Measuring quality in the therapeutic relationship--part 1: objective approaches.

BACKGROUND The therapeutic relationship is complex. Any attempt to capture its quality in a score or metric must involve an element of reductionism. But policymakers increasingly ignore the unmeasured. AIM To review the different concepts, theoretical models and empirical approaches which researchers have used to capture the relationship between practitioner and patient in terms of scales, categories and other objective metrics. METHOD Drawing on the principles of meta-narrative systematic review (but without seeking an exhaustive inventory of every paper ever published), we considered different research traditions in terms of their respective philosophical assumptions, methodological strengths and limitations and empirical findings. We applied published quality criteria from each tradition to papers within that tradition. RESULTS Three main research approaches were oriented to producing objective data about the therapeutic relationship. These appeared to have emerged in different research traditions: patient satisfaction surveys (health services research), rate-your-relationship surveys (social psychology) and interaction analysis (cognitive psychology). Each emphasised a different dimension and produced a different perspective on quality. CONCLUSIONS Objective metrics, when well designed, offer important insights into the therapeutic relationship, but its elusive essence remains imperfectly captured by the best of them.