title: The relationship between therapeutic alliance and service user satisfaction in mental health inpatient wards and crisis house alternatives: a cross-sectional study.
abstract: 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.
  
  
  RESULTS
  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
  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.
authors.affiliation: Division of Psychiatry, UCL, London, United Kingdom.
authors.forename: Angela
authors.initials: A
authors.lastname: Sweeney
authors.affiliation: Division of Psychiatry, UCL, London, United Kingdom.
authors.forename: Sarah
authors.initials: S
authors.lastname: Fahmy
authors.affiliation: Centre for Outcomes Research and Effectiveness (CORE), UCL, London, United Kingdom; Camden and Islington NHS Foundation Trust, London, United Kingdom.
authors.forename: Fiona
authors.initials: F
authors.lastname: Nolan
authors.affiliation: University of Cambridge, Cambridge, UK & UCL, London, United Kingdom.
authors.forename: Nicola
authors.initials: N
authors.lastname: Morant
authors.affiliation: Joint Research Office and Institute of Neurology, UCL, London, United Kingdom.
authors.forename: Zoe
authors.initials: Z
authors.lastname: Fox
authors.affiliation: Division of Psychiatry, UCL, London, United Kingdom.
authors.forename: Brynmor
authors.initials: B
authors.lastname: Lloyd-Evans
authors.affiliation: Division of Psychiatry, UCL, London, United Kingdom.
authors.forename: David
authors.initials: D
authors.lastname: Osborn
authors.affiliation: Division of Psychiatry, UCL, London, United Kingdom.
authors.forename: Emma
authors.initials: E
authors.lastname: Burgess
authors.affiliation: Institute of Psychiatry, Kings College London, London, United Kingdom.
authors.forename: Helen
authors.initials: H
authors.lastname: Gilburt
authors.affiliation: University of Exeter Medical School, Exeter, United Kingdom.
authors.forename: Rosemarie
authors.initials: R
authors.lastname: McCabe
authors.affiliation: Institute of Psychiatry, Kings College London, London, United Kingdom.
authors.forename: Mike
authors.initials: M
authors.lastname: Slade
authors.affiliation: Ment Division of Psychiatry, UCL, London, United Kingdom; Camden and Islington NHS Foundation Trust, London, United Kingdom.
authors.forename: Sonia
authors.initials: S
authors.lastname: Johnson
mesh_terms: D000328:Adult; D001291:Attitude of Health Personnel; D003430:Cross-Sectional Studies; D004777:Environment; D005260:Female; D006282:Health Personnel / Q000523:psychology; D006801:Humans; D007297:Inpatients / Q000523:psychology*; D008297:Male; D008605:Mental Health Services / Q000706:statistics & numerical data*; D008962:Models, Theoretical; D009013:Morale; D017060:Patient Satisfaction / Q000706:statistics & numerical data*; D012944:Social Support