Household factors and prevalence of squalor: meta-analysis and meta-regression.

BACKGROUND: Severe domestic squalor occurs when a person lives in a dwelling that is significantly unclean, disorganised and unhygienic. The limited previous research has primarily focused on the characteristics of those who live in squalor and the associated risk factors. Robust and reliable studies of squalor prevalence have not been conducted. This study sought to produce a reliable estimate of the point prevalence of squalor. METHODS: Using data from 13-years of the English Housing Survey, N = 85,681 households were included in a prevalence meta-analysis. Squalor prevalence over time, subgroup analysis and logistic regression investigated the role played by household and community characteristics. RESULTS: The point prevalence of squalor was estimated to be 0.85% and squalor was seen to decrease significantly over time. More significant community deprivation, a rented dwelling, lower income and high numbers of people in the home was associated with a greater risk of squalor. CONCLUSIONS: Squalor prevalence was higher than previous estimates and supports community care services in associated service planning. The results regarding household characteristics help to inform which households and individuals may be at a higher risk of living in squalid conditions.

Experiences of support for people who access voluntary, community and social enterprise (VCSE) organisations for self-harm: a qualitative study with stakeholder feedback.

BACKGROUND: Prevalence of self-harm In England is rising, however contact with statutory services remains relatively low. There is growing recognition of the potential role voluntary, community and social enterprise sector (VCSE) organisations have in the provision of self-harm support. We aimed to explore individuals' experiences of using these services and the barriers and facilitators to accessing support. METHODS: Qualitative, online interviews with 23 adults (18+) who have accessed support from VCSE organisations for self-harm in the Yorkshire and the Humber region were undertaken. Interviews were audio recorded and transcribed verbatim. Thematic analysis was undertaken using NVivo software. RESULTS: Participants described how a lack of service flexibility and the perception that their individual needs were not being heard often made them less likely to engage with both statutory and VCSE organisations. The complexity of care pathways made it difficult for them to access appropriate support when required, as did a lack of awareness of the types of support available. Participants described how engagement was improved by services that fostered a sense of community. The delivery of peer support played a key role in creating this sense of belonging. Education and workplace settings were also viewed as key sources of support for individuals, with a lack of mental health literacy acting as a barrier to access in these environments. CONCLUSIONS: VCSE organisations can play a crucial role in the provision of support for self-harm, however, pathways into these services remain complex and links between statutory and non-statutory services need to be strengthened. The provision of peer support is viewed as a crucial component of effective support in VCSE organisations. Further supervision and training should be offered to those providing peer support to ensure that their own mental health is protected.

The association between income inequality and adult mental health at the subnational level-a systematic review.

PURPOSE: A systematic review was undertaken to determine whether research supports: (i) an association between income inequality and adult mental health when measured at the subnational level, and if so, (ii) in a way that supports the Income Inequality Hypothesis (i.e. between higher inequality and poorer mental health) or the Mixed Neighbourhood Hypothesis (higher inequality and better mental health). METHODS: Systematic searches of PsycINFO, Medline and Web of Science databases were undertaken from database inception to September 2020. Included studies appeared in English-language, peer-reviewed journals and incorporated measure/s of objective income inequality and adult mental illness. Papers were excluded if they focused on highly specialised population samples. Study quality was assessed using a custom-developed tool and data synthesised using the vote-count method. RESULTS: Forty-two studies met criteria for inclusion representing nearly eight million participants and more than 110,000 geographical units. Of these, 54.76% supported the Income Inequality Hypothesis and 11.9% supported the Mixed Neighbourhood Hypothesis. This held for highest quality studies and after controlling for absolute deprivation. The results were consistent across mental health conditions, size of geographical units, and held for low/middle and high income countries. CONCLUSIONS: A number of limitations in the literature were identified, including a lack of appropriate (multi-level) analyses and modelling of relevant confounders (deprivation) in many studies. Nonetheless, the findings suggest that area-level income inequality is associated with poorer mental health, and provides support for the introduction of social, economic and public health policies that ameliorate the deleterious effects of income inequality. CLINICAL REGISTRATION NUMBER: PROSPERO 2020 CRD42020181507.

