What do patients expect of psychiatric services? A systematic and critical review of empirical studies

Abstract

The article reviews literature concerning patients’ expectations of psychiatric care. Early research (pre-1980) is outlined, followed by a systematic review of 21 studies fulfilling specific inclusion criteria from 1980 onwards. Overall, patients expected to improve as a result of psychiatric treatment, and had higher expectations of the helpfulness of psychological and combined treatments than other interventions. Few studies considered expectations of the process of psychiatric care or determinants of expectations. The majority of studies focused on examining the relation between expectations and outcomes. There were indications that expectations of improvement were linked to clinical outcomes, although the relationship appeared to be complex. There was also some evidence that when expectations of the process of care were incongruent with the service provided, outcomes were poorer. The findings of studies in the systematic review were generally congruent with earlier work (pre-1980), although expectations of improvement appeared to be higher in the later studies. Interventions to prepare patients for what to expect were found to have beneficial effects on attendance, satisfaction and the accuracy of expectations about the process of psychiatric care. Future research should focus on developing valid and reliable measures for use in different settings, and on determining the mechanism by which expectations may relate to outcomes, including clinical outcomes, attendance and satisfaction.

Introduction

The need to incorporate patients’ views when evaluating psychiatric services has been increasingly recognised (Balogh, Simpson & Bond, 1995; Morrison, 1991; Uhlmann, Inui & Carter, 1984; Uys, Thanjekwayo & Volkywan, 1997) and has been highlighted by evidence of patient dissatisfaction with services (Kingman, 1993; Rogers & Pilgrim, 1993). Patients’ attitudes and beliefs about psychiatric care have been linked to uptake of services and drop out (Britten, 1998). It has been argued that considering patients’ views is particularly important in psychiatric care, as users of services are often socially and economically marginalised (Bjorkman, Hansson, Svensson & Berglund, 1995). However, reservations among professionals about the ability of psychiatric patients to evaluate services continue to be a problem (Crawford & Kessel, 1999; Uys et al., 1997; Williams & Wilkinson, 1995). Some writers have commented that there is a need to avoid basing services purely on the views of providers, to ensure that service provision does not only serve the needs of powerful professional groups (Bjorkman et al., 1995; Calnan, 1988). Research considering the patient's perspective of psychiatric care has examined many constructs, including attitudes, perceptions, preferences, wishes, goals, needs, requests, expectations, satisfaction and evaluations of the quality of care (Bjorkman et al., 1995; Morrison, 1991; Noble, Douglas & Newman, 1999; Ross, Frommelt, Hazelwood & Chang, 1994; Uhlmann et al., 1984).

A conceptual framework for analysing lay evaluations of health care was described by Calnan (1988), who demonstrated the interaction between patients’ goals, experiences of health care, lay beliefs about health and evaluations of care. A particular distinction has been made between what patients expect and what they want from services (Lazare & Eisenthal, 1977; Ross et al., 1994; Uhlmann et al., 1984). Uhlmann et al. (1984) suggested a model in which patients have desires (what they want) and expectations (anticipations about what will happen). They suggested that patients’ desires ‘primarily reflect a valuation, a perception that a given event is wanted’. Because patients do not necessarily communicate what they want to those providing care, the term requests was coined to denote patients’ desires and wishes which are expressed (Frank, Eisenthal & Lazare, 1978; Uhlmann et al., 1984). A recent systematic review of the literature considering patients’ requests of psychiatric care found that there were certain core requests made irrespective of the type of service attended (Noble et al., 1999). Patients mainly requested psychological interventions, but psychiatrists often failed to identify what their patients wanted.

Patients’ requests of psychiatric care are, however, constrained by the types of care and treatment that they expect will be available to them. In contrast to requests, patients’ expectations ‘are usually implicitly held, seldom-verbalised beliefs about roles, techniques, content, duration and outcome’ (Frank et al., 1978). Patients’ expectations include events they wish to happen, do not wish to happen or about which they have no preference. The concept of expectations is therefore broader than that of requests. What patients expect from services may not reflect what they want (Duckro, Beal & George, 1979). Patients also have expectations about the outcome of care, which may determine their responses to proposed interventions. To obtain a comprehensive picture of patients’ views about psychiatric care, it is therefore important to consider what patients expect in addition to their requests.

The last systematic review of patients’ expectations of psychiatric care was conducted by Duckro et al. (1979), who examined the impact of disconfirmed expectations on outcomes. However, the last comprehensive review of studies was by Goldstein (1962a). As there have been marked changes in the provision of psychiatric services over the past few decades, it is important to consider patients’ expectations in a modern context. This review will systematically consider evidence from empirical studies from 1980 onwards. The literature prior to 1980 will be summarised to provide a background to the review.