2013. Vol.4, No.6A1, 45-49
Published Online June 2013 in SciRes (
Copyright © 2013 SciRes. 45
Is Interpersonal Fairness in the Doctor-Patient Relationship
Associated with Long-Term Compliance in
Patients with Schizophrenia?*
Eva Jonas1, Guenter W. Maier2, Werner Kissling3, Johannes Hamann3
1Department of Psychology, University of Salzburg, Salzburg, Austria
2Department of Psychology, Bielefeld University, Bielefeld, Germany
3Psychiatric Department, Technical University Munich, Munich, Germany
Received March 28th, 2013; revised April 29th, 2013; accepted May 26th, 2013
Copyright © 2013 Eva Jonas et al. This is an open access article distributed under the Creative Commons Attri-
bution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the
original work is properly cited.
Does an interpersonal fair treatment of patients with schizophrenia by their hospital psychiatrists improve
patients’ intentions to take the antipsychotic medicine when leaving the hospital, long-term compliance
and the perceived quality of medical treatment? 71 acutely ill in-patients with a diagnosis of schizophre-
nia and their doctors were included in this study. At hospital discharge patients received a questionnaire
measuring their interpersonal fairness perceptions, the perceived quality of medical treatment, and inten-
tion to take the medicine. After 6 month we also measured patients’ long-term compliance. Data were
analyzed by correlational analyses and path model. The results indicated that interpersonal fairness in-
creased patients’ long-term compliance, which was mediated by the intention to take the medicine when
leaving the hospital and the perceived quality of medical attendance. Thus, without consuming more time,
an interpersonal fair treatment of patients by their doctors seems to have beneficial effects on patients’
perceived quality of medical care and long-term compliance. Theoretical and practical implications of the
results are briefly discussed.
Keywords: Interpersonal Fairness; Schizophrenia; Therapeutic Relationship; Adherence; Compliance;
Psychiatric patients see the therapeutic relationship as the
most valuable part of satisfactory psychiatric care (Johansson &
Eklund, 2003). Even more importantly, individuals who view
their treatment and the therapeutic relationship more positively
are more likely to have better treatment results, which include
less severe symptoms, a lower rate of rehospitalization, and
higher quality of life, as well as better social functioning (e.g.,
Frank & Gunderson, 1990; Hewitt & Coffey, 2005; Priebe &
Gruyters, 1995). Thus, a superior therapeutic relationship seems
to cause patients to be more accepting of their treatment, which
then positively influences the overall outcome (Chue, 2006).
This is especially the case for patients with schizophrenia (Kik-
kert et al., 2006; Misdrahi, Verdoux, Lancon, & Bayle, 2009;
Misdrahi, Petit, Blanc, Bayle, & Llorca, 2012).
Despite the importance attributed to the therapeutic alliance
there is relatively little knowledge as to what actually consti-
tutes good therapeutic alliance or to how psychiatrists should
communicate with their patients (McCabe & Priebe, 2008).
Recent research has emphasized on procedural fairness that
is, how fair do patients perceive the procedures undertaken?
Here, most notably the issues of coercion and hospital admis-
sion (e.g., Day et al., 2005; Galon & Wineman, 2010; Jaeger &
Rossler, 2010; Lidz et al., 1998) and of shared decision making
(e.g., Hamann, Leucht, & Kissling, 2003) have been investi-
gated. Surprisingly little attention has been paid to interpersonal
fairness, that is, whether patients feel treated with respect, po-
liteness and dignity.
The Concept of Interpersonal Fairness
Research from different areas in psychology shows that fair-
ness in various situations in daily professional and private life
affects a wide range of human emotion, attitude and behavior.
For example in organizational psychology research differenti-
ates between four aspects of fairness: distributive (how fair are
resources distributed?), procedural (how fair are the used pro-
cedures?), informational (is the provision of information ade-
quate?) and interpersonal fairness (Colquitt, Conlon, Wesson,
Porter, & Ng, 2001). Interpersonal fairness (Greenberg, 1993)
refers to the interpersonal treatment in an organization, typi-
cally by the supervisor, for example do people feel they are
treated with respect and propriety? Interpersonal fairness posi-
tively influences psychological outcomes such as evaluation of
*Financal Discolsure: Dr. Hamann has received honoraria and/or research
support from Janssen-Cilag, Eli Lilly, Astra Zeneca, and Otsuka. Dr.
Kissling has received honoraria from Janssen-Cilag, San-ofi-Aventis,
Johnson & Johnson, Pfizer, Bristol-Myers Squibb, AstraZeneca, Lundbeck,
ovartis, and Eli Lilly.
an authority, job satisfaction, well-being, affective commitment
toward the company and organizational citizenship behavior
(Colquitt et al., 2001). Interpersonal fairness and the quality of
the relationship between supervisors and subordinates are
strongly related (Roch & Shanock, 2006).