A mixed methods exploration of "Creativity in Mind", an online creativity-based intervention for low mood and anxiety.

BACKGROUND: Within the current context of a global pandemic, the value of the Internet has been greatly elevated for many people. This study is an investigation into a 30-day online intervention called Creativity in Mind (CIM). AIMS: To provide a preliminary indication of the relationship between participation in CIM and change in mood symptoms and wellbeing. METHODS: A co-produced mixed methods design was used to evaluate CIM. Data was obtained from 55 participants. Each day for 30 days participants received a predetermined creative challenge that they were encouraged to complete and share within the group. Measures of mood and wellbeing were collected at three time points, including a 3-month follow-up. Qualitative interviews were undertaken with 18 participants and analysed using framework analysis. RESULTS: Scores on mood and wellbeing measures showed an overall significant improvement following completion of the programme. However, only a small number of participants demonstrated clinically significant improvement (14%) or deterioration (5%). The qualitative data indicated that CIM was experienced positively, with some negative emotions arising from the volume of interactions and negative comparisons made between participants. CONCLUSIONS: Preliminary results demonstrate that the pattern of clinically significant change across individual participants was comparable to other psychological therapy.

Feasibility and Patient Experiences of Method of Levels Therapy in an Acute Mental Health Inpatient Setting.

This study sought to investigate the feasibility and acceptability of a flexible psychotherapeutic approach - the Method of Levels (MOL) - in an acute mental health inpatient setting. A multi methods approach was used. The feasibility of implementation was investigated by examining the referral rate and the attendance patterns of participants. The acceptability of MOL was explored using a thematic analysis of participant interviews and by recording attendance patterns of participants. Inpatient staff consistently referred patients and the majority of eligible people accepted invitations for therapy. Thematic analysis of peoples' experiences of the therapy generated themes that described participants' experiences of MOL in contrast to routine NHS care, having spent meaningful time with the therapist, and having gained something from the session. The referral rate and uptake of MOL therapy indicates that the resource was appropriate for the setting and acceptable to most participants. Qualitative analyses indicated that participants were comfortable with the therapists' approach, felt understood, and there was a meaningful quality to their interaction. Participants also valued the opportunity to reflect and generate new perspectives of their difficulties. Further research is required to determine the effectiveness of the approach and its translational value beyond this pilot investigation.

Family intervention in a prison environment: A systematic literature review.

BACKGROUND: The prison population in England and Wales is approximately 85,000, and elevated rates of mental health difficulties have been reported among the prisoners. Despite frequent recommendations for family interventions to optimise prisoner outcomes, the evidence for its use and impact in prison remain unclear. AIM: The aim of the study is to conduct a systematic review of published literature on family interventions in prisons. METHODS: Embase, PsychINFO and Medline were searched using terms for family interventions and for prisoners or young offenders. No limit was imposed on study design, but, for inclusion, we required that papers were written in English and published in peer-reviewed journals. RESULTS: Nine hundred eighty-three titles were retrieved. Twenty-two met criteria for inclusion. Three were case studies, 12 were descriptive, 6 were quasi-experimental and one was a randomised controlled trial. Interventions and study methods were too heterogeneous for meta-analysis. All studies gave positive conclusions about family interventions, but empirical data on effectiveness were slight. CONCLUSIONS: Consistency in findings across the wide-ranging studies suggested that family therapies may indeed be helpful for prisoners and their families, so further research is warranted. The fact that a randomised controlled trial proved feasible should encourage researchers to seek more robust data and to determine which form of intervention is effective and in which circumstances. It would also be useful to develop an improved understanding of mechanisms of change. Copyright © 2016 John Wiley & Sons, Ltd.

Psychological Therapy for At Risk Mental State for Psychosis in a Prison Setting: A Case Study.

