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: 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

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

This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited

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

Needs-oriented discharge planning and monitoring for high utilisers of psychiatric services (NODPAM): Design and methods

<p>Abstract</p> <p>Background</p> <p>Attempts to reduce high utilisation of psychiatric inpatient care by targeting the critical time of hospital discharge have been rare.</p> <p>Methods</p> <p>This paper presents design and methods of the study "Effectiveness and Cost-Effectiveness of Needs-Oriented Discharge Planning and Monitoring for High Utilisers of Psychiatric Services" (NODPAM), a multicentre RCT conducted in five psychiatric hospitals in Germany. Inclusion criteria are receipt of inpatient psychiatric care, adult age, diagnosis of schizophrenia or affective disorder, defined high utilisation of psychiatric care during two years prior to the current admission, and given informed consent. Consecutive recruitment started in April 2006. Since then, during a period of 18 months, comprehensive outcome data of 490 participants is being collected at baseline and during three follow-up measurement points.</p> <p>The manualised intervention applies principles of needs-led care and focuses on the inpatient-outpatient transition. A trained intervention worker provides two intervention sessions: (a) Discharge planning: Just before discharge with the patient and responsible clinician at the inpatient service; (b) Monitoring: Three months after discharge with the patient and outpatient clinician. A written treatment plan is signed by all participants after each session.</p> <p>Primary endpoints are whether participants in the intervention group will show fewer hospital days and readmissions to hospital. Secondary endpoints are better compliance with aftercare, better clinical outcome and quality of life, as well as cost-effectiveness and cost-utility.</p> <p>Discussion</p> <p>If a needs-oriented discharge planning and monitoring proves to be successful in this RCT, a tool will be at hand to improve patient outcome and reduce costs via harmonising fragmented mental health service provision.</p> <p>Trial Registration</p> <p>ISRCTN59603527</p

Study protocol: cross-national comparative case study of recovery-focused mental health care planning and coordination (COCAPP).

BACKGROUND: The collaborative care planning study (COCAPP) is a cross-national comparative study of care planning and coordination in community mental healthcare settings. The context and delivery of mental health care is diverging between the countries of England and Wales whilst retaining points of common interest, hence providing a rich geographical comparison for research. Across England the key vehicle for the provision of recovery-focused, personalised, collaborative mental health care is the care programme approach (CPA). The CPA is a form of case management introduced in England in 1991, then revised in 2008. In Wales the CPA was introduced in 2003 but has now been superseded by The Mental Health (Care Co-ordination and Care and Treatment Planning) (CTP) Regulations (Mental Health Measure), a new statutory framework. In both countries, the CPA/CTP requires providers to: comprehensively assess health/social care needs and risks; develop a written care plan (which may incorporate risk assessments, crisis and contingency plans, advanced directives, relapse prevention plans, etc.) in collaboration with the service user and carer(s); allocate a care coordinator; and regularly review care. The overarching aim of this study is to identify and describe the factors that ensure CPA/CTP care planning and coordination is personalised, recovery-focused and conducted collaboratively. METHODS/DESIGN: COCAPP will employ a concurrent transformative mixed methods approach with embedded case studies. Phase 1 (Macro-level) will consider the national context through a meta-narrative mapping (MNM) review of national policies and the relevant research literature. Phase 2 (Meso-level and Micro-level) will include in-depth micro-level case studies of everyday 'frontline' practice and experience with detailed qualitative data from interviews and reviews of individual care plans. This will be nested within larger meso-level survey datasets, senior-level interviews and policy reviews in order to provide potential explanations and understanding. DISCUSSION: COCAPP will help identify the key components that support and hinder the provision of personalised, recovery-focused care planning and provide an informed rationale for a future planned intervention and evaluation

A mixed-methods feasibility study of a novel AI-enabled, web-based, clinical decision support system for the treatment of major depression in adults

Background:- The objective of this paper is to discuss perceived clinical utility and impact on physician-patient relationship of a novel, artificial-intelligence (AI) enabled clinical decision support system (CDSS) for use in treating adults with major depression. Methods:- A single arm, naturalistic follow-up study aimed at assessing the acceptability and useability of the software. Patients had a baseline appointment, followed by a minimum of two appointments with the CDSS. Study exit questionnaires and interviews were conducted to assess perceived clinical utility, impact on patient-physician relationship, and understanding and trust. 7 physicians and 17 patients, of which 14 completed, consented to participate. Results:- 86 % of physicians (6/7) felt the information provided by the CDSS provided more comprehensive understanding of patient situations. 71 % (5/7) felt the information was helpful. 86 % of physicians (6/7) reported the AI/predictive model was useful when deciding treatment. 62 % of patients (8/13) reported improved care due to the tool, and 46 %(6/13) reported a significantly or somewhat improved physician-patient relationship 54 % reported no change. 71 % of physicians (5/7) and 62 % of patients (8/13) rated trusting the tool. Limitations:- Small sample size and treatment changes prior to CDSS introduction limits ability to verify impact on outcomes. Conclusions:- Qualitative results from 12 patient exit interviews are analyzed and presented. Findings suggest physicians perceived the tool as useful in conducting appointments and used it while deciding treatment. Physicians and patients generally found the tool trustworthy, and it may have positive effects on physician-patient relationships. (Study identifier: NCT04061642)

Evaluating the clinical feasibility of an artificial intelligence–powered, web-based clinical decision support system for the treatment of depression in adults: longitudinal feasibility study

Background:- Approximately two-thirds of patients with major depressive disorder do not achieve remission during their first treatment. There has been increasing interest in the use of digital, artificial intelligence–powered clinical decision support systems (CDSSs) to assist physicians in their treatment selection and management, improving the personalization and use of best practices such as measurement-based care. Previous literature shows that for digital mental health tools to be successful, the tool must be easy for patients and physicians to use and feasible within existing clinical workflows. Objective:- This study aims to examine the feasibility of an artificial intelligence–powered CDSS, which combines the operationalized 2016 Canadian Network for Mood and Anxiety Treatments guidelines with a neural network–based individualized treatment remission prediction. Methods:- Owing to the COVID-19 pandemic, the study was adapted to be completed entirely remotely. A total of 7 physicians recruited outpatients diagnosed with major depressive disorder according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition criteria. Patients completed a minimum of one visit without the CDSS (baseline) and 2 subsequent visits where the CDSS was used by the physician (visits 1 and 2). The primary outcome of interest was change in appointment length after the introduction of the CDSS as a proxy for feasibility. Feasibility and acceptability data were collected through self-report questionnaires and semistructured interviews. Results:- Data were collected between January and November 2020. A total of 17 patients were enrolled in the study; of the 17 patients, 14 (82%) completed the study. There was no significant difference in appointment length between visits (introduction of the tool did not increase appointment length; F2,24=0.805; mean squared error 58.08; P=.46). In total, 92% (12/13) of patients and 71% (5/7) of physicians felt that the tool was easy to use; 62% (8/13) of patients and 71% (5/7) of physicians rated that they trusted the CDSS. Of the 13 patients, 6 (46%) felt that the patient-clinician relationship significantly or somewhat improved, whereas 7 (54%) felt that it did not change. Conclusions:- Our findings confirm that the integration of the tool does not significantly increase appointment length and suggest that the CDSS is easy to use and may have positive effects on the patient-physician relationship for some patients. The CDSS is feasible and ready for effectiveness studies