In psychiatric research fairness is also an important topic, al-
though the focus has been more on procedural justice. Several
studies, especially in the context of civil commitment hearings1
suggest that the procedural fairness patients perceive is a major
issue in the context of psychiatric treatment. For example, it
was found that patients who thought their point of view had
been heard and taken into consideration (Susman, 1994), that is,
who experienced procedural justice, rated the process as more
fair than patients who did not feel like they had been heard
sufficiently or taken seriously. Procedural fairness and the rat-
ings of outcome fairness were also strongly related.
Yet, interpersonal fairness has also been shown to be impor-
tant in the context of civil commitment hearings. To many pa-
tients testifying psychiatrists, state attorneys, and judges ap-
peared to be disrespectful, untrusting and disinterested (Greer,
O’Regan, & Traverso, 1996). In addition, the testimony of the
psychiatrist often discloses private information concerning the
details of the patients’ illness, which leads to embarrassment on
the side of the patient. Along with Tyler we suggest that coop-
eration can be improved by the way mentally ill persons view
their participation, the treatment of their dignity, and trust dur-
ing such hearings (Tyler, 1992). The respectful and dignified
treatment of respondents by legal authorities during hearings, as
well as a chance at stating their case (i.e., voice), may cause
patients to be more agreeable to the notion of involuntary com-
mitment. This may then lead to a domino effect, as this kind of
acceptance may increase their participation within the therapeu-
tic environment and, ultimately, incidents of aggressive behav-
ior that necessitate seclusion and restraints may even decrease
(Cascardi, Poythress, & Hall, 2000).
Yet, with regard to the perceived fairness during psychiatric
hospital admissions the picture may be different. In one study it
was, for example, found that 80% of participants were treated
with “fairness” in the admission process-whereby the volun-
tary sample perceived having been treated significantly more
fairly than the involuntary sample (McKenna, Simpson, Cover-
dake, & Laidlaw, 2001). Does this render fairness to be a less
important topic when looking at the stay in the hospital? We
think not. There is evidence that procedural justice can signifi-
cantly lessen the perception of coercion during hospital admis-
sion (Galon & Wineman, 2010). However, what about inter-
personal fairness regarding the doctor’s behavior? Building on
the research reported above on the findings of interpersonal
fairness in organizations we predict that interpersonal fairness
in the doctor-patient relationship also positively affects the
patients’ attitude towards their medication and compliance be-
havior. However, what does this mean in specific? Can doctors
influence the patients’ compliance by just being polite, respect-
ful and considerate of the patients’ dignity?
Interpersonal fairness is part of the doctor’s conduct toward
the patient but the crucial point is how fair the doctor’s conduct
is subjectively perceived by the patient. We propose that the
perception of fairness increases the patients’ motivation to take
their medicine after they have left the hospital because the per-
ception of fairness should increase the patients’ perception of
quality of the medical treatment and their intention (to take the
medication), which has been shown to be an immediate antici-
pant of behavior (Ajzen, 1991); both of which should then in-
crease the patients’ long-term compliance to follow the recom-
mended treatment.
Finally, one might ask whether interpersonal fair treatment is
doable. Do doctors have sufficient time for a fair treatment of
their patients-considering the high workload of doctors in the
German health system? Yet, does it actually take longer to treat
patients with interpersonal fairness?
It was the aim of the present analysis to test the hypothesis
that an interpersonal fair treatment of patients with schizophre-
nia increases patients’ long-term compliance. In addition we
investigated whether this effect was mediated by patients’ in-
tention to take the recommended medicine when leaving the
hospital and their perception of the quality of medical treatment.
Finally, we tested whether it actually took longer to treat pa-
tients with interpersonal fairness.
Seventy one acutely ill in-patients (37 [52.1%] women, 34
[47.9%] men) with a diagnosis of schizophrenia and their doc-
tors were included in this study.
The study took place from February 2003 to January 2004 in
two psychiatric state hospitals in Germany. The data collection
was embedded in a larger interventional study on a shared deci-
sion making program on antipsychotic drug choice (Hamann et
al., 2006; Hamann, Cohen, Leucht, Busch, & Kissling, 2007).
For the present analysis we used all patients with complete data
irrespectively to their allocation (intervention/control group) in
the original trial.
