A new scale to assess the therapeutic relationship in community mental health care: STAR

Background. No instrument has been developed specifically for assessing the clinician-patient therapeutic relationship (TR) in community psychiatry. This study aimed to develop a measure of the TR with clinician and patient versions using psychometric principles for test construction. Method. A four-stage prospective study was undertaken, comprising qualitative semi-structured interviews about TRs with clinicians and patients and their assessment of nine established scales for their applicability to community care, administering an amalgamated scale of more than 100 items, followed by Principal Components Analysis (PCA) of these ratings for preliminary scale construction. test-retest reliability of the scale and administering the scale in a new sample to confirm its factorial structure. The sample consisted of patients with severe mental illness and a designated key worker in the care of 17 community mental health teams in England and Sweden. Results. New items not covered by established scales were identified, including clinician helpfulness in accessing services, patient aggression and family interference. The new patient (STAR-P) and clinician scales (STAR-C) each have 12 items comprising three subscales: positive collaboration and positive clinician input in both versions, non-supportive clinician input in the patient version, and emotional difficulties in the clinician version. Test-retest reliability was r = 0(.)76 for STAR-P and r = 0(.)68 for STAR-C. The factorial structure of the new scale was confirmed with a good fit. Conclusions. STAR is a specifically developed, brief scale to assess TRs in community psychiatry with good psychometric properties and is suitable for use in research and routine care

Attachment Aware Schools

‘Attachment Aware Schools’ is a collaborative program of support which is promoting public understanding of the underlying causes of children’s behavior, stimulating political debate about inclusive educational provision and is helping to transform professional practice within schools and community settings. The program hinges upon attachment theory and attachment-based strategies for supporting children’s social and emotional development. This paper documents the positive impact of pilot programs within the UK on national policy and in developing sustainable improvements in systemic school-wide practices relating to children’s behavior and well-being. It illustrates collaborative research evidence between practitioners and academics, generating civic participation and engagement, which has also informed policy directives within national and local government, and public and private sector organisations

Attachment Aware Schools:Working with Families to Enhance Parental Engagement and Home-School Relationships

Background:- Application of attachment theory in school contexts lacks empirical evidence. The Attachment Aware Schools pilot project was commissioned by two Local Authorities in England to improve the educational outcomes of Looked After Children, and to build an evidence base. Informed by attachment research, Attachment Aware Schools programs provide a coherent and integrated theoretical framework, discourse, and practice for all practitioners working with children and young people. Objective:- The primary focus was to provide whole school and targeted attachment-based strategies to support children’s well-being, behaviour, and academic attainment. This paper; however, documents a secondary objective, which was to facilitate collaborative partnerships with families. Method:- As part of the mixed methods approach to the Attachment Aware Schools project, a series of case studies were collected and thematically coded. The case studies were generated by practitioners using an outcomes-based framework. Results:- Although the case study sample size is small (N=10), the case studies presented here illustrate how Attachment Aware Schools programs can promote increased home-school engagement and shared practice between home and school. Outcomes include improved home-school relationships, reductions in behavioral incidents, and improved family dynamics. Conclusion:- Attachment Aware Schools can be a vehicle for facilitating supportive home-school collaborative partnerships with positive outcomes for vulnerable children and young people

Attachment Aware Schools: the impact of a targeted and collaborative intervention

The Attachment Aware Schools (AAS) project was a targeted and collaborative intervention between academics and school-based practitioners. The aim of the project was to promote practitioner awareness of attachment in relation to child behaviours and learning. It focused on using relational-based strategies and interventions to address the needs of children and young people. The AAS framework promoted Emotion Coaching as a universal, relational-based practice approach, with specialised targeted support for children with additional needs. Supportive managerial strategies and setting policies sustained the integration and maintenance of attachment-informed practice and school ethos. This article reports the findings from the project which included over 200 participants (107 teaching and support staff and 94 pupils aged 5 to 16 years), from 40 schools, in two different Local Authorities within the UK. Adopting a mixed methods approach, qualitative and quantitative data provided hard and soft indicators of improved pupil and adult outcomes. Findings demonstrated significant improvements in pupils’ academic achievement in reading, writing and maths. There were significant decreases in sanctions, exclusions and overall difficulties. Practitioners reported a positive impact on professional practice, adult self-regulation and emotional self-control, and were more confident when talking with children about emotions. This project contributes to the growing evidence based on the effectiveness of whole school attachment-based strategies and is already demonstrating policy implications at a national level

Differences between placement and non-placement students: a mixed methods approach

While there is much research to suggest the benefits of placements to the graduate destinations of students in higher education (Lowden et al., 2012; Pegg et al., 2012) there is little literature on the possible differences between students who choose to go on placements compared to those who do not. To this end, a mixed-methods approach was taken to explore these possible differences. Quantitative data included self-reported findings on the Aspiration Scale (O'Brien and Hepner, 1996), Employability skills (Reddy and Moores, 2006), Hope Trait Scale (Snyder et al., 1991) and Self-Perceived Employability Scale (Rothwell et al., 2009). Quantitative data focusing on the differences between placement and non-placement students on said scales were supplemented by qualitative data based on two unstructured focus groups. The qualitative data suggest differences in confidence (placement self-efficacy) and guilt (taking limited placement resources) that might impact on the decision or likelihood of applying for placement. Questions over primary responsibility for securing placements (the individual or the institution) were raised. Implications regarding the heterogeneity of students (especially mature students) were identified suggesting that a 'one size fits all' approach to placements is unlikely to be fruitful

