Assertive Community Treatment For People With Alcohol Dependence: A Pilot Randomized Controlled Trial.

AIMS: A pilot randomized controlled trial (RCT) to assess the feasibility and potential efficacy of assertive community treatment (ACT) in adults with alcohol dependence. METHODS: Single blind, individually randomized, pilot RCT of 12 months of ACT plus treatment as usual (TAU) versus TAU alone in adults (age 18+ years) with alcohol dependence and a history of previous unsuccessful alcohol treatment attending specialist community alcohol treatment services. ACT aimed to actively engage participants for 12 months with assertive, regular, minimum weekly contact. ACT was combined with TAU. TAU comprised access to the full range of services provided by the community teams. Primary outcome is mean drinks per drinking day and percent days abstinent at 12 months follow up. Analysis of covariance was conducted using 80% confidence intervals, appropriate in the context of a pilot trial. RESULTS: A total of 94 participants were randomized, 45 in ACT and 49 in TAU. Follow-up was achieved with 98 and 88%, respectively at 12 months. Those in ACT had better treatment engagement, and were more often seen in their homes or local community than TAU participants. At 12 months the ACT group had more problems related to drinking and lower quality of life than TAU but no differences in drinking measures. The ACT group had a higher percentage of days abstinent but lower quality of life at 6 months. The ACT group had less unplanned healthcare use than TAU. CONCLUSIONS: An trial of ACT was feasible to implement in an alcohol dependent treatment population. TRIAL REGISTRATION: ISRCTN22775534.

Navigating the Alcohol Treatment Pathway: A Qualitative Study from the Service Users' Perspective.

AIMS: Provision of effective treatment for dependent drinkers has been identified as a priority in England yet evidence suggests that access is problematic and there are low levels of retention. This qualitative study explores how the alcohol treatment system is experienced by service users, identifying barriers and facilitators that influence treatment outcomes. METHODS: A total of 20 semi-structured face-to-face interviews were conducted with patients from community alcohol treatment services in three London boroughs in 2012. Interviews were undertaken one year after initially entering treatment. A thematic analysis was conducted, with the results further abstracted to relate them to specific aspects of the treatment journey. RESULTS: Patients journeys were characterized by a perceived lack of control leading to help-seeking, with treatment outcomes influenced by an individuals' self-efficacy and the capabilities and skills of staff in actively engaging and supporting patients on the journey. A focus of services on the detoxification process and fragmented care pathways impacted negatively on engagement. CONCLUSIONS: Current alcohol care pathways require significant levels of motivation and self-efficacy to navigate that few patients possess. Pathways need to better reflect the capacity and capabilities of patients to be successful in supporting recovery.

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.

Promoting recovery-oriented practice in mental health services: a quasi-experimental mixed-methods study.

BACKGROUND: Recovery has become an increasingly prominent concept in mental health policy internationally. However, there is a lack of guidance regarding organisational transformation towards a recovery orientation. This study evaluated the implementation of recovery-orientated practice through training across a system of mental health services. METHODS: The intervention comprised four full-day workshops and an in-team half-day session on supporting recovery. It was offered to 383 staff in 22 multidisciplinary community and rehabilitation teams providing mental health services across two contiguous regions. A quasi-experimental design was used for evaluation, comparing behavioural intent with staff from a third contiguous region. Behavioural intent was rated by coding points of action on the care plans of a random sample of 700 patients (400 intervention, 300 control), before and three months after the intervention. Action points were coded for (a) focus of action, using predetermined categories of care; and (b) responsibility for action. Qualitative inquiry was used to explore staff understanding of recovery, implementation in services and the wider system, and the perceived impact of the intervention. Semi-structured interviews were conducted with 16 intervention group team leaders post-training and an inductive thematic analysis undertaken. RESULTS: A total of 342 (89%) staff received the intervention. Care plans of patients in the intervention group had significantly more changes with evidence of change in the content of patient's care plans (OR 10.94. 95% CI 7.01-17.07) and the attributed responsibility for the actions detailed (OR 2.95, 95% CI 1.68-5.18). Nine themes emerged from the qualitative analysis split into two superordinate categories. 'Recovery, individual and practice', describes the perception and provision of recovery orientated care by individuals and at a team level. It includes themes on care provision, the role of hope, language of recovery, ownership and multidisciplinarity. 'Systemic implementation', describes organizational implementation and includes themes on hierarchy and role definition, training approaches, measures of recovery and resources. CONCLUSIONS: Training can provide an important mechanism for instigating change in promoting recovery-orientated practice. However, the challenge of systemically implementing recovery approaches requires further consideration of the conceptual elements of recovery, its measurement, and maximising and demonstrating organizational commitment.