On average, the participants were 37.7 years old (SD = 11.4,
range: 21 - 64 years), they had been ill for 9.6 years (SD =
9.17), had been hospitalized with schizophrenia for 4 times (SD
= 5) (including the present stay), 22 (31%) had been treated
because of compulsory admission, and they had stayed on av-
erage for 14 days (SD = 9) on the ward when the study began
and for 33 days (SD = 28) when they were discharged. The
following measures were applied before hospital discharge:
Interpersonal fairness. As the independent variable, three items
adapted from the scale interpersonal justice of the German ver-
sion of organizational justice scales (Maier, Streicher, Jonas &
Woschée, 2007) were used (i.e., To what extent has the physi-
cian treated you 1) in a polite manner, 2) with dignity, 3) with
respect). The items were measured with scales ranging from 1
(not at all) to 5 (absolutely), Cronbach’s alpha = .83.
Dependent variables. At the time of discharge from hospital
(time 1), patients were asked to complete the following scales:
1) A self-report measure of the patients’ intention to take their
medication, which consisted of four self-constructed items with
scales ranging from 1 (totally disagree) to 5 (totally agree)
(Items: I am firmly committed to take the medication. I will
continue to take the medication in any case. I can well imagine
to autonomously stop the mediation one day (inverted). I will
surely never autonomously stop the medication), Cronbach’s
alpha = .70;
1In civil commitment hearings a decision is made regarding whether or not
a person who is mentally ill and who might be a danger to him/herself or
others and/or who might be unable to care for him/herself without the help
of another person needs an involuntary psychiatric hospitalization.
2) Perceived quality of treatment, which was assessed with 8
items (e.g., How would you judge the quality of treatment you
received?), on scales ranging from 1 (low quality) to 4 (high
Copyright © 2013 SciRes.
Copyright © 2013 SciRes. 47
criteria suggested by Baron and Kenny (1986). The correlations
between interpersonal fairness and each of the two mediators
(intention to take the medication and quality of treatment) were
significant. Furthermore, the correlation between the mediator
and the criteria follow-up compliance with medication was
significant with regard to intention to take the medication and
marginal when it comes to quality of treatment. Thus, the re-
quirements for a mediation effect were met. In order to test the
indirect effect, we conducted a path model using MPlus 4.2. As
the criterion was binary, parameters were estimated by the
WLSMV method (weighted least squares with robust standard
errors, mean and variances adjusted).
quality), Cronbach’s alpha = .90 (Langewitz, Keller, Denz,
Wossmer-Buntschu, & Kiss, 1995). In addition, we asked the
physicians how time intensive the therapeutical care of this pa-
tient was compared to others (1 = much below average to 5 =
much above average).
At the 6-months follow up the following data were obtained:
As an indicator of long-term compliance with medication 6
months after discharge, a rating was used based on 1) patients’
self report (MARS Scale) (Thompson, Kulkarni, & Sergejew,
2000), 2) ratings from the outpatient psychiatrists of compli-
ance of their patients on a 4-point scale raging from “poor com-
pliance” to “very good compliance”, and 3) physicians were
also asked to make unannounced measures of plasma levels of
the prescribed anti-psychotics from the patients 6 months after
discharge (to which patients had signed informed consent dur-
ing the index hospitalization). For the 6-month follow-up there
were n = 22 plasma levels available. Overall compliance was
considered “good” (high compliance rated as 1) if patient and
physician agreed in their (positive) estimates. In all other cases
(incongruence of ratings, both rating poor compliance) compli-
ance was rated as “poor” (low compliance rated as 0). Results
were corrected in the direction towards the results of the plasma
level evaluation if plasma levels indicated compliance or non-
compliance different from that derived from self-rating/physi-
cians’ rating (in n = 2 cases). The study was approved by the
ethics committee of the Technical University Munich.
The correlation analysis showed the more interpersonally fair
the patients judged the behavior of their doctor, the stronger
their self-reported intention to take the medication when leav-
ing the hospital, r = .41, p < .001, the higher patients’ percep-
tion of the quality of the treatment they had received in the
hospital, r = .44, p < .001, and the stronger their long-term
compliance, r = .27, p < .03. Moreover, quality of treatment
was also positively associated with the intention to take the me-
dication, r = .46, p < .001 and long-term compliance, r = .23, p
< .06. Finally, also intention to take the medication was corre-
lated with long-term compliance, r = .41, p < .001.
The indirect effect of interpersonal fairness on the follow-up
rating of compliance mediated by self-reported intention to take
the medication at discharge from hospital was .21, p < .01. The
indirect effect of interpersonal fairness on the follow-up rating
of compliance mediated by quality of treatment at discharge
from hospital was .09, p < .10 (Figure 1).