There is a very high prevalence of psychosis in U.K. prisons; moreover, a significant number of prisoners meet risk criteria for psychosis. We provide a report of psychological therapy with a client who met risk criteria for psychosis that took place in a prison setting. We applied a self-reflectivity framework when formulating the case, which we believe allowed the flexibility required by the presenting problem and, crucially, the demands of the setting. This approach had two key advantages. First, it enabled the therapist to tailor the work according to the level of self-reflectivity demonstrated by the client. We believe this approach ensured that the client understood the therapist's interventions. Second, it helped prepare, and choose a appropriate point, for a move to more traditional interventions for managing the client's main presenting problem. We believe this work represents progress in working with clients in this complex and demanding setting.

Treating Multiple Incident Post-Traumatic Stress Disorder (PTSD) in an Inner City London Prison: The Need for an Evidence Base.

BACKGROUND: Mental health problems have been found to be more prevalent in prison populations, and higher rates of post-traumatic stress disorder (PTSD) have been found in sentenced populations compared to the general population. Evidence-based treatment in the general population however has not been transferred and empirically supported into the prison system. AIMS: The aim of this manuscript is to illustrate how trauma focused work can be applied in a prison setting. METHOD: This report describes a two-phased approach to treating PTSD, starting with stabilization, followed by an integration of culturally appropriate ideas from narrative exposure therapy (NET), given that the traumas were during war and conflict, and trauma-focused cognitive behavioural therapy (TF-CBT). RESULTS: PTSD and scores on paranoia scales improved between start and end of treatment; these improvements were maintained at a 6-month follow-up. CONCLUSION: This case report 1 illustrates successful treatment of multiple incident PTSD in a prison setting using adaptations to TF-CBT during a window of opportunity when individuals are more likely to be free from substances and live in relative stability. Current service provision and evidence-based practice for PTSD is urgently required in UK prisons to allow individuals to engage in opportunities to reduce re-offending, free from mental health symptoms.

The Feasibility and Acceptability to Service Users of CIRCuiTS, a Computerized Cognitive Remediation Therapy Programme for Schizophrenia.

BACKGROUND: Cognitive remediation (CR) is a psychological therapy, effective in improving cognitive performance and functioning in people with schizophrenia. As the therapy becomes more widely implemented within mental health services its longevity and uptake is likely to depend on its feasibility and acceptability to service users and clinicians. AIMS: To assess the feasibility and acceptability of a new strategy-based computerized CR programme (CIRCuiTS) for people with psychosis. METHOD: Four studies were conducted using mixed methods. Perceptions of attractiveness, comprehensibility, acceptability and usability were assessed using self-report questionnaires in 34 non-clinical participants (study 1), and five people with a schizophrenia diagnosis and three experienced CR therapists (studies 2 and 3). The ease with which pre-specified therapy programmes could be assembled was also assessed by three therapists (Study 2). Finally, the satisfaction of 20 service users with a diagnosis of schizophrenia regarding their experience of using CIRCuiTS in the context of a course of the CR therapy was assessed in a qualitative interview study (study 4). RESULTS: Ratings of perceived attractiveness, comprehensibility, acceptability and usability consistently exceeded pre-set high targets by non-clinical, clinical and therapist participants. Qualitative analysis of satisfaction with CIRCuiTS showed that receiving the therapy was generally seen to be a positive experience, leading to perceptions that cognitive functioning had improved and attempts to incorporate new strategy use into daily activities. CONCLUSIONS: CIRCuiTS demonstrates high acceptability and ease of use for both service users with a schizophrenia diagnosis and clinicians.

GP perspectives regarding suicide prevention: a systematic scoping review.