Assertive Community Treatment for alcohol dependence (ACTAD): study protocol for a randomised controlled trial.

BACKGROUND: Alcohol dependence is a significant and costly problem in the UK yet only 6% of people a year receive treatment. Current service provision based on the treatment of acute episodes of illness and emphasising personal choice and motivation results in a small proportion of these patients engaging with alcohol treatment. There is a need for interventions targeted at the population of alcohol dependent patients who are hard to engage in conventional treatment. Assertive Community Treatment (ACT), a model of care based on assertive outreach, has been used for treating patients with severe mental illnesses and presents a promising avenue for engaging patients with primary alcohol dependence. So far there has been little research on this. METHODS/DESIGN: In this single blind exploratory randomised controlled trial, a total of 90 alcohol dependent participants will be recruited from community addiction services. After completing a baseline assessment, they will be assigned to one of two conditions: (1) ACT plus care as usual, or (2) care as usual. Those allocated to the ACT plus care as usual will receive the same treatment that is routinely provided by services, plus a trained key worker who will provide ACT. ACT comprises intensive and assertive contact at least once a week, over 50% of contacts in the participant's home or local community, and comprehensive case management across social and health care, for a period of one year. All participants will be followed up at 6 months and 12 months to assess outcome post randomisation. The primary outcome measures will be alcohol consumption: mean drinks per drinking day and percentage of days abstinent measured by the Time Line Follow Back interview. Secondary outcome measures will include severity of alcohol dependence, alcohol related problems, motivation to change, social network involvement, quality of life, therapeutic relationship and service use. Other outcome variables are treatment engagement including completion of assessment, detoxification and aftercare. DISCUSSION: Results of this trial will help clarify the potential beneficial effects of ACT for people with alcohol dependence and provide information to design a definitive trial. TRIAL REGISTRATION NUMBER: ISRCTN: ISRCTN22775534.

Service users' experiences of residential alternatives to standard acute wards: qualitative study of similarities and differences.

BACKGROUND: Little is known about the preferences and experiences of people with mental illness in relation to residential alternatives to hospital. AIMS: To explore patients' subjective experiences of traditional hospital services and residential alternatives to hospital. METHOD: In-depth interviews were conducted with 40 purposively selected patients in residential alternative services who had previously experienced hospital in-patient stays. Transcripts were coded and analysed for thematic content. RESULTS: Patients reported an overall preference for residential alternatives. These were identified as treating patients with lower levels of disturbance, being safer, having more freedom and decreased coercion, and having less paternalistic staff compared with traditional in-patient services. However, patients identified no substantial difference between their relationships with staff overall and the care provided between the two types of services. CONCLUSIONS: For patients who have acute mental illness but lower levels of disturbance, residential alternatives offer a preferable environment to traditional hospital services: they minimise coercion and maximise freedom, safety and opportunities for peer support.

Alternatives to standard acute in-patient care in England: readmissions, service use and cost after discharge.

BACKGROUND: Residential alternatives to standard psychiatric admissions are associated with shorter lengths of stay, but little is known about the impact on readmissions. AIMS: To explore readmissions, use of community mental health services and costs after discharge from alternative and standard services. METHOD: Data on use of hospital and community mental health services were collected from clinical records for participants in six alternative and six standard services for 12 months from the date of index admission. RESULTS: After discharge, the mean number and length of readmissions, use of community mental health services and costs did not differ significantly between standard and alternative services. Cost of index admission and total 12-month cost per participant were significantly higher for standard services. CONCLUSIONS: Shorter lengths of stay in residential alternatives are not associated with greater frequency or length of readmissions or greater use of community mental health services after discharge.

Residential alternatives to acute in-patient care in England: satisfaction, ward atmosphere and service user experiences.

