BRIEF REPORT

The Relationship Between Consumer Insight and Provider-Consumer Agreement Regarding Consumer’s Quality of Life

Ilanit Hasson-Ohayon • David Roe •

Shlomo Kravetz • Itamar Levy-Frank •

Taly Meir

Received: 3 July 2009 / Accepted: 3 January 2011 / Published online: 14 January 2011

� Springer Science+Business Media, LLC 2011

Abstract This study examined the relationship between

insight and mental health consumers and providers agree-

ment regarding consumers rated quality of life (QoL).

Seventy mental health consumers and their 23 care pro-

viders filled-out parallel questionnaires designed to mea-

sure consumer QoL. Consumers’ insight was also assessed.

For most QoL domains, agreement between consumers and

providers was higher for persons with high insight. For the

Psychological well being dimension a negative correlation

was uncovered for persons with low insight indicating

disagreement between consumer and provider. These

findings are discussed within the context of the literature on

insight and agreement between consumer and provider as

related to the therapeutic alliance.

Keywords Insight � Quality of life �Severe mental illness � Agreement

Introduction

Past research revealed frequent disagreement between

mental health consumers and providers in a broad range of

areas (Roe et al. 2002), including consumer quality of life

(QoL) (Sainfort et al. 1996; Kravetz et al. 2002; Lasalvia

and Ruggeri 2007). Such disagreement was found to be

related to non adherence and lower satisfaction with

treatment (Mitchel et al. 1983; Perrault et al. 1996). These

findings are consistent with first person accounts of persons

with SMI (Hatfield and Lefley 1993; Deegan 2004, 2005).

The limited agreement between consumers and provid-

ers perspectives on consumers’ QoL is important due to its

putative relevance for the quality of the therapeutic rela-

tionship which is an important component of effective

mental health care (Priebe et al. 2005, 2010; Couture et al.

2006; Lasalvia and Ruggeri 2007). A widely accepted

definition of the therapeutic alliance characterizes it in

terms of three core dimensions: a positive emotional rela-

tionship, agreement with regard to tasks, and consensus

with regard to the goals of therapy (Bordin 1979; Horvath

and Bedi 2002). This conceptualization of the therapeutic

alliance has been the most heuristically rich and influential

model of the effective bond in psychotherapy (Friedlander

et al. 2006). The term therapeutic alliance is also used in

psychiatric rehabilitation to describe the quality of the

relationship between various mental health consumers and

providers (see for example: Tam and Law 2007; Solomon

et al. 1995).

QoL has been used as a framework for formulating

consumer and provider goals in psychiatric rehabilitation

(Coorigan et al. 2008). Thus, agreement between them on

goals and QoL are likely to have a positive impact on the

therapeutic alliance which in turn improves treatment

outcome. Due to the major role that the agreement between

consumer and provider play in treatment, uncovering the

factors that influence this agreement is important.

The present study examined the relation between insight

into illness and consumer and provider agreement as to the

consumer’s QoL. Lack of insight among persons with a

diagnosis of a schizophrenia spectrum disorder has found

to be common with rates ranging between 50 and 80%

(Amador et al. 1991, 1994; Lincoln et al. 2007).

I. Hasson-Ohayon (&) � S. Kravetz � I. Levy-Frank � T. Meir

Department of Psychology, Bar-Ilan University,

52900 Ramat-Gan, Israel

e-mail: hasoni@mail.biu.ac.il

D. Roe

Department of Community Mental Health,

University of Haifa, Haifa, Israel

123

Community Ment Health J (2011) 47:607–612

DOI 10.1007/s10597-011-9380-2

McCabe and Priebe (2004) discussed the importance of

insight as it relates to the agreement between therapist and

client and the therapeutic alliance. Langdon and Ward

(2008) provide evidence for a relation between insight and

the individual’s metacognitive ability to see one’s self as

others perceive her or him. They interpret these findings as

implying that this metacognitive ability may lead to insight

because it contributes to the capacity to reflect upon one’s

own mental health from the perspective of others.

The present study examined whether insight into illness

moderates consumer and provider agreement as to clients

QoL in a number of life domains. On the basis of the above

literature review, it specifically tested the hypothesis that

more agreement will be found for consumers with high

insight than for consumers with low insight.

