis process (Dale, Bhavsar and Bhugra, 2007; Bayne, 2011; Vestermark, 1952; Thompson, 1953; Law et al., 2011). This study examines the effectiveness of a therapeutic relationship training programme (TREP) for medical and psychiatry-related health professionals that used a combination of experiential learning methods supported by new technologies.

 

One of the most important elements of all psychiatric treatments is the relationship between the healthcare professional and the patient. Qualitative researchers have suggested that the therapeutic relationship in mental health care plays an essential role in patients’ recovery from severe mental illness, such as schizophrenia (McCabe and Priebe, 2004)and that the relationship directly affects outcomes (Bendapudi et al., 2006)and this has been shown in studies that have investigated self or peer-rating assessments, observation studies, quasi-experiments, and interviews (Priebe et al., 2011; Ditton-Phare et al., 2017). Conducting multi-faceted studies in therapeutic relationships and providing effective psychiatric healthcare are suggested to be increasingly crucial in response to the rise in psychological distress in the population (Ditton-Phare et al., 2017; Fu et al., 2013; World Health Organization, 2014; Pescosolido et al.,2013). However, due to the heterogeneity of studies there is still little known about the therapeutic relationship within different psychiatric approaches (Ditton-Phare et al., 2017; Maguire and Pitceathly, 2002), and the frameworks of the therapeutic relationship in psychiatric healthcare remain unclear (Bayne, 2011; Priebe et al., 2011). Thus, developing mental health professionals’ therapeutic relationship knowledge and skills could be one of the essential focuses for the future of psychiatric and psychiatry-related professional education (Alberts and Eldstein, 1990; Messina, Sambin and Palmieri, 2013).

 

Therapeutic Relationship in Psychiatry

In mainstream mental health care, the definitions and approaches of therapeutic relationship are varied; such as the term therapeutic relationship (Alexander and Coffey,1997) meaning a therapist and a patient that engage with each other to effect beneficial change in the patient, therapeutic alliance (Clarkin, Hurt and Crilly,1987)which means creating a bond between patient and therapist to formulate and apply judgment precisely and help patients define and reach their goals, the helping relationship (Goering and Stylianos,1988)which is a relationship between the helper and the helpee facilitating the quality of the relationship with five characteristics: listening attentively, understanding the other person's point of view, accepting the person non-judgmentally, caring enough to be committed and involved (but not overly involved), and being genuine, and lastly the working alliance (Gehrs and Goering, 1994) which consists of three parts: tasks, goals and bond agreed by both parties to help reach the client's goals.

         

Regardless of the various approaches to the therapeutic relationship, studies have indicated that a mutual experience of the therapeutic relationship is an influential factor to assist the clients through the treatment (Cornelius-White et al., 2018; McGuire, McCabe and Pierbe, 2001). Moreover, a systematic review of research identified 129 studies between 1990 to 2009 that had addressed the correlation between the patients’ prognosis and the therapeutic relationship. The review suggested there was an overall small effect size r= .22 (Martin, Garsle and Davis, 2000). 33 of the 129 studies were identified as investigations on whether the therapeutic relationship predicted the outcome of the treatment; 22 of these studies used clinician- or patient-rated measures and results reported in 3 of 6 studies with hospitalized patients showed that a better therapeutic relationship was associated with fewer hospitalizations, 3 of 10 measured the level of patient’s symptoms and reported that the therapeutic relationship was one of the most influential factors for symptom reduction, and 6 out of 6 studies evaluating the patient’s functioning showed significant associations with the therapeutic relationship (Priebe et al., 2011). 

         

A systematic review of current approaches of communication skills for those in the psychiatric and psychiatry-related professions indicated an improvement in empathy and interview skills after experiencing therapeutic-relationship-related training protocols (Ditton-Phare et al., 2017). Medical students in a quasi-experimental study on learning doctor-patient communication reported that 84 students (male=32, female=52, mean age=21.9) showed significant learning progress on communication skills (p<0.001) at the beginning and the end of a 39-hour course over two semesters. The course involved tutors with groups of 8-12 students working together, using doctor-patient role play, giving and receiving feedback, analysing video, and a video exam (Cämmerer, Martin and Rockenbauch, 2016). Another quasi-experimental study on psychiatric nurses’ communication skills training was conducted as a short-term course with lectures, problem-solving, brainstorming, members sharing experiences and discussion, and using personal computer and whiteboards as educational tools. The study discovered that the level of stress of the random-assigned members in the experimental group (N=23, mean stress score difference = -.1) decreased significantly one month after the intervention while and the control group’s stress level (N=22, mean stress score difference = +.4) continued to increase. Ghazavis concluded that psychiatric nurses are often influenced by the stressful working environment which leads to desensitizing in therapeutic relationship with their patients, and he also suggested providing an appropriate working environment forward nurses to learn communication skills that could lower the workload and improve the therapeutic relationship with patients (Ghazavi, Lohrasbi and Mehrabi, 2010). 

         

Despite these recent studies, the underlying premise of the therapy relationship in psychiatric education remains confusing as it can be positioned from multiple theoretical perspectives. There are at least six conceptual and theoretical frameworks of mental health professional training that have traditionally been applied, and five of them have emphasized the importance of developing therapeutic relationship competence during training. For example, the role theory focuses upon the functions and patterns of behaviours of the practitioners and patients in the relationship, the social constructionism looks at the process of patients’ interpretation about their experience through the communication with the practitioners, the systems theory is functioning as a reconstruction of patients’ external systems, such as their family, in the therapeutic settings, social psychology emphasizes the interpersonal interaction between the practitioners and patients; and lastly, the cognitive behaviourism bridges patients’ cognition and behaviours by facilitating a working relationship in the psychiatric settings (McGuire, McCabe and Pierbe, 2001). 