BACKGROUND: Suicide is a major public health issue and is the leading cause of death of men under the age of 50 in the UK. Patients are more likely to visit their GP in the month leading up to a suicide attempt, thus highlighting the key role GPs play in suicide prevention. AIM: The aim of this systematic scoping review was to explore the current qualitative research on GPs' perspectives of suicide prevention in primary care. METHOD: This review was reported in accordance with PRISMA-ScR guidance. A three-step search strategy was used. Articles at full-text review were assessed for their inclusion in the study against predetermined eligibility criteria (English language, qualitative in nature, and a focus on GPs' perspectives of suicide prevention). Data was extracted using a standardised form and a narrative approach was used to describe the main themes elicited from the studies. RESULTS: There were 2210 articles screened. Twelve studies from seven countries were included at full text review. The majority of studies used semi-structured interviews (n=9) and transcripts were analysed using variations of thematic analysis. Four main themes were elicited from the included studies: challenges to managing suicidal behaviour, fragmented relationships with mental health services, personal attitudes of GPs regarding suicidal behaviour, and identified needs to improve suicide prevention in primary care. CONCLUSION: The challenges experienced by GPs when managing suicidal behaviour are well documented. More work is needed to explore what approaches GPs find effective in managing suicidal behaviour, especially in younger patients.

Effects of age and cognitive reserve on cognitive remediation therapy outcome in patients with schizophrenia.

OBJECTIVE: Older people with a diagnosis of schizophrenia seem to show fewer benefits following cognitive remediation therapy (CRT). It is not clear whether cognitive reserve modifies the relationship with age. METHODS: A total of 134 individuals with schizophrenia were pooled from one randomized control trial and one observational trial. Eighty-five participants received more than 20 sessions of CRT and 49 participants received fewer than 20 sessions of CRT or treatment as usual. Participants were divided into two groups according to their age (younger than 40 years: younger, N = 77; and 40 years or older: older, N = 57). Cognition (working memory, cognitive flexibility, and planning) was assessed at baseline and posttreatment. Premorbid IQ and vocabulary at baseline were used as cognitive reserve proxies. RESULTS: There was a significant effect of CRT on working memory in younger but not older participants. Better premorbid IQ was associated with better working memory performance in younger participants irrespective of treatment. No significant effects of treatment or cognitive reserve were revealed in older participants. Cognitive reserve proxies did not modify CRT treatment effect. CONCLUSION: In conclusion, the effects of CRT were limited in older people with schizophrenia. Cognitive reserve could not be shown to influence the relationship of age with CRT efficacy. Better premorbid IQ was associated with increased practice effects on working memory in younger but not older individuals.

Black people's experiences of being asked about adverse childhood experiences in the UK: A qualitative study.

INTRODUCTION: The objectives for this study were to explore Black people's experiences of being asked about ACEs by mental health or counselling professionals, both broadly, and also as part of routine enquiry with a commonly used ACE questionnaire. An additional aim was to understand their perspectives on how services should be asking about ACEs. METHODS: This study used a qualitative methodology, with a critical realist reflexive thematic analysis approach. Ten people who identified as Black and had been asked about ACEs by a mental health professional or counsellor, were interviewed about their experiences and perspectives using semi-structured interviews. RESULTS: Four overarching themes, some with subthemes, were established: Trust and safety as individual and systemic (subthemes: Distrust in the system; Distrust in the clinician; Racism in health care; Keeping safe); It is the person, not the questions (subthemes: Being heard and understood; Similarity and difference); Engaged client, 'hard-to-reach' clinician? and People are not tick-boxes. CONCLUSIONS: The results highlight that people find it important and useful to be asked about ACEs, if it is done in an appropriate manner. Establishing trust and a therapeutic relationship is key to fostering this. Participants stated that the ACE questionnaire might miss important context, and they relayed a preference for being asked about ACEs using more inclusive definitions of ACEs.

Evaluating the impact of sling provision and training upon maternal mental health, wellbeing and parenting: A randomised feasibility trial.