Method

Research Setting

This study was carried-out in psychiatric rehabilitation

settings located in the community in central Israel. Each

setting employs multi-professional staffs that include social

workers, occupational therapists, psychologists and reha-

bilitation counselors.

Research Participants

Seventy persons diagnosed with a SMI spectrum disorder

participated in this study (age: M = 41.8, SD = 12.73;

number of previous hospitalizations: M = 6.12,

SD = 4.88). Inclusion criteria were fluency in Hebrew and

sufficient competence to provide informed consent. Out of

83 persons that were initially approached and asked to

participate in the study 13 refused or could not provide

informed consent. 87% of the participants were diagnosed

with schizophrenia spectrum disorders while the others had

affective disorders, obsessive compulsive disorders and

severe personality disorders. 47% of the participants lived

in hostels, 77% worked in sheltered work and 71% are

single.

Twenty-three therapists (social workers, occupational

therapists, psychologists, nurses and rehabilitation work-

ers) participated in this study. These providers were

members of the professional staffs of the above mentioned

rehabilitation settings. In general, the providers met their

clients on a weekly basis. Duration of acquaintance with

consumers was less than six months for 57.1% of the

therapists and more than two years for 25.7%. Natures of

acquaintance were personal meetings, group meetings or

engaging in various social activities on a regular basis.

Instruments

QoL was assessed by the Hebrew version (Kravetz et al.

2002) of the Wisconsin Quality of life Questionnaire-

Mental Health (Becker et al. 1993). This questionnaire

consists of 58 self-report items which reflect QoL in

occupational activities, psychological well-being, psychi-

atric symptoms, physical health, social relations, financial

status, and activities of daily living (ADL). Previous

studies showed this scale to be valid and reliable (Becker

et al. 1993; Van Nieuwenhuizen et al. 1997; Kravetz et al.

2002). Cronbach’s alpha in the current study was .64 for

the total score.

Quality of Life-Therapist Questionnaire

The structure of the therapist version of the Wisconsin

Quality of Life parallels that of the client’s version.

Cronbach’s alpha in the current study was .70 for the total

score.

Insight into Serious Mental Illness

Insight was assessed using the Schedule for Assessment of

Insight-Expanded version (SAI-E) (Kemp and David 1995,

1997). This scale is made-up of three dimensions of

insight. These dimensions are awareness of the illness, the

capacity to re-label psychotic experiences as abnormal and

awareness of symptoms, and treatment compliance. Higher

scores on the SAI-E items indicate higher levels of insight.

This scale was found to be valid and reliable (Sanz et al.

1998; Chopra 2004). In the present study, the Cronbach

alpha ranged from .64 to .83 for the different dimensions.

Procedure

After the study was approved by a hospital based ethics

committee, the staffs of the rehabilitation centers agreed to

participate in the study and selected the potential research

participants. All instruments were self report measures and

were administrated individually by the same research

assistant (a psychologist) in one meeting with each

participant.

Statistical Method

Pearson product moment correlations were calculated

between consumer and provider evaluation of the con-

sumer’s QoL for all of the QoL subscales. These correla-

tions were calculated for the total sample of participants

and then for participants with high (median and above) and

low insight (below the median). In addition, one way

MANOVAs were carried out with level of insight [high

608 Community Ment Health J (2011) 47:607–612

123

(median and above) and low insight (below the median)] as

the independent variable and the QoL measures as the

dependent variables.

Results

Pearson product moment correlations between the various

measures of insight and client QoL as reported by the

providers and by the consumers showed that the most

consistent finding is the statistically significant negative

correlations between the awareness of the illness dimen-

sion and six of the seven consumer self reported QoL

domains. Thus, consumer with high insight reported less

QoL and consumer with low insight reported more. How-

ever, for client QoL as reported by the providers, statisti-

cally significant positive correlations appeared between

several measures of insight and a number of the QoL

subscales. When re-labeling was the insight dimension, this

positive correlation appeared with regard to the domain of

symptom QoL. However, when compliance was the insight

dimension, this statistically significant correlation appeared

for six of the seven provider reported QoL domains. Thus,

from the provider’ point of view, consumer with high

insight experienced more QoL than consumer with low

insight, especially when insight was defined as adherence.