         

Carl Rogers, a pioneer of Humanistic Psychology and psychotherapy and specifically the person-centred approach, developed the theory of the six necessary and sufficient conditions of the therapeutic relationship (Rogers, 1957). Rogers gave the therapeutic relationship a wider definition where it also advocates providing a non-judgmental and non-directional therapeutic atmosphere where clients and therapists experience six therapeutic conditions, three of which are specific to the therapist: empathic understanding, unconditional positive regard, and congruence(Rogers, 1957)Rogers’ therapeutic relationship conditions would be a complex of mutual, reciprocal, and dual interaction between mental health professionals and their clients (Rogers, 1957; Barrett-Lennard, 2011; Murphy, Cramer, and Joseph, 2012). The six necessary and sufficient conditions are as follows (Rogers, 1957, pp. 95):1) Two persons are in psychological contact.2) The first, whom we shall term the client, is in a state of incongruence, being vulnerable or anxious. 3) The second person, whom we shall term the therapist, is congruent or integrated into the relationship. 4) The therapist experiences unconditional positive regard for the client. 5) The therapist experiences an empathic understanding of the client’s internal frame of reference and endeavours to communicate this experience to the client. 6) The communication to the client of the therapists’ empathic understanding and unconditional positive regard is to a minimal degree achieved. By maintaining an experience of these conditions, a therapeutic relationship would benefit both clients and professional practitioners. The theory provides a useful framework for positioning the therapeutic relationship within psychiatry.

 

Pedagogy in Psychiatry

The registered number of psychiatrists in South East Asia and Africa in 2014 has increased 25% since 2011, and the population of other mental health professionals, such as psychiatric nurses, has also grown by 37% (World Health Organization, 2014, pp. 53). This increasing supply of mental health professionals reflects the growing prevalence of psychological distress in the general population. For example, in Taiwan in East Asia, it was reported that there were 1 in 4 people suffering from common mental health problems, such as depression and anxiety disorder (Fu et al., 2013). The numbers of mental health service users are still multiplying rapidly (World Health Organization, 2014). Therefore, providing effective training for mental health care becomes essential.

         

According to McCann et al. (2012), there are currently five approaches applied to develop a mental health professional covering pedagogical and quality aspects which including professional developmenttopics and teaching methodspractice placements and supervised sessions, and quality assurance mechanisms. Firstly, professional development providers students with current policy, services and practice development. Secondly, topics and teaching methods typically is a mixture of lecture format and other didactic methods, self-directed learning, and experiential learning. Thirdly, assessment of learning is used in assessing students on most courses. Fourthly, practice placements and supervised sessions require students to complete formal reports on placement supervision. Lastly, most courses use external examiners and formal feedback from students as the quality assurance mechanisms in the educational programmes (McCann et al.,2012). Hypothetically, mental health professional students acquire knowledge and skills to work in psychiatric healthcare and achieve the expectations of     

 

“working in partnership, respecting diversity, practicing ethically, challenging inequality, promoting recovery, identifying people’s need and strengths, user-centered care, making a difference, promoting safety and positive risk taking, and personal development and learning." (McCann et al., 2012, pp. 383). 

 

The current medical education in the Mandarin-speaking world, and specifically Taiwan, has been influenced by Western culture due to the colonial and post-colonial history (Cheng, 2011). For example, standard Taiwanese medical education is a 7-year Western education programme for doctors and a 4 or 5-year programme for other health professionals, such as nurses, dentists and psychotherapists. The curriculum of doctors’ education includes 2 years of pre-medical courses, 2.5-3 years of clinical course and 2.5-3 years of clerkship and internship. The programme of nurses and psychotherapists’ education comprises 1-1.5 years of integrated and basic clinical courses, and 2.5 years of practical placement in the medical settings (Chou et al., 2012). Before determining which subfield to serve in, medical students in Taiwan are required to follow the curriculum of medical education provided by the Ministry of Education (Chouet al., 2012). Following the principle of medical education given by the Accreditation Council for the Graduate Medical Education (ACGME) in the United States, the medical education in Taiwan has stated that the performance of health providers is determined by the framework of their competencies of medical knowledge, practice-based learning and improvement, professionalism, systems-based practice, patient care, and interpersonal and communication skills (Rider and Nawotniak, 2010). Importantly, ACGME has emphasized the capabilities of taking care of patients and the abilities of interacting and communication should be taught to students within medical education (Rider and Nawotniak, 2010). Acknowledging the professional practitioner-patient communication and the improvement of practitioners’ empathy skills are essential factors to influence patients’ prognosis and overcome the potential shortcomings associated with limited health-literacy capabilities (Bendapudi et al., 2006; Chu and Tseng, 2013).  In this vein, the Ministry of Education in Taiwan has embraced the American and British standards of practitioner’s training to bring humanities into many areas of medical education, such as curriculum, licensing, student enrolment and the continuing education in health services (Chiu and Tsai, 2009). There is not only the medical knowledge and practice to be gained through the 7-year programme, but also seminars about professional practitioner-patient relationship, such as empathic understanding of patients, communication skills and so on, which have to be learned during the pre-medical courses as part of the curriculum as required by the Ministry of Education in numerous of the medical schools (Chou et al., 2012; Chu and Tseng, 2013; Chiu and Tsai, 2009).

      

This challenges the current medical educators, clinical supervisors, preceptors and medical staffs in the psychiatric departments to consider revising current pedagogy and to design suitable educational programmes for mental health professional students. Although proactively applying a range of traditional and non-traditional learning methods to introduce health professional students to humanities courses, pre-medical and clinical courses (Chou et al., 2012; Chu and Tseng, 2013; Chiu and Tsai, 2009), the Ministry of Education Taiwan has requested more medical education concepts and models from other countries to be developed (Chou et al., 2012).

