Be nice to patients and they will get better? Therapeutic alliance and service user satisfaction


It is widely known that admission to hospital at times of mental distress can be an un-therapeutic intervention.

Alternatives to acute inpatient care have been in existence for as long as there have been modern mental health services and range from therapeutic communities (Lees et al, 1999), Soteria project (Calton et al, 2008), crisis houses and sanctuaries.

In the UK they have struggled to demonstrate their effectiveness and to be funded, despite the minimal evidence of effectiveness and huge costs associated with inpatient mental health services.

The aim of this new cross-sectional study was to examine therapeutic alliances between crisis houses and acute wards.


Service users were recruited from acute wards or crisis houses in inner city London. Five measures were distributed including:

  1. Scale to assess therapeutic relationships (STAR-P)
  2. Client satisfaction questionnaire (CSQ)
  3. Interpersonal relationship inventory (IPR)
  4. Recovery assessment scale (RAS)
  5. Negative events schedule for staff and patients (NES-S, NES-P)

A qualitative study was embedded within this.

Crisis houses offer short term accommodation for people experiencing a mental health crisis.

Crisis houses offer short term accommodation for people experiencing a mental health crisis.


A total of 355 service users participated, 108 from crisis houses (n=4) and 247 services users were recruited acute wards (n=16).

Significant differences between crisis houses and acute wards existed, in favour of crisis houses:

  • Therapeutic relationships were 8.74 points higher (STAR-P, 95% CI: -12.3 to -5.19)
  • Satisfaction 6.5 points higher (95% CI: -7.59 to -2.94)
  • Stages of recovery appeared higher in those in inpatient settings, the authors suggested that this was related to the influence of diagnosis
  • Peer support 12.08 points higher (95% CI: -18.53 to -5.63)
  • Staff (and other service user) negative events appeared to have a key feature in therapeutic relationships. This includes theft, discrimination, ignoring, and being treated with force

Qualitative findings emphasised the importance of therapeutic relationships of which human qualities, staff dedication to the role, interest and engagement appeared key. Other key factors focused on the organisation of services particularly around compulsory admissions, how services promote freedom and choice, the atmosphere and environment and finally access to and availability of staff.


Unsurprisingly, this study reinforces the importance of human qualities such as kindness, warmth, interest and engagement.


The authors concluded:

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.

One of the most important determinants of therapeutic alliance was the basic personal qualities and interpersonal skills of staff: detailed accounts consistently underscored the importance of kindness, warmth, interest and engagement, and the damage caused by disinterest and disrespect.


Notwithstanding the differences between crisis houses and acute wards particularly in terms of population; acute wards had a much higher prevalence of psychosis and detention under the Mental Health Act. Crisis houses appear to be acting in a much more therapeutic manner. Maybe some of this is about staff and their perspectives. It could be argued that the primary focus of mental health nurses, the main staff group of acute wards, is not developing therapeutic relationships with their service users. Unfortunately this is a not a new finding.

Researchers and clinicians need to invest their energies into improving the therapeutic alliances on acute wards and examining whether this leads to positive outcomes for the mental health of service users. We have known for too long that these services are essentially viewed as un-therapeutic.

Researchers and clinicians need to invest their energies into improving the therapeutic alliances on acute wards.

Researchers and clinicians need to invest their energies into improving the therapeutic alliances on acute wards.


Sweeney et al (2014) The Relationship between Therapeutic Alliance and Service User Satisfaction in Mental Health Inpatient Wards and Crisis House Alternatives: A Cross-Sectional Study. DOI: 10.1371/journal.pone.0100153

Lees J, Manning N, Rawlings B. (1999) Therapeutic community effectiveness. A systematic international review of therapeutic community treatment for people with personality disorders and mentally disordered offenders (PDF). University of York, CRD report 17.

Calton T, Ferriter M, Huband N, Spandler H. A systematic review of the Soteria paradigm for the treatment of people diagnosed with schizophrenia. Schizophr Bull. 2008 Jan;34(1):181-92. Epub 2007 Jun 14.

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John Baker

John Baker was appointed to Chair of Mental Health Nursing in 2015. John's research focuses on developing complex clinical and psychological interventions in mental health settings. He is particularly interested in i) acute/inpatient mental health services and clinical interventions; ii) medicines management in mental health care; iii) the attitudes and clinical skills of mental health workers, iv) the mental health workforce. The good practice manuals which he developed have been evaluated, cited as examples of good practice, and influenced clinical practice in the UK and abroad. The training package for patients, service users and carers to promote research awareness and understanding has been cited by the MHRN and NICE as an exemplar of good practice.

John is a member of the NIHR post-doctoral panel, sits on the Editorial boards for Journal of Psychiatric and Mental Health Nursing & International Journal of Mental Health Nursing. He is a Registered Nurse Teacher with the Nursing, Midwifery Council (NMC) and is active within Mental Health Nursing Academics (UK).

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