BACKGROUND: Close body contact interventions such as Kangaroo Mother Care have been shown to improve maternal mental health following birth. Infant carriers ('slings') facilitate hands-free close body contact. No studies have specifically examined whether sling use improves maternal mental health. A full-scale efficacy study is needed to examine whether sling use is beneficial to maternal mental health. The current study is a feasibility study designed to gather information to support the design of a future RCT, such as acceptability and study parameters, including recruitment rates, consent rate and attrition. METHOD: Mothers of infants aged 0-6 weeks were randomised to one of two conditions: intervention (n = 35) vs. waitlist control (n = 32). Intervention participants received sling training, support, and free sling hire for 12 weeks. Participants completed self-report measures of mood, wellbeing and parenting at baseline (Time 1), and 6- (Time 2) and 12- (Time 3) weeks post-baseline. RESULTS: Eligibility and consent rates met feasibility objectives, though there were some difficulties with retention of participants in the study. Preliminary effectiveness analyses showed a non-significant improvement with a small effect size in postnatal depression from T1 to T3, and a significant improvement with a medium effect size in maternal self-efficacy from T1 to T3. Qualitative feedback indicated acceptability of the intervention and study participation. Intervention participants attributed greater autonomy, bonding with their baby, and parental self-confidence, to the intervention. CONCLUSIONS: These findings indicate a randomised study of the impact of a sling and related support intervention upon maternal mental health is feasible. These findings should be interpreted within the context of sampling bias (due to the use of volunteer sampling methods), an absence of feedback from those who discontinued participation in the study, and the study not being adequately powered. TRIAL REGISTRATION: Registration number ISRCTN88575352.

The effect of working alliance on adherence and outcome in cognitive remediation therapy.

Cognitive remediation therapy (CRT) for schizophrenia has been effective in improving cognitive and global functioning outcomes. It is now important to determine what factors maximize benefit. The quality of relationship--or working alliance--between clients and therapists may be one such factor that improves outcome. To investigate this, 49 individuals with schizophrenia were recruited into a naturalistic study of the impact of CRT on work and structured activity outcomes. Participant's cognitive skills, severity of symptoms, and social skills were assessed at baseline. Both client and therapist working alliance ratings were gathered early in therapy. After controlling for depression, clients who rated the alliance more favorably stayed in therapy longer and were more likely to improve on their main target complaint but notably not on working memory performance or self-esteem. Therapist's ratings of the alliance were not associated with memory outcome. These findings indicate that working alliance is important for client satisfaction with therapy.

The relationship of metacognition with jumping to conclusions among persons with schizophrenia spectrum disorders.

BACKGROUND: Jumping to conclusions (JTC) is a reasoning bias in which persons arrive at conclusions with relatively little data. It is prevalent in schizophrenia and tied to outcomes. To understand the correlates and the roots of this phenomenon, this study explored whether deficits in mastery, a domain of metacognition which reflects the ability to use knowledge about oneself and others to cope with psychological problems, was linked to a heightened tendency to jump to conclusions. SAMPLING AND METHODS: Participants were 40 adults with a schizophrenia spectrum disorder in a nonacute phase being treated in an outpatient setting. JTC was assessed using the Beads Test, and mastery was measured as an element of metacognition using the Metacognition Assessment Scale. To rule out the possibility that results were the effect of impairments in memory or executive function, the Wisconsin Card Sorting Test and Hopkins Verbal Learning Test were included. RESULTS: Partial correlations controlling for memory and executive function revealed that lower levels of mastery were correlated with a lower average number of beads requested before reaching a conclusion, or a greater tendency to jump to conclusions (r = 0.39, p < 0.05). CONCLUSIONS: Results are consistent with the possibility that deficits in metacognition influence or are influenced by reasoning biases.

Why Do We Need Computational Models of Psychological Change and Recovery, and How Should They Be Designed and Tested?