 

Learning Interpersonal Skills in Psychiatry  

Integrating the five pedagogical approaches of developing mental health professional students, using the Helping Skills Model becomes one of the common educational methods for mental health professional students (Hill and Lent, 2006) and is considered an experiential learning method (Slovák et al., 2015). It integrates aspects from three traditional methods: Human Relation Training (Carkhuff,1972), Micro-Counselling (Ivey,1971), and Interpersonal Process Recall (Kagan,1984). Human Relation Training (HRT) develops mental health professional students by rotating the roles of practitioner, client and observer during the interpersonal skills practice. Micro-Counselling (MC) focuses on developing specific interpersonal skills during role-play practice, with the tutor’s feedback and guidance. Interpersonal Process Recall (IPR) helps mental health professional students review their practice with their peers to reflect and deepen the understanding of what happened in the practice session (Slovák et al.,2015). The methods of the Helping Skills Model include direct instruction where the instructor gives information about target skills, modelling involves demonstration of specific skills and feedback from either the instructor or the other participants. These methods are often performed through the use of audio recording and video capture to facilitate practice (Slováket al., 2015). Studies have found that video recording with peer feedback in real-time consultation is in favour of contemporary medical education with UK medical students (N=162) during training (Eeckhout et al.,2016), and also has indicated that self-reflecting on non-verbal behaviours, such as facial expression, un-purposive moment, body position, unnecessary giggling improved the communication skills of the medical students in the experimental group (N=134) with a significant change through using video training (Park and Park, 2018). 

          

mPath, a new technology software, advances the methods of the Helping Skills Model, as an innovative online software system developed specifically for mental health professional students. It provides the opportunity for a structured analysis of the mental health professional students’ practice sessions and aims to elicit and receive specific feedback from clients. The software has been produced by a cross-disciplinary team and offers the possibility for new technology to be added to existing methods of developing therapeutic relationship helping skills (Slovák et al., 2015; Murphy et al., 2017; Murphy et al., under review). It does this by deploying multiple tools to reflect on various aspects of peoples' experiences. The entire process is all tightly linked with the video-recording of the session and designed to facilitate a time-efficient reflective feedback process.

         

To gain a deeper self-reflection on the session of mental health professional students’ education, mPath provides the opportunity of a structured reflection for students, allowing the opportunity to process a self-analysis whilst attaching specific thoughts or comments left as text annotations to the recorded video. mPathalso creates the space for interactions between the students as practitioners to collaborate with their clients. For example, the clients are able to share their thoughts, feelings and internal processes with the practitioners by giving feedback to them within the system. Furthermore, mPath offers the chance to enhance students’ therapeutic relationship competence by making annotation notes on the recorded practice videos, adapting to review different perspectives, requesting client’s feedback, deepening understanding of affect, and observing body movements (Slovák et al., 2015; Murphy et al., 2017; Murphy et al., under review). 

Methods

Objective

The aim of the study was to test the effectiveness of a 3-day training on mental health professional students’ competence in the Rogerian therapeutic relationship skills. The objectives were to clarify the group’s and the individual’s baseline at the beginning of the study and evaluate the training effects at both group and individual level. To this end, the following research questions were posed.

  • Is there any difference in baseline performance (pre-test, the first assessment) in terms of maturation by specialities education, such as nursing, occupational therapy, medicine, clinical psychology and others?
  • If the participants obtained same baseline competence of Rogerian therapeutic relationship skills, do the control and experimental group show a significant difference in escalating behaviour before, at the end of and two weeks after the training intervention?
  • If the participants obtained a difference in the baseline of Rogerian therapeutic relationship skills, does each group of each medical speciality show a significant difference in developing the competence before, at the end of and two weeks after the training intervention?
  • Do the training results depend on the frequency of exposure in the experiential learning?

Design

A pretest-posttest with follow-up within-and-between-group design was used. A cross-sectional analysis was performed to understand the participants’ competency in person-centred therapeutic relationship skills with and without the intervention to evaluate whether the therapeutic relationship skills could be learned in a short period of time and if the impact can be sustained at two weeks after the intervention (Law, et al., 2011; Barrett-Lennard, 2011; Barrett-Lennard 1962; Barrett-Lennard, 2018; Aukes et al., 2008; Nau, et al., 2010).

         

The Therapeutic Relationship Enabling Program (TREP) was designed as a process- and theory-oriented workshop where the participants were divided into two groups: the experimental group and control group (Barrett-Lennard, 2011; Barrett-Lennard, 2018; Law, et al., 2011). The control group did not receive the TREP intervention while the experimental group was exposed to the 3-day TREP workshop. Each group was presented with three assessments of the Mandarin-Chinese version of the Barrett-Lennard Relationship Inventory (B-L RI:MC) (Liao, Murphy and Barrett-Lennard, 2018)used to rate their relationship competency, at the beginning, end of and two weeks after the intervention (Barrett-Lennard, 1974/1975; Liao, Murphy and Barrett-Lennard, 2018). By comparing the multi-faceted outcomes of the within-and-between evaluations of the two groups, the effectiveness of the TREP would be considered.

 

Sample and participants

Estimating the effective sample size for increasing the degree of confidence is preferred to recruit a statistical population on the basis of a relatively small amount of sample data (Ellis, 2010; Kelley and Preacher, 2012). Cohen suggested that the effect sizes of small, medium and large are with a of .2, .5, and .8 (Hill and Lent, 2006; Cohen, 1988). According to the meta-analysis of the effectiveness of helping skills training surveyed by Hill and Lent, the aggregated effect size (d+) was .89 for conducting a training program (Hill and Lent, 2006).