In general, few relations were found between consumer

insight and provider ratings of client QoL. Only with

regard to the symptom dimension of QoL were the rela-

tions between QoL and insight negative for the consumer

QoL ratings and positive for the provider QoL ratings.

A MANOVA analysis was used to assess whether sta-

tistically significant differences exist in levels of QoL as

reported by the consumer or by the provider between con-

sumers with high and low insight. The consumers were

divided according to their level of insight by the median

(Md) into high and low insight on four measures of insight;

awareness of illness (Md = 4.00), re-labeling (Md = 5.25),

compliance (Md = 5.00) and total insight score

(Md = 11.00). The four measures of insight were the

independent variables and QoL from the consumer’s point

of view and QoL from the provider’s point of view were the

dependent variables.

The analysis uncovered statistically significant differ-

ences only for QoL, as reported by the consumer, for the

total insight score (F(13,56) = 7.62, P \ .01) and for re-

labeling dimension of insight (F(13,56) = 4.3, P \ .05).

Thus, consumers with low overall insight and low re-

labeling insight reported more QoL (M = 5.07, 5.08

respectfully) than consumers with high overall insight and

high re-labeling insight (M = 4.42, 4.44 respectfully). No

other statistically significant differences were found. Thus,

the MANOVA replicated the tendency of insight into the

illness to correlate negatively with consumer reported QoL.

More pervasive relations between these variables and the

positive relation between insight into the illness and pro-

viders reported QoL were not uncovered by the MANOVA

probably because of the loses of information incurred by

the transformation of a continuous variable to a nominal

variable on the basis of the median.

Pearson product moment correlations between consumer

and provider reports of the consumer’s QoL in each of the

seven QoL domains were calculated for the total sample as

well as separately for consumers with high and low insight

for all four measures of insight (awareness of illness, re-

labeling, compliance, total insight score). From these

analyses it is evident that for the whole consumer sample,

positive correlations between consumers and providers on

QoL were found to be statistically significant only for the

economic and ADL QoL domains and for the total QoL

score. Thus, for five of the seven QoL domains, agreement

was not found between consumers and providers with

regard to consumer QoL. However, when the consumers

were divided according to their level of insight by the

median (high and low), additional statistically significant

correlations were uncovered.

For persons with high insight, significant positive cor-

relations between consumers and providers reports of the

consumer QoL were found for four of the QoL domains

and for the total QoL scale. These correlations emerged for

the ADL domain (for all three insight dimensions and the

total insight score: r = .46–.56), for the occupational

domain (for the awareness of illness insight dimension and

for the compliance insight dimension: r = .31–.33), for the

symptoms (for the total insight score: r = .34), for the

economic domain (for the compliance insight dimension:

.36), and for the total QoL score (for the awareness of

illness dimension, the compliance dimension, and the total

insight score: r = .37–.53). For the ADL and symptom

domains and for the total QoL scores, no correlations

appeared for the consumers with low insight. However, for

the occupational and economic domains, statistically sig-

nificant positive correlations between the consumers and

providers were also found for consumers who were char-

acterized as exhibiting low insight. For the occupational

domain, this correlation was found only for the awareness

of insight dimension whereas (r = .34), for the economic

QoL domain, it was found for the total insight score, re-

labeling and compliance dimensions (r = .28–.35). Statis-

tically significant negative correlations between provider

and consumer reports on QoL were found for the psycho-

logical well-being domain for all three dimensions of

insight (r = -.31 to -.47). Thus, there was a negative

relation between the consumers’ and providers’ reports of

the psychological well-being of persons who exhibit low

insight into their SMI. Apparently, what persons with low

Community Ment Health J (2011) 47:607–612 609

123

insight view as high psychological well-being is viewed by

their providers as low psychological well being.

Discussion

Consistent with past research which revealed discrepancies

between the perceptions of mental health consumers and

providers (Perrault et al. 1996; Roe et al. 2001, 2002;

Sainfort et al. 1996; Kravetz et al. 2002), the current study

found a gap in the evaluation of consumers QoL. For the

total sample of research participants, agreement was found

only for the economic and ADL QoL domains. These

findings suggest that agreement might be more easily

attained in relatively objective QoL domains.