Miscommunication in Doctor-Patient Communication

The effectiveness of medical treatment depends on the quality of the patient–clinician relationship. It has been proposed that this depends on the extent to which the patient and clinician build a shared understanding of illness and treatment. Here, we use the tools of conversation analysis (CA) to explore this idea in the context of psychiatric consultations. The CA “repair” framework provides an analysis of the processes people use to deal with problems in speaking, hearing, and understanding. These problems are especially critical in the treatment of psychosis where patients and health care professionals need to communicate about the disputed meaning of hallucinations and delusion. Patients do not feel understood, they are frequently non‐adherent with treatment, and many have poor outcomes. We present an overview of two studies focusing on the role of repair as a mechanism for producing and clarifying meaning in psychiatrist–patient communication and its association with treatment outcomes. The first study shows patient clarification or repair of psychiatrists’ talk is associated with better patient adherence to treatment. The second study shows that training which emphasizes the importance of building an understanding of patients’ psychotic experiences increases psychiatrists’ self‐repair. We propose that psychiatrists are working harder to make their talk understandable and acceptable to the patient by taking the patient's perspective into account. We conclude that these findings provide evidence that repair is an important mechanism for building shared understanding in doctor–patient communication and contributes to better therapeutic relationships and treatment adherence. The conversation analytic account of repair is currently the most sophisticated empirical model for analyzing how people construct shared meaning and understanding. Repair appears to reflect greater commitment to and engagement in communication and improve both the quality and outcomes of communication. Reducing potential miscommunication between psychiatrists and their patients with psychosis is a low‐cost means of enhancing treatment from both the psychiatrist and patient perspective. Given that misunderstanding and miscommunication are particularly problematic in psychosis, this is critical for improving the longer term outcomes of treatment for these patients who often have poor relationships with psychiatrists and health care services more widely

Skills use and common treatment processes in dialectical behaviour therapy for borderline personality disorder

Background and Objectives Dialectical behaviour therapy (DBT) trains participants to use behavioural skills for managing their emotions. The study aimed to evaluate whether skills use is associated with positive treatment outcomes independently of treatment processes that are common across different therapeutic models. Method Use of the DBT skills and three common treatment processes (therapeutic alliance, treatment credibility and self-efficacy) were assessed every 2 months for a year in 70 individuals with borderline personality disorder receiving DBT. Mixed-multilevel modelling was used to determine the association of these factors with frequency of self-harm and with treatment dropout. Results Participants who used the skills less often at any timepoint were more likely to drop out of DBT in the subsequent two months, independently of their self-efficacy, therapeutic alliance or perceived treatment credibility. More frequent use of the DBT skills and higher self-efficacy were each independently associated with less frequent concurrent self-harm. Treatment credibility and the alliance were not independently associated with self-harm or treatment dropout. Limitations The skills use measure could not be applied to a control group who did not receive DBT. The sample size was insufficient for structural equation modelling. Conclusion Practising the DBT skills and building an increased sense of self-efficacy may be important and partially independent treatment processes in dialectical behaviour therapy. However, the direction of the association between these variables and self-harm requires further evaluation

Effectiveness of structured patient-clinician communication with a solution focused approach (DIALOG+) in community treatment of patients with psychosis - a cluster randomised controlled trial

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Service user involvement in the coproduction of a mental health nursing metric : The Therapeutic Engagement Questionnaire

Service users’ involvement in mental health service research is increasingly acknowledged as important, yet, whilst involving users of mental health services as research participants is commonplace, seeking out their experience and indeed their “expertise” to facilitate the development of tools to be used within mental health services is in its infancy. This article describes the involvement and views of service users in the development of a nursing metric—the Therapeutic Engagement Questionnaire. It presents their role in the three stages of development: generation, statement reduction and authentication

The Relationship between Therapeutic Alliance and Service User Satisfaction in Mental Health Inpatient Wards and Crisis House Alternatives: A Cross-Sectional Study

Background Poor service user experiences are often reported on mental health inpatient wards. Crisis houses are an alternative, but evidence is limited. This paper investigates therapeutic alliances in acute wards and crisis houses, exploring how far stronger therapeutic alliance may underlie greater client satisfaction in crisis houses. Methods and Findings Mixed methods were used. In the quantitative component, 108 crisis house and 247 acute ward service users responded to measures of satisfaction, therapeutic relationships, informal peer support, recovery and negative events experienced during the admission. Linear regressions were conducted to estimate the association between service setting and measures, and to model the factors associated with satisfaction. Qualitative interviews exploring therapeutic alliances were conducted with service users and staff in each setting and analysed thematically. Results We found that therapeutic alliances, service user satisfaction and informal peer support were greater in crisis houses than on acute wards, whilst self-rated recovery and numbers of negative events were lower. Adjusted multivariable analyses suggest that therapeutic relationships, informal peer support and negative experiences related to staff may be important factors in accounting for greater satisfaction in crisis houses. Qualitative results suggest factors that influence therapeutic alliances include service user perceptions of basic human qualities such as kindness and empathy in staff and, at service level, the extent of loss of liberty and autonomy. Conclusions and Implications We found that service users experience better therapeutic relationships and higher satisfaction in crisis houses compared to acute wards, although we cannot exclude the possibility that differences in service user characteristics contribute to this. This finding provides some support for the expansion of crisis house provision. Further research is needed to investigate why acute ward service users experience a lack of compassion and humanity from ward staff and how this could be changed