         

In 2016, there were 8,661 mental health professionals registered to work in psychiatric settings in Taiwan including hospitals, psychiatric clinics, day-care institutions and psychiatric nursing homes. There were 1,601 psychiatrists, 5,146 psychiatric nurses, 521 social workers, 685 clinical psychologists, 708 occupational therapists, 897 administers, 483 para-medical personnel, and 47 others worked in the licensed mental health professionals who have been working in the psychiatric settings and approximately 1,201 students studied in learning and practising psychiatric knowledge in medical schools (University Admissions Committee, 2014; Ministry of Health and Welfare, 2015). The target population is less than 2% of the entire population of Taiwan. Taiwanese mental health professional students are considered as a rare population. As the result of the estimation of an effective sample size, the minimum required sample size of the therapeutic relationship enabling program will approximately be 26 participants if the desired statistical power level is set as 0.8 and the probability level is 0.05 comparing to the whole population in Taiwan where there are 23,496,813 people. In this study, the aim was to have 3 workshops where 8 participants were in the experimental group in each workshop in order to reach 24 participants for the experimental group and 24 people for the control group sufficiently in this study. Therefore, it aimed to recruit more than 48 Taiwanese mental health professional students across two groups. The characteristics of the target group would be mental health professional students from medical-relevant professions in medical schools in Taiwan, such as psychiatrists, psychiatric nurses, clinical psychotherapists, occupational therapists, and the students practising/learning psychiatric knowledge in the psychiatric settings/schools and would be considered as a specific group providing psychiatric healthcare. 

          

To identify prospective participants, snowball sampling was one of the suitable methods to access the target population (Voicu and Babonea, 2011). The snowball sampling, also named referral sampling, is often used to target hidden populations, such as a particular group of people which is less than 2% of the entire population (Voicu and Babonea, 2011). It allows researchers to use the participant’s social networks to refer to other prospective participants who could potentially contribute to the research (Heckathorn,1997). However, this study aimed to recruit more than 24 Taiwanese mental health professional students for each experimental and control group to evaluate the change in the person-centred therapeutic relationship competence before, at the end and two weeks after the Therapeutic Relationship Enabling Programme.

Measuring Therapeutic Relationship in Psychiatry: Barrett-Lennard Relationship Inventory Mandarin-Chinese Version OS-40

The Barrett-Lennard Relationship Inventory (B-L RI) is a multiple-choice questionnaire, which is designed specifically for evaluating interpersonal relationships. It was developed by Barrett-Lennard when working with Carl Rogers in the University of Wisconsin where Rogers and his colleagues studied psychotherapy with people with a diagnosis of schizophrenia during the later 1950s and early 1960s(Thorne and Sanders, 2013, pp.112). Acknowledging the positive impact of Rogers’ theory, the B-L RI has been expanded and applied in evaluating different kinds of relationship. For example, therapist-client relationship, teacher-student relationship, family relationship, friendship, partnership, etc. B-L RI has been gradually adapted into different forms, such as 64-items and 40-items (Liao, Murphy and Barrett-Lennard, 2018). 

 

In this study, the Mandarin-Chinese version of Barrett-Lennard Relationship Inventory: Form Other Toward Self-40 (OS-40) will be used as the measure indicates promising reliability and construct validity in measuring therapeutic relationship conditions in Mandarin contexts (Liao, Murphy and Barrett-Lennard, 2018). In Form OS-40, there are four dimensions in the Barrett-Lennard Relationship Inventory Mandarin-Chinese version, level of regard, empathic understanding, unconditionality of regard and congruence, and each dimension obtains 10 items (Barrett-Lennar, 2015; Liao, Murphy, & Barrett-Lennard, 2018). The level of regard refers to the affection of one person’s response to another, and it might embed positive or negative feelings (Barrett-Lennard, 2015, pp. 11). The concept of empathic understanding is defined as one person is conscious of and aware of another (Barrett-Lennard, 2015, pp.10). The definition of unconditionality of regard is given as the effective response and self-experiences of one person towards another (Barrett-Lennard, 2015, pp. 11). 

         

Finally, the concept of congruence is the consistency between the whole present experience and awareness. For example, a congruent person can be honest, sincere and direct to another without hesitation or feeling compelled during the communication (Barrett-Lennard, 2015, pp. 11). Each item is rated on differing strengths of No or Yes in the range -3 to +3 (Barrett-Lennard, 2015, pp. 26-34; 40-41). Each score of the scale would result in a possible range of -30 to +30. If avoiding negative values is necessary, it could add a constant of +30 to each obtained scale score to convert the scores with a possible range of 0 to 60 (Barrett-Lennard, 2015, pp.122). Applying the standard scoring method of the 64-item scale in the 40-item scale, B-L RI:MC OS-40 would result in a score with a range of -30 (or -3 x10) to +30 (or +3 x 10) in each 10-item. A sub-score of 20 would indicate an average item score of 2 after converting the scores to the negatively worded items and represents an obvious affirmation of a person who experiences a positive therapeutic condition, like empathy, level of regard, etc. A sub-score of 15 would represent a less helpful relationship. Lastly, with a sub-score of 10, an assessment would discover a respondent experiencing a conceivably less than adequate level of therapeutic relationship (Barrett-Lennard, 2015, pp. 39-42). However, the development and adaption of the Barrett-Lennard Relationship Inventory and its Mandarin-Chinese version were absolutely aligned with the core concept of person-centred therapeutic relationship (Liao, Murphy and Barrett-Lennard, 2018).

         

Therefore, the Mandarin-Chinese version of the Barrett-Lennard Relationship Inventory (B-L RI:MC) was administered to the participants in both the control group and experimental group prior to the TREP as a pre-test evaluation. The post-test evaluation was conducted at the end of the TREP. The final assessment was performed 2 weeks after the TREP and before a qualitative interview took place (Liao, Murphy and Barrett-Lennard, 2018; Messina, Sambin and Palmieri, 2013).