Traditional research methodologies typically assume that humans operate on the basis of an "open loop" stimulus-process-response rather than the "closed loop" control of internal state. They also average behavioral data across repeated measures rather than assess it continuously, and they draw inferences about the working of an individual from statistical group effects. As such, we propose that they are limited in their capacity to accurately identify and test for the mechanisms of change within psychological therapies. As a solution, we explain the advantages of using a closed loop functional architecture, based on an extended homeostatic model of the brain, to construct working computational models of individual clients that can be tested against real-world data. Specifically, we describe tests of a perceptual control theory (PCT) account of psychological change that combines the components of negative feedback control, hierarchies, conflict, reorganization, and awareness into a working model of psychological function, and dysfunction. In brief, psychopathology is proposed to be the loss of control experienced due to chronic, unresolved conflict between important personal goals. The mechanism of change across disorders and different psychological therapies is proposed to be the capacity for the therapist to help the client shift and sustain their awareness on the higher level goals that are driving goal conflict, for sufficiently long enough to permit a trial-and-error learning process, known as reorganization, to "stumble" upon a solution that regains control. We report on data from studies that have modeled these components both separately and in combination, and we describe the parallels with human data, such as the pattern of early gains and sudden gains within psychological therapy. We conclude with a description of our current research program that involves the following stages: (1) construct a model of the conflicting goals that are held by people with specific phobias; (2) optimize a model for each individual using their dynamic movement data from a virtual reality exposure task (VRET); (3) construct and optimize a learning parameter (reorganization) within each model using a subsequent VRET; (3) validate the model of each individual against a third VRET. The application of this methodology to robotics, attachment dynamics in childhood, and neuroimaging is discussed.

To Mix or Not To Mix? A Meta-Method Approach to Rethinking Evaluation Practices for Improved Effectiveness and Efficiency of Psychological Therapies Illustrated With the Application of Perceptual Control Theory.

Progress in the development of more effective and efficient psychological therapies could be accelerated with innovative and nuanced approaches to research methodology. Therapy development has been dominated by a mono-methodology attitude with randomized controlled trials (RCTs) regarded as a "gold standard" despite the concept of a single methodology being ascribed gold standard status having been called into question. Rather than one particular methodology being considered superior to all others, the gold standard approach should be matching appropriate methodologies to important research questions. The way in which that matching should occur, however, is far from clear. Moving from a mono-methodological approach to mixed-method designs has not been straightforward. The ways in which methods should be mixed, to arrive at robust and persuasive answers to genuine research questions, is not entirely clear. In this paper, we argue that attention to the meta-methods underpinning all research designs will improve research precision and provide greater clarity about the contribution of any particular program of research to scientific progress in that field. From a meta-method perspective, the matter of what changed can be delineated from why or how these changes occurred. Different methods and different types of mixing can be justified for each meta question. A meta-method approach should make explicit the assumptions that guide the development of research designs and also promote the articulation of putative mechanisms that might be relevant. By paying greater attention to assumptions such as how causality occurs, and important mechanisms of change, the mixing of methodologies that are still not mainstream in this area such as routine outcome monitoring and evaluation and functional model building, can occur. By adopting methodologies that focus on learning about a program's strengths and weaknesses rather than presiding over judgments of whether or not the program is deemed to be effective, we will move much closer to a position of being able to understand what programs under which conditions people find most helpful for their purposes.

The simulation heuristic, paranoia, and social anxiety in a non-clinical sample.

BACKGROUND AND OBJECTIVES: Quality of reasoning within non-clinical paranoia and mental simulation of future paranoia themed events was investigated by use of a simulation task to determine whether paranoid individuals would be restricted or more adept at reasoning about paranoia relevant material in comparison to a social anxiety group and a group with low paranoia and social anxiety. METHOD: Participants (N = 63) were divided into the three groups based on paranoia and social anxiety scores. They were presented with the beginning and end of an imaginary situation and were asked to describe, step-by-step, what they imagined would happen between those two points. They were also administered a beads task to evaluate the jumping to conclusion decision making bias. RESULTS: The prediction of more adept reasoning was not supported for paranoia. However, the social anxiety comparison group on average better simulated a scenario with congruent (socially anxious) thematic content compared to ones with non-congruent content. Further, in an exploratory analysis, jumping to conclusions bias was found to be positively related to goodness of simulation for paranoia themed scenarios within the paranoia group. LIMITATIONS: Study groups were relatively small and so power was an issue. CONCLUSION: The results are discussed in the context of the sometimes paradoxical findings in the area of cognitive biases and paranoia.