Interestingly, agreement between consumers and pro-

viders was related to consumer’s level of insight. For most

domains of QoL, higher agreement between consumer and

provider was found for consumers with higher levels of

insight than for persons with lower levels of insight. In the

occupation and economy QoL domains, agreement

between consumer and provider was also found for con-

sumers with low insight. In addition, for persons with low

insight, significant disagreement between consumers and

providers was found in the psychological well-being QoL

domain. These correlations in the psychological well-being

QoL domain were the only negative correlations that were

found between the consumers’ and providers’ perceptions

of client QoL.

Accounts of this study’s major finding might differ in

accordance with different explanations regarding the eti-

ology of lack of insight. If lack of insight is attributed to the

illness itself and related to difficulty in monitoring reality,

one would expect that persons with high insight would

better monitor reality and, thus achieve a more accurate

evaluation of their QoL, which, in turn, would be more

likely to be in accord with their clinician’s evaluation.

Support for this explanation stems from research on the

negative association between insight and illness severity

(Cuesta and Peralta 1994; Schwartz 1998) and research

suggesting that lack of insight might interfere with accurate

reports of QoL (Doyle et al. 1999). This explanation,

however, is not supported by our finding that in a number

of QoL domains, consumer–provider agreement was high

among consumers with low insight. This finding may be

better understood when viewing the etiology of lack of

insight as a defense against the stigmatic impact of the

mental illness label. Roe and Kravetz (2003) distinguish

between descriptive and narrative insight and suggested

that persons with SMI may develop coherent accounts of

their mental illness that provide them with meaning in life

and, at the same time, enable them to avoid such conse-

quences of the mental illness label as stigma. This

explanation is consistent with our finding of a correlation

between low insight and agreement in few QoL domains.

According to the above explanation, the coherence of a

person’s illness narrative rather then its specific content

may also facilitate provider empathy with regard to that

client’s QoL. Providers might form better rapport with

clients whose narratives are coherent than with clients

whose narratives lack coherence and invest more in their

work with these clients. This interpretation is consistent

with studies showing that differences between consumer

and provider perceptions of the consumer’s condition and

QoL are negatively related to consumer satisfaction with

treatment (Perrault et al. 1996; Sainfort et al. 1996; Roe

et al. 2001). These differences may be the result of the

provider’s failure to take the client’s perspective into

consideration due to the apparent incoherence of some of

the clients’ narratives.

Viewing clinical psychiatric insight as a narrative that

serves to facilitate effective therapeutic communication as

well as a professional and scientific description of a state of

affairs would be in keeping with narrative approaches to

psychotherapy (Angus and McLeod 2004). It is also in line

with research on narratives of persons with SMI that

showed a positive relation between the coherence of per-

sonal narratives and insight (Lysaker et al. 2002).

The study’s findings, together with previous research,

suggest that agreement between consumers and providers

of care is important but difficult to achieve. This conclu-

sion has a number of important implications. If the dis-

agreement between them is due, in part, to lack of insight

and if lack of insight is a consequence of such cognitive

impairments such as the limited empathic and metacogni-

tive ability to adopt the perspective of others (Langdon and

Ward 2008; Lee 2006), strategies that have been found to

help clients improve this ability (see review Hasson-Oha-

yon et al. 2010) may help clients increase their insight and

improve consumer–provider agreement.

While considering this study’s results one should note

the following limitations. First, both the provider and the

consumer samples were heterogeneous with regard to

consumer diagnoses, provider profession and duration of

relationship between them. Although research suggests that

consumers tend to be consistent in their rating of the

therapeutic alliance at different stages of treatment (Martin

et al. 2000), it might be that the relatively low duration of

relationship and that few of these relationship included

tutor or social guide influence agreement. Second, this

study is cross sectional and results varied depended on QoL

specific domains. Finally, future research that will address

these limitations and will include a narrative evaluation of

insight might have contributed to the clarification of the

complex manner in which insight and consumer–provider

agreement affect each other.

610 Community Ment Health J (2011) 47:607–612

123

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