 

Intervention: Therapeutic Relationship Enabling Programme

The TREP consisted of a 3-day workshop of 5 didactic lectures, 5 conversational-simulation experiential exercises, and 5 non-directive reflection and self-reflecting processes with technology support which was followed by one more conversational-simulation experience and a semi-structured interview after two weeks (Figure 1) (Aukes et al., 2008; Bridges et al., 2011; Cornelius-White et al., 2018; Slovák et al., 2015). There were 5 sessions designed in the intervention. Each session took 2 hours consisting of 1 didactic lecture, 1 conversational-simulation experience, 1 technological-based reflection with mPath and a break. The first and second assessments took place before and after the intervention to evaluate any change of participants’ performance and the effectiveness of the intervention. The final assessment was given after the 6th conversational-simulation experience and before the interview to investigate the sustainability and development of the effect over time.

 

In the first session, an interactive activity was conducted to help learn about the different perspective of unconditional positive regard of each individual. The concepts of Rogers’ person-centredtherapy and therapeutic relationship were addressed by giving an introduction and a demonstration video. After giving a tutorial of mPath the participants, with their practice partner, were requested to videotape a 3-minute communicative practice and upload it to the software system, and then leave some annotations on mPath. Secondly, one of four dimensions of Rogerian therapeutic relationship was addressed in the course followed by another demonstration video. The participants then videotaped a 5-minute conversational-simulation experience with their peers, and then self-processed with the use of mPath. Thirdly, another dimension of Rogerian therapeutic relationship was given followed by a group process activity on mPathand an 8-minute conversational-simulation experience. The participants would self-analyse, share their thoughts and ask their partner for feedback in the system. Fourthly, the final two dimensions of Rogerian therapeutic relationship were introduced in mini-lecture format, and the participants had a 10-minute conversational-simulation experience. Finally, the participants had a 15-minute conversational-simulation experience with their partners, and then made annotation notes on the recorded practice videos, adapting to review different perspectives, requesting the partners’ feedback, deepening understanding of emotional affect, and observing their body movements. 

 

Figure 1: Procedure of Therapeutic Relationship Enabling Programme and the Quasi-Experiment

 

The workshop was developed to fulfil three requirements. First of all, it aimed to ensure that Rogers’ person-centred theory was well-implemented in the workshop. For instance, the medical-educated trainer must specialize in the person-centred approach to counselling and psychotherapy in order to create a non-directive and non-judgmental atmosphere and adjust the training schedule flexible for the participants to experience the nature of person-centred approach and enhance their learning (Rogers,1957; Aukes et al., 2008; Barrett-Lennard, 2011; Barrett-Lennard, 2018). Secondly, it promoted the development of knowledge and competency of therapeutic relationship skills by giving the definitions of 4 conditions in Rogerian therapeutic relationship and then illustrating some of the examples of therapeutic competencies in the person-centred and experiential psychotherapy using video clips (Rogers,1957; Freire, Elliott and Westwell, 2014; Barrett-Lennard, 2011; Barrett-Lennard, 2018). Lastly, it delivered the theoretical, conception and empirical evidence for each element in the TREP. For example, the research ethics and rationale of the training workshop, the results of the validation of Barrett-Lennard Relationship Inventory Mandarin-Chinese version, and the publications of the development and application of the helping learning technology mPath (Slovák et al., 2015; Barrett-Lennard, 1962; Barrett-Lennard, 2018; Liao, Murphy and Barrett-Lennard, 2018).

Results/Analysis

Demography of Participants

59 mental health professional students, with a mean of age 24 in Taiwan were recruited to this study, including 26 people in the experimental group and 33 people in the control group. 50 of 59 participants were female, and 9 of them were male (Table 1). 30 were nursing students, 6 were studying in occupational therapy, 10 were medical students, 10 were in clinical psychology, and 3 were students in other mental-health-relevant professions. All participants had completed psychiatric-related lectures in medical schools, such as neurology, psychology, psychiatric nursing, psychotherapy, psychological occupational therapy, however, they reported little or no prior exposure to psychiatric settings.

         

In the experimental group, the participants were requested to participate in the TREP in pairs to evaluate the change of the therapeutic relationship competence of their partners. There were 24 females and 2 males with a mean of age 22 years. 15 of them were trained in nursing, 5 in occupational therapy, 4 in medicine, 2 in clinical psychology, and none in other mental-health-relevant professionals. 18 of 26 participants in the experimental group were rating a peer-relationship with 3 to 5 years. 8 of them were rating relationships with either 1 to 3 years or more than 5 years. 

         

On the other hand, the controls were recruited through snowball sampling. They were required to complete 3 evaluations of the therapeutic relationship competence of a mental health professional student who did not experience the Therapeutic Relationship Enabling Program. With a mean of age 24 years, the majority of the controls were female and nursing students. 26 females and 7 males. There were 15 controls studying in nursing, 1 in occupational therapy, 6 in medicine, 8 in clinical psychology and 3 in other mental-health-relevant specifies. In terms of years of the evaluated peer-relationship, the relationship with 3 to 5 years was mostly rated, and then the one with 1 to 3 years went second, and finally one with more than 5 years was the last. None of the evaluated relationships were less than 12 months.

         

The result of the Mandarin-Chinese version of Barrett-Lennard Relationship Inventory: Form OS-40 (B-L RI:MC OS-40), 59 participants rated a total mean score of 43.20 and standard deviation of 23.10 in the scale where the sub-scales of level of regard(M= 17.49, SD= 6.64), empathic understanding(M= 9.92, SD= 8.73),unconditionality of regard(M= 2.14, SD= 6.20) and congruence(M= 13.66, SD= 8.74) were embedded (Table 4). The result above was aligned with other samples where the average score of level of regard tended to be higher than other sub-scales and the scores of unconditionality of regard were the lowest one in the scale (Barrett-Lennard, 2015, pp. 41).

