A mixed-methods study exploring therapeutic relationships and their association with service user satisfaction in acute psychiatric wards and crisis residential alternatives

Background Service user dissatisfaction with acute psychiatric wards is frequent. Previous studies indicate that service users prefer crisis houses, but we lack clear quantitative evidence about why. Qualitative studies suggest the quality of staff–service user relationships may be key. Aims (1) To test the hypothesis that stronger therapeutic alliances are achieved in crisis houses than in hospital. (2) To develop a model of service user satisfaction with acute services, exploring its relationship to service type, service user characteristics, therapeutic relationships, perceived peer support, recovery and negative events experienced. (3) To understand the factors that impede and facilitate good staff–service user relationships in acute settings. Method Quantitative data were collected from 108 crisis house users and 247 acute ward service users regarding service satisfaction, therapeutic relationships with staff, peer support, self-rated recovery and experience of negative events. Main outcomes were compared for crisis house and ward groups, adjusting for participants’ characteristics. A model of service user satisfaction was derived through multivariable linear regression. Qualitative interviews were conducted with 29 service users and 16 staff recruited from wards and crisis houses. Interviews were largely conducted by service user researchers and covered the characteristics of good staff–service user relationships and factors impeding or facilitating them. Interviews were analysed thematically. Results Participants’ ratings of therapeutic relationships, satisfaction and peer support were higher in crisis houses than acute wards. Therapeutic relationships, perceived peer support and experience of negative events associated with staff behaviour were all independently associated with service user satisfaction; service users’ characteristics and self-rated recovery were not. Service type ceased to be independently related to satisfaction once all these variables were included in a model. Qualitative interviews revealed that the basic human qualities of staff – such as warmth, kindness and honesty – underpin all positive therapeutic relationships. Service users also valued relationships with staff who were interested in and engaged with them, and who were professional but at times able to step beyond professional boundaries to act with compassion and humanity. Service users further identified the importance of time to talk and listen; a focus on recovery and hope; and whether or not staff appeared dedicated to their vocation. Staff participants typically had similar views, but emphasised the importance of having time to talk to service users. Factors identified as helpful in promoting good relationships included maximising freedom and autonomy; a calm and quiet service atmosphere; staff engagement in shared activities with service users; staff availability and presence; and staff morale. Conclusion This study corroborates previous findings of greater satisfaction with crisis houses compared with acute wards. This satisfaction was not closely related to service user characteristics or perceived recovery. The emphasis in interviews on staff personal qualities and willingness to engage in activities and communication suggests that initiatives to enhance effective recruitment and staff training merit further research. Funding The National Institute for Health Research Health Services and Delivery Research programme.