Are socioenvironmental factors associated with psychotic symptoms in people with first-episode psychosis? A cross-sectional study of a West London clinical sample.

OBJECTIVES: To determine whether neighbourhood-level socioenvironmental factors including deprivation and inequality predict variance in psychotic symptoms after controlling for individual-level demographics. DESIGN: A cross-sectional design was employed. SETTING: Data were originally collected from secondary care services within the UK boroughs of Ealing, Hammersmith and Fulham, Wandsworth, Kingston, Richmond, Merton, Sutton and Hounslow as part of the West London First-Episode Psychosis study. PARTICIPANTS: Complete case analyses were undertaken on 319 participants who met the following inclusion criteria: aged 16 years or over, resident in the study's catchment area, experiencing a first psychotic episode, with fewer than 12 weeks' exposure to antipsychotic medication and sufficient command of English to facilitate assessment. OUTCOME MEASURES: Symptom dimension scores, derived from principal component analyses of the Scale for the Assessment of Positive Symptoms and Scale for the Assessment of Negative Symptoms, were regressed on neighbourhood-level predictors, including population density, income deprivation, income inequality, social fragmentation, social cohesion, ethnic density and ethnic fragmentation, using multilevel regression. While age, gender and socioeconomic status were included as individual-level covariates, data on participant ethnicity were not available. RESULTS: Higher income inequality was associated with lower negative symptom scores (coefficient=-1.66, 95% CI -2.86 to -0.46, p<0.01) and higher levels of ethnic segregation were associated with lower positive symptom scores (coefficient=-2.32, 95% CI -4.17 to -0.48, p=0.01) after adjustment for covariates. CONCLUSIONS: These findings provide further evidence that particular characteristics of the environment may be linked to specific symptom clusters in psychosis. Longitudinal studies are required to begin to tease apart the underlying mechanisms involved as well as the causal direction of such associations.

Individual psychological therapy in an acute inpatient setting: Service user and psychologist perspectives.

OBJECTIVES: The acute inpatient setting poses potential challenges to delivering one-to-one psychological therapy; however, there is little research on the experiences of both receiving and delivering therapies in this environment. This qualitative study aimed to explore service users' and psychologists' experiences of undertaking individual therapy in acute inpatient units. It focused on the relationship between service users and psychologists, what service users found helpful or unhelpful, and how psychologists attempted to overcome any challenges in delivering therapy. DESIGN: The study used a qualitative, interview-based design. METHODS: Eight service users and the six psychologists they worked with were recruited from four acute inpatient wards. They participated in individual semi-structured interviews eliciting their perspectives on the therapy. Service users' and psychologists' transcripts were analysed together using Braun and Clarke's (2006, Qualitative Research in Psychology, 3, 77) method of thematic analysis. RESULTS: The accounts highlighted the importance of forming a 'human' relationship - particularly within the context of the inpatient environment - as a basis for therapeutic work. Psychological therapy provided valued opportunities for meaning-making. To overcome the challenges of acute mental health crisis and environmental constraints, psychologists needed to work flexibly and creatively; the therapeutic work also extended to the wider context of the inpatient unit, in efforts to promote a shared understanding of service users' difficulties. CONCLUSIONS: Therapeutic relationships between service users and clinicians need to be promoted more broadly within acute inpatient care. Psychological formulation can help both service users and ward staff in understanding crisis and working collaboratively. Practice-based evidence is needed to demonstrate the effectiveness of adapted psychological therapy models. PRACTITIONER POINTS: Developing 'human' relationships at all levels of acute inpatient care continues to be an important challenge for clinical practice. Due to the distress of individuals and the constraints of the acute inpatient environment, psychologists need to be flexible and adaptable in delivering individual therapy. Making meaning and psychological formulation can give service users a sense of hope and empowerment, and can contribute to a shared understanding within the ward team of service users' difficulties.