 

Table 1: Characteristic of the Sample of Mental Health Professional Students in Taiwan

Characteristic

Experimental Group (N=26)

Control Group (N=33)

Total (N=59)

N

%

N

%

N

%

Age (years)

           

20-29

24

92.30

27

81.82

51

86.44

30-39

1

3.85

3

9.09

4

6.78

40-49

1

3.85

1

3.03

2

3.39

>50

0

0.00

2

6.06

2

3.39

Means (M)

22.96

 

25.21

 

24.22

 

Standard Deviations (SD)

5.64

 

8.02

 

7.10

 

Gender

           

Male

2

7.70

7

21.20

9

15.30

Female

24

92.30

26

78.80

50

84.70

Other

0

0.00

0

0.00

0

0.00

Specialties

           

Nursing

15

57.70

15

45.50

30

50.80

Occupational Therapy 

5

19.20

1

3.00

6

10.20

Medicine

4

15.40

6

18.20

10

16.90

Clinical Psychology

2

7.70

8

24.20

10

16.90

Others

0

0.00

3

9.10

3

5.10

Year of Evaluated Peer-relationship

           

Less than 6 months

0

0.00

0

0.00

0

0.00

6-12 months

0

0.00

0

0.00

0

0.00

1-3 years

4

15.38

12

36.36

16

27.10

3-5 years

18

69.23

15

45.45

33

55.90

More than 5 years

4

15.38

6

18.18

10

16.90

 

 

Examining Participants’ Baseline Competence of Rogerian Therapeutic Relationship: Between Specialties

A one-way between subject ANOVA was conducted to compare the baseline competence rating of therapeutic relationship skills of the mental health professional students across specialities: nursing, occupational therapy, medicine, clinical psychology and others (Table 2; Table 3). There was no significant difference in amount of baseline competence on participants’ specialties at the p> .05 level for the five specialties [F (4, 54) = .28, p= .887]. This tests the null hypothesis that the error variance of the dependent variable is equal across groups. Furthermore, the baseline competence of therapeutic relationship of participants who specialize in nursing (N=30, M= 46.43, SD= 21.55) did not significantly differ from the participants who were studying in occupational therapy (N=6, M= 48.17, SD= 23.77), medicine (N=10, M= 43.30, SD= 25.54), clinical psychology (N=10, M= 32.30, SD= 25.56) and others (N=3, M= 37.00, SD= 23.90) (Table 2; Table 3). In the table of the pairwise comparisons between specialities, with p > .05, it shows that there was no significant difference of the therapeutic relationship competence between each speciality of the mental health professional students. For example, the values resulted in .868 with the occupational therapy students, .713 with the medical students, .102 with the clinical psychology students, and .506 with the students in other subjects if pair-comparing with the nursing students. With the occupational therapy students, there was no significant difference between the students in medicine with a value of .687, clinical psychology with a p value of .192 and other subjects with a value of .500. The medicine and clinical psychology students also showed no statistically significant difference from each other with a value of .295 (Table 3).

 

Table 2: Descriptive Statistics Between Specialties of Participants Dependent Variable

Specialities

Mean

Std. Deviation

N

Nursing

46.43

21.548

30

Occupational Therapy

48.17

23.769

6

Medicine

43.30

25.539

10

Clinic Psychology

32.30

25.561

10

Others

37.00

23.896

3

Total

43.20

23.099

59

 

Table 3: Pairwise Comparisons Between Specialties Dependent Variable

(I) Specialities

Mean Difference (I-J)

 

Std. Error

Sig.a

95% Confidence Interval for Differencea

Lower Bound

Upper Bound

Nursing

Occupational Therapy

-1.733

10.396

.868

-22.577

19.110

Medicine

3.133

8.489

.713

-13.885

20.152

Clinical Psychology

14.133

8.489

.102

-2.885

31.152

Others

9.433

14.077

.506

-18.789

37.655

Occupational Therapy

Nursing

1.733

10.396

.868

-19.110

22.577

Medicine

4.867

12.005

.687

-19.201

28.934

Clinical Psychology

15.867

12.005

.192

-8.201

39.934

Others

11.167

16.438

.500

-21.790

44.123

Medicine

Nursing

-3.133

8.489

.713

-20.152

13.885

Occupational Therapy

-4.867

12.005

.687

-28.934

19.201

Clinical Psychology

11.000

10.396

.295

-9.843

31.843

Others

6.300

15.303

.682

-24.381

36.981

Clinical Psychology

Nursing

-14.133

8.489

.102

-31.152

2.885

Occupational Therapy

-15.867

12.005

.192

-39.934

8.201

Medicine

-11.000

10.396

.295

-31.843

9.843

Others

-4.700

15.303

.760

-35.381

25.981

Others

Nursing

-9.433

14.077

.506

-37.655

18.789

Occupational Therapy

-11.167

16.438

.500

-44.123

21.790

Medicine

-6.300

15.303

.682

-36.981

24.381

Clinical Psychology

4.700

15.303

.760

-25.981

35.381

Based on estimated marginal means

a. Adjustment for multiple comparisons: Least Significant Difference (equivalent to no adjustments).

 

Examining Participants’ Baseline Competence of Rogerian Therapeutic Relationship: Between Conditions

An independent-sample t-test was conducted to compare participants’ competence of therapeutic relationship in the intervention and non-intervention conditions. There was not a significant difference in the total score of Barrett-Lennard Relationship Inventory Mandarin-Chinese version for the experimental group (M= 44.50, SD= 18.99) and the control group (M= 42.18, SD= 26.14); t(57) = .38, p= .71. These results suggest that the participants in both experimental and control group obtained similar baseline competence of Rogerian therapeutic relationship skills at recruitment (Table 4; Table 5). A report of Box’s test of Equality of Covariance Matrices also indicated the null hypothesis that the observed covariance matrices of the dependent variables (p= .024) are equal across groups. Therefore, it can be concluded that there was no statistically significant difference in Rogerian therapeutic relationship competence between participants and the two groups. 