Finally, with regard to time intenseness correlation analyses
showed that it did not take the doctors longer to treat their pa-
The descriptive statistics and correlations are displayed in
Table 1. We tested our mediation hypotheses following the
Table 1.
Means, standard deviations, reliabilities and intercorrelations of study variables.
Variable M SD 1 2 3 4
1 Interpersonal fairness 4.45 .62 (.83)
2 Quality of the treatment 3.14 .59 .44*** (.90)
3 Intention to take the medication 4.15 .94 .41*** .46*** (.70)
4 Long-term compliance .46 .50 .27* .23+ .41***
5 Time intensenessa 3.29 .62 .10 .01 .11 .02
Note: N = 71. aN = 69 because of missing data. Values in parentheses along the diagonal indicate reliability estimates (Cronbach’s Alpha). ***p < .001; **p < .01; *p = < .05; +p
< .06 (two-tailed).
intention to take medication
interpersonal fairness long-term compliance
quality of treatment
Figure 1.
Pathmodel with standardized coefficients. ***p < .001; +p < .09.
tients fairly, r = .10, p > .40; patients did not perceive the qual-
ity of treatment to be higher when they had spent more time
with their doctor, r = .01, p > .90, nor did their intention to
take the medication, r = .11, p > .35, or their long-term compli-
ance r = .02, p > .85 depend on the time the doctors spent for
the treatment.
The results supported our hypotheses: Interpersonal fairness
was shown to increase patients’ long-term compliance with
medication, which was mediated by their intention to take the
medication when leaving the hospital and the perceived quality
of treatment in the hospital. Moreover, a fairer treatment was
not associated with the length of interaction the doctor had with
the patients.
We think these results have important implications. There is
a body of literature on patient compliance in schizophrenia
treatment (e.g., Fenton, Blyler, & Heinssen, 1997) suggesting
that compliance is a complex issue. Elaborate interventions to
improve compliance have been developed and have proven
their efficacy (e.g., Velligan et al., 2010). However, our evi-
dence also suggests that the simple fact whether a patient feels
treated in a polite manner might make a difference when it
comes to acceptance of and adherence with medication. As
research by Hamann et al. (2011) suggests the stronger partici-
pants’ perception of fairness the less important it seems to them
to be involved in participating in the medical decision process.
And in fact, our results even showed that there is an association
between interpersonal fairness and long-term compliance. This
association is mediated by patients’ intention at discharge whe-
ther they want to pursue with their medication or not, which
was positively influenced by the perception of interpersonal
fairness regarding their doctor’s behavior.
With regard to theoretical implications the therapeutic rela-
tionship has been proven to be crucial for achieving good
treatment results (e.g., Chue, 2006; Frank & Gunderson, 1990;
Hewitt & Coffey, 2005; Priebe & Gruyters, 1995). However,
what constitutes a good therapeutic relationship and which
theoretical concepts help to understand the therapeutic rela-
tionship? Our research suggests that the perception of interper-
sonal fairness might play an especially important role in con-
stituting a good therapeutic relationship. Further research is
needed to better understand how the concept of interpersonal
fairness is related to other aspects constituting a good therapeu-
tic relationship and which aspect is crucial in achieving long-
term compliance among patients.
Our findings also have important practical implications. First,
physicians as well as other staff members must be aware that
despite the complexity of a hospital stay and despite the proven
efficacy of other therapeutic strategies patients appear to be
strongly influenced by a seemingly small variable—how staff
talks to them. Thus, the awareness of psychiatrists that they
offer a service to patients and that client satisfaction is one ma-
jor goal of service provision should be adopted more thor-
oughly in clinical practice. Probably this issue is often ne-
glected under time pressure but it is important to keep in mind
that interpersonal fairness (e.g. to apologize for a delay, to ac-
cept complaints) is necessary and influences long-term out-
comes. As shown, interpersonal fairness is also doable since it
did not cost the psychiatrists in our study more time. Second,
obviously the quality of long-term compliance is in part already
certain at the time of discharge, showing the necessity to pick
up the issue of compliance in therapeutic communication al-
ready during hospital stay.
The significance of our results is limited since we undertook
a post hoc analysis. In addition psychiatrists behavior with re-
gard to interpersonal fairness was not manipulated which also
limits our ability to draw causal conclusions.
An interpersonally fair treatment of patients by their doctors
seems to be very beneficial. Without consuming more time of
interaction it increases the perceived quality of medical treat-
ment and also improves long-term compliance and is thus ex-
pected to reduce re-hospitalizations.
The authors would like to thank all participating patients and
physicians. The trial was funded by the German Ministry of
Health and Social Security (217-43794-5/9) within the funding
project “Der Patient als Partner im medizinischen Entschei-
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