BACKGROUND: Alternatives to traditional in-patient services may be associated with a better experience of admission. AIMS: To compare patient satisfaction, ward atmosphere and perceived coercion in the two types of service, using validated measures. METHOD: The experience of 314 patients in four residential alternatives and four standard services were compared using the Client Satisfaction Questionnaire (CSQ), the Service Satisfaction Scale - Residential form (SSS-Res), the Ward Atmosphere Scale (WAS) and the Admission Experience Scale (AES). RESULTS: Compared with standard wards, service users from alternative services reported greater levels of satisfaction (mean difference CSQ 3.3, 95% CI 1.8 to 4.9; SSS-Res 11.4, 95% CI 5.0 to 17.7). On the AES, service users in alternatives perceived less coercion (mean difference -1.3, 95% CI -1.8 to -0.8) and having more ;voice' (mean difference 0.9, 95% CI 0.6 to 1.2). Greater autonomy, more support and less anger and aggression were revealed by WAS scores. Differences in CSQ and AES scores remained significant after multivariable adjustment, but SSS-Res results were attenuated, mainly by detention status. CONCLUSIONS: Community alternatives were associated with greater service user satisfaction and less negative experiences. Some but not all of these differences were explained by differences in the two populations, particularly in involuntary admission.

A national survey of psychiatric mother and baby units in England.

OBJECTIVE: This study identified all mother and baby units (MBUs) (defined in this study as inpatient psychiatric units where mothers and babies could be admitted that had at least four beds and were separate from other wards) in England and established the operating procedures of MBUs and the clinical characteristics of their inpatients. METHODS: A national cross-sectional survey of alternatives to standard acute inpatient care was conducted in England in 2005. Multiple methods, including telephone inquiries and consultation with relevant experts, were used to identify services. All MBUs identified were contacted and invited to participate in an interview with a researcher. RESULTS: Twenty-six facilities that accommodated mothers and babies were identified. Thirteen were excluded from the final analysis, because they did not fulfill the study's operationalized criteria for a MBU. Twelve of the 13 facilities with an MBU agreed to participate. Nationally, MBUs had fewer beds than needed and marked geographical variation. Ward size ranged between four and 12 beds, average occupancy was 78%, and the mean length of stay was 56 days. On admission, 45% of women were experiencing psychotic symptoms, and 18% were detained compulsorily. A significant proportion of MBUs did not offer psychological treatments (42%). CONCLUSIONS: The provision of MBUs in England is inequitable, and the clinical and operating characteristics of these services are highly variable. However, this study demonstrated that MBUs are serving women with severe mental illness. If services are to expand and develop in the future, more qualitative and quantitative studies are required to identify the most effective components of MBUs and examine for whom the MBUs are most helpful.

In-patient and residential alternatives to standard acute psychiatric wards in England.

BACKGROUND: Acute psychiatric wards have been the focus of widespread dissatisfaction. Residential alternatives have attracted much interest, but little research, over the past 50 years. AIMS: Our aims were to identify all in-patient and residential alternatives to standard acute psychiatric wards in England, to develop a typology of such services and to describe their distribution and clinical populations. METHOD: National cross-sectional survey of alternatives to standard acute in-patient care. RESULTS: We found 131 services intended as alternatives. Most were hospital-based and situated in deprived areas, and about half were established after 2000. Several clusters with distinctive characteristics were identified, ranging from general acute wards applying innovative therapeutic models, through clinical crisis houses that are highly integrated with local health systems, to more radical voluntary sector alternatives. Most people using the alternatives had a previous history of admission, but only a few community-based services accepted compulsory admissions. CONCLUSIONS: Alternatives to standard acute psychiatric wards represent an important, but previously undocumented and unevaluated, sector of the mental health economy. Further evidence is needed to assess whether they can improve the quality of acute in-patient care.

The importance of relationships in mental health care: a qualitative study of service users' experiences of psychiatric hospital admission in the UK.

BACKGROUND: While a number of studies have looked at life on service users' experiences of life on psychiatric wards, no research exists that have approached these experiences from the user perspective since the introduction of community care. METHODS: This user-led study uses a participatory approach to develop an understanding of the processes and themes which define the user experience of hospitalisation. Nineteen service users who had all had inpatient stays in psychiatric hospitals in London were interviewed in the community. RESULTS: Relationships formed the core of service users' experiences. Three further codes, treatment, freedom and environment defined the role of hospital and its physical aspects. Themes of communication, safety, trust, coercion, and cultural competency contributed to the concept of relationships. CONCLUSION: Relationships with an individual which comprised effective communication, cultural sensitivity, and the absence of coercion resulted in that person being attributed with a sense of trust. This resulted in the patient experiencing the hospital as a place of safety in terms of risk from other patients and staff. Barriers to positive relationships included ineffective and negative communication, a lack of trust, a lack of safety in terms of staff as ineffective in preventing violence, and as perpetrators themselves, and the use of coercion by staff. This unique perspective both acts as a source of triangulation with previous studies and highlights the importance of the therapeutic relationship in providing a safe and therapeutic milieu for the treatment of people with acute mental health problems.