 

Table 4: Groups Statistics BEFORE the Intervention

Measure

Group

N

Mean

Std. Deviation

Std. Error Mean

Total Score of B-L RI:MC 

Experimental Group

26

44.50

18.98

3.72

Control Group

33

42.18

26.14

4.55

Experimental + Control Group

59

43.20

23.10

3.01

Level of Regard

Experimental Group

26

17.92

5.97

1.17

Control Group

33

17.15

7.19

1.25

Experimental + Control Group

59

17.49

6.64

0.86

Empathic Understanding

Experimental Group

26

10.38

6.93

1.36

Control Group

33

9.55

10.01

1.74

Experimental + Control Group

59

9.92

8.73

1.14

Unconditionality of Regard

Experimental Group

26

2.35

6.21

1.22

Control Group

33

1.97

6.29

1.09

Experimental + Control Group

59

2.14

6.20

0.81

Congruence

 

Experimental Group

26

13.85

8.55

1.68

Control Group

33

13.52

9.01

1.57

Experimental + Control Group

59

13.66

8.74

1.14

 

Table 5: Independent Samples Test of Experimental and Control Group BEFORE the Intervention

Measure

Levene's Test for Equality of Variances

t

df

Sig. (2-tailed)

t-Test for Equality of Means

95% Confidence Interval of the Difference

F

Sig.

Mean Difference

Std. Error Difference

Lower

Upper

Total Score of B-L RI:MC 

Equal variances assumed

3.07

0.09

0.38

57.00

0.71

2.32

6.10

-9.90

14.54

Equal variances not assumed

   

0.39

56.67

0.70

2.32

5.88

-9.46

14.09

Level of Regard

Equal variances assumed

1.48

0.23

0.44

57.00

0.66

0.77

1.75

-2.74

4.28

Equal variances not assumed

   

0.45

56.83

0.65

0.77

1.71

-2.66

4.20

Empathic Understanding

Equal variances assumed

3.58

0.06

0.36

57.00

0.72

0.84

2.31

-3.78

5.46

Equal variances not assumed

   

0.38

56.17

0.71

0.84

2.21

-3.59

5.27

Unconditionality of Regard

Equal variances assumed

0.26

0.61

0.23

57.00

0.82

0.38

1.64

-2.91

3.66

Equal variances not assumed

   

0.23

54.12

0.82

0.38

1.64

-2.91

3.66

Congruence

 

Equal variances assumed

0.00

0.97

0.14

57.00

0.89

0.33

2.31

-4.30

4.96

Equal variances not assumed

   

0.14

55.01

0.89

0.33

2.30

-4.27

4.93

 

Changes and Influences on Learning Progress 

A one-way repeated measures ANOVA was conducted to compare the change of the competence of Rogerian therapeutic relationship on mental health professional students, before, at the end and 2 weeks after the Therapeutic Relationship Enabling program. There was a significant change of the competence, Wilk’s Lambda= .731,F(2, 56) = 10, p= .000 (Table 6). It reported that the participants’ competence of Rogerian therapeutic relationship had a significant difference overall. 

 

Table 6: Multivariate Tests of Repeated Measure One-Way ANOVA

Effect

Value

F

Hypothesis df

Error df

Sig.

Partial Eta Squared

Before_At theEnd_Two Weeks After

Pillai's Trace

.269

10.286b

2.000

56.000

.000

.269

Wilks' Lambda

.731

10.286b

2.000

56.000

.000

.269

Hotelling's Trace

.367

10.286b

2.000

56.000

.000

.269

Roy's Largest Root

.367

10.286b

2.000

56.000

.000

.269

Before_At theEnd_Two Weeks After * Condition

Pillai's Trace

.289

11.396b

2.000

56.000

.000

.289

Wilks' Lambda

.711

11.396b

2.000

56.000

.000

.289

Hotelling's Trace

.407

11.396b

2.000

56.000

.000

.289

Roy's Largest Root

.407

11.396b

2.000

56.000

.000

.289

a. Design: Intercept + Condition
 Within Subjects Design: Before_At theEnd_Two Weeks After

b. Exact statistic

 

To measure the within-subjects effects in the test (Table 7), the result of Greenhouse-Geisser correction reported that when using an ANOVA with repeated measures with a Greenhouse-Geisser correction, the mean scores for the evaluations were statistically significantly different (F(1.709, 97.386) = 14.721, p= .000) between time points. It also indicated a significant difference between the experimental and control group with the mean scores F(1.709, 97.386) = 16.38, p= .000. Thus, it can say that those attending the TREP showed a statistically significant change in the level of competence in developing the therapeutic relationship with others over time.

 

Table 7: Tests of Within-Subjects Effects

Sources

Type III Sum of Squares

df

Mean Square

F

Sig.

Partial Eta Squared

Before_At theEnd_Two Weeks After

Sphericity Assumed

2600.023

2

1300.011

14.721

.000

.205

Greenhouse-Geisser

2600.023

1.709

1521.787

14.721

.000

.205

Huynh-Feldt

2600.023

1.787

1455.001

14.721

.000

.205

Lower-bound

2600.023

1.000

2600.023

14.721

.000

.205

Before_At theEnd_Two Weeks After * Condition

Sphericity Assumed

2894.644

2

1447.322

16.389

.000

.223

Greenhouse-Geisser

2894.644

1.709

1694.228

16.389

.000

.223

Huynh-Feldt

2894.644

1.787

1619.874

16.389

.000

.223

Lower-bound

2894.644

1.000

2894.644

16.389

.000

.223

Error (Before_At theEnd_Two Weeks After)

Sphericity Assumed

10067.605

114

88.312

     

Greenhouse-Geisser

10067.605

97.386

103.378

     

Huynh-Feldt

10067.605

101.857

98.841

     

Lower-bound

10067.605

57.000

176.625

     

 

Three paired samples t-tests were used to make post hoc comparisons between each evaluation (Figure 2). In the experimental group, a first paired sample t-test indicated that there was a significant difference between the mental health professional students’ competence of Rogerian therapeutic relationship before (M= 44.50, SD= 18.98) and at the end (M= 54, SD= 19.05) of the intervention; t (25) = -3.51, p= .002. A second paired samples t-test indicated that there was a significant difference between the mental health professional students’ competence of Rogerian therapeutic relationship at the end of (M= 54, SD= 19.05) and two weeks after (M= 63.92, SD= 17.83) the intervention; t(25) = -.348, p= .002. A third paired samples t-test indicated that there was a significant difference between the mental health professional students’ competence of Rogerian therapeutic relationship before (M= 44.50, SD= 18.98) and two weeks after (M= 63.92, SD= 17.83) the intervention; t(25) = -5.12, p= .000 (Table 8). Hence, it can be concluded that Therapeutic Relationship Enabling Program initiates the participants’ therapeutic relationship competence in a short-term period, furthermore, the competence remains and increases while the participants were no longer exposed to the training environment.

 

Figure 2: Estimated Marginal Means of Score

 

Table 8: Descriptive Statistics and Paired Samples T-Test of Experimental Group and Control Group

Groups

Descriptive Statistics

Paired Differences

Test Time

Mean

SD

 

Mean

SD

Std. Error Mean

95% Confidence Interval of the Difference

t

df

Sig. (2-tailed)

Lower

Upper

Experi-mental Group (N=26)

Before

44.50

18.98

Pair 1

Before - 
At the End

-9.500

13.785

2.703

-15.068

-3.932

-3.514

25

.002

 At the End

54.00

19.05

Pair 2

At the End - 
Two Weeks After

-9.923

14.555

2.854

-15.802

-4.044

-3.476

25

.002

Two Weeks After

63.92

17.83

Pair 3

Before -    
Two Weeks After

-19.423

19.346

3.794

-27.237

-11.609

-5.119

25

.000

Control Group (N=33)

Before

42.18

26.14

Pair 1

Before - 
At the End

-.182

9.551

1.663

-3.568

3.205

-.109

32

.914

 At the End

42.36

27.51

Pair 2

At the End - 
Two Weeks After

.697

9.729

1.694

-2.753

4.147

.412

32

.683

Two Weeks After

41.67

24.29

Pair 3

Before - 
Two Weeks After

.515

12.314

2.144

-3.851

4.881

.240

32

.812

 

In contrast, the report of three paired samples t-test in the control group showed no significant difference between each evaluation. A first paired sample t-test indicated that there was no significant difference between the mental health professional students’ competence of Rogerian therapeutic relationship before (M= 42.18, SD= 26.14) and at the end (M= 42.36, SD= 27.51) of the intervention; t(33) = -.109, p= .914. A second paired samples t-test indicated that there was no significant difference between the mental health professional students’ competence of Rogerian therapeutic relationship at the end of (M= 42.36, SD= 27.51) and two weeks after (M= 41.67, SD= 24.49) the intervention; t(32) = .412, p= .683. A third paired samples t-test indicated that there was no significant difference between the mental health professional students’ competence of Rogerian therapeutic relationship before (M= 42.18, SD= 26.14) and two weeks after (M= 41.67, SD= 24.49) the intervention; t(32) = .240, p= .812 (Table 8). Thus, it can conclude that the level of therapeutic relationship competence of the participants who were not exposed to the Therapeutic Relationship Enabling Program showed no significant difference before and at the end of the intervention. Nevertheless, instead of remaining at the level of competence, there was a decrease in the participants’ therapeutic relationship competence appeared over time.

Discussion

The goal of this study was to examine the expectation that a theoretically informed, experientially-based training workshop with the use of a theory-designed technology would enhance mental health professional students' learning on therapeutic relationship skills. The workshop, Therapeutic Relationship Enabling Programme (TREP), has given the participants a person-centred-theory-based definition of therapeutic relationships in mental healthcare and provided an interactive method for fostering self-reflection in mental healthcare training. These findings provide some evidence that a short-period training is suitable to enhance Taiwanese mental health professional students' competence in therapeutic relationships, and after attending a person-centred learning workshop, students' competence remained and further increased.

Participants' Baseline Competence of Therapeutic Relationship

The study showed the participants obtained an identical baseline of therapeutic relationship competence regardless of which group they were in the Therapeutic Relationship Enabling Programme and their specialities in medical schools. As the result in this study, the statistical report with p&gt; .05 indicated that the students who are specializing in nursing, occupational therapy, medicine, clinical psychology and other subjects had no difference significantly to each other before they participated in the Therapeutic Relationship Enabling Programme (Table 3). It showed that the current medical education in Taiwan had provided mental health professional students with a similar insight of therapeutic relationship with a mean score 43.20 and standard deviation 23.10 regardless various pedagogical approaches in the educational programs (Table 2). Therefore, it could be concluded that although the participants were voluntarily recruited and snowball-sampled from 7 medical schools in Taiwan, they nevertheless shared a similar level of understanding the therapeutic relationship.

 

The findings also showed although the speciality of participants, including the experimental and control group, were very, there was no significant difference of therapeutic relationship competence between the nursing (N=30), medicine (N=10), clinical psychology (N=10), occupational therapy (N=6) and others (N=3) students before the intervention. In Table 3, the p values of each comparison between the groups of nursing, occupational therapy, medicine, clinical psychology and other students all resulted in more than .05 which accepted the null hypothesis of no difference of the baseline therapeutic relationship competence between each speciality. It also evidenced that the overall mental health professional students in Taiwan would demonstrate a similar level of therapeutic relationship competence regardless of their specialities, educational pedagogies, and learning enviro