Katherine Berry

Improving staff and patient
relationships in psychiatric
rehabilitation settings
Katherine Berry
Clinical Research Fellow
School of Psychological Sciences
 Christine
 Gillian Haddock
 Chris Roberts
 Yvonne Awenat
 All participating staff and service users
Schizophrenia is significant mental health
problem, characterised by psychotic
symptoms, which alter perceptions,
thoughts, affect and behaviour (NICE, 2009).
The diagnosis is frequently associated with
high levels of distress in both service users
and those who support them (NICE, 2009).
Schizophrenia Commission Report (2012)
‘The Abandoned Ilness’ highlighted the
inadequate care people with the diagnosis
receive in the NHS.
In particular the report emphasised the antitherapeutic nature of inpatient care and high
costs incurred by people being detained in
secure services over long periods of time.
Hence the need to improve inpatient
environments and improve outcomes in
long-stay secure settings.
One key predictor of outcome across a range
of different settings and clinical groups,
including inpatients with schizophrenia is the
quality of relationships between staff and
patients (McCabe & Priebe, 2004; Berry et al.,
In patient surveys, the therapeutic
relationship has also repeatedly been
reported as the most important component
of care (e.g. MIND, 2011).
Long stay secure services or psychiatric
rehabilitation services can be highly
stressful environments, not only for service
users, but also staff, as service users
typically have complex presentations and are
hard to engage (RCP, 2009)
Front line staff have direct and regular
exposure to ‘challenging behaviours’, but
often limited training in psychological
models or interventions. (Endley & Berry,
2011; Berry et al., 2012).
With high stress levels and limited
understanding, staff may respond with
criticism, hostility, increasing restraints or
reducing helping behaviour (Berry et al.,
 But limited research on interventions to
improve staff-service user relationships and
stand alone training sessions have limited
impact on practice (Berry et al., 2011).
 Therefore need to develop a more effective
intervention and evaluate it.
Developing the intervention
Starting point: Family interventions which
have been shown to improve outcomes and
relationships for people with schizophrenia
and their relatives (e.g. Pharoah et al., 2010).
Successful family interventions are
individualised, involve psychoeducation and
problem solving and focus on the
relationship between the carer and service
user (NICE, 2009).
Developing the intervention
Clinical practice: Improving staff
understanding and relationships by
developing formulations of individual service
users’ psychological needs with teams of
staff (BPS, 2011).
Aims of the intervention
To emphasise staff members’ own skills in
understanding and working with service
To provide a framework for thinking about
psychological factors motivating individual
service users and driving problems.
To use psychological explanations to
develop support plans.
To give everybody in the team an opportunity
to input into support plans.
Initial meetings with key workers to establish
background information.
Team meetings organised and attended by all
available staff on the ward.
1 - 1 ½ hours long carried out over
‘handover’ period.
Focused on specific service user each
Staff asked to identify service user strengths
and followed by any issues they are
struggling with or want to understand better.
Examples identified include: aggression,
paranoia, poor motivation, social withdrawal
or ‘attention seeking’.
List significant events and relationships in
the service user’s life pre- and postdiagnosis.
Staff asked to think about impact of events
on the service user’s beliefs, including
positive and negative beliefs about self,
others and world in general.
Generate hypotheses about triggers for
stress and preferred ways of coping.
Ways of coping linked to ‘problem’
Discuss maintenance cycles, with an
emphasis on the role of staff responses.
Concludes by discussing implications for
support plans.
Following the team meeting, a report
detailing the key issues discussed is fed
back to the team and service user.
Intervention is carried out over 6 months in
each rehabilitation unit and each service
user is discussed and reviewed at least once.
Formulation framework
Life events and interpersonal
Beliefs about self, other people and world in general
Ways of coping with stress
and ways of relating to others
Physically abused by parents
Bullied at school
Violence in adulthood
‘I’m vulnerable’, ‘Other people are aggressive’, ‘The world is
a dangerous place’
Defensive, hostile and aggressive towards other
people and when challenged.
Preliminary evaluation
Pilot study developing formulations with 30
staff in psychiatric rehabilitation units which
showed promising results in terms of staff
perceptions of their relationships (Berry et al
But limitations of pilot work
- Small uncontrolled study with no follow-ups.
- Lack of established measures of
relationships and no assessment of changes
in practice.
NIHR Project
Aims to develop this programme of research
by assessing the feasibility and acceptability
of the intervention on a larger scale with
more valid outcomes and controls.
Recruitment target is 80 staff and 40 service
users from 10 psychiatric rehabilitation units
in Greater Manchester.
Uses a cluster randomised design with 5
units receiving the intervention and 5 units
receiving treatment as usual.
NIHR project
Standardised interviews and questionnaires
to assess service user symptoms, staff
stress and relationships at baseline, 6months and 12-month follow-ups.
Feedback interviews post-intervention
analysed for key themes.
Data on uptake to study and intervention.
Results of study will be used to inform larger
scale RCTs.
Progress so far
Recruited 87 staff and 50 service users at
baseline across 10 units.
Intervention has been carried out in 4 units,
with 5 control units.
Currently carrying out interventions in unit 5.
Progress so far
Achieved target of recruiting 50% of staff and
25% of service users from each unit.
Although some loss of service users at followup, due to ‘move-ons’ (so far, 80% retained at 6months and 56% at 12-months).
Initial target of 10 meetings per staff member,
but so far staff have only attended a mean of 5
meetings (range = 1-8).
Progress so far
Meetings have been attended by 1-15
members of staff (mean = 6).
All staff have attended at least one meeting.
All service users who were not scheduled for
discharge have been discussed.
Experiences so far
Intervention well received by managers and
all levels of staff.
Key themes from feedback interviews
Importance of recognising staff view points
Recognising strengths of the team
Understanding why service users might be
behaving in a certain way and increased
Generates new ideas for support plans
Opportunity to “off load” about daily hassles
Experiences so far
Need to flexible with days of meetings and
the need for interruptions.
Importance of non-expert stance.
Emphasis on support plans.
Limited remit of intervention and other
aspects of psychologist’s role.
Experiences of control group and importance
of offering them the intervention.
‘Add-on’ projects
When follow-ups are complete interventions
are being carried out in control units with the
aim of developing a fidelity measure.
Evaluation of reports from intervention
meetings as part of an assessment of fidelity.
Investigating factors associated with
relationship quality using baseline data.
Diary study to investigate the influence of
social relationships on symptoms.
Key references
Berry, K., Barrowclough, C., Innes, C., Fitzgerald, M., Hartley, S.,
& Haddock, G. (2012). A description and evaluation of a
challenging behaviour workshop. Journal of Mental Health, 21,
Berry, K., Barrowclough, C. & Haddock, G. (2011). The role of
Expressed Emotion in relationships between psychiatric staff
and people with a diagnosis of psychosis: A review of the
literature. Schizophrenia Bulletin, 37, 958-972.
Berry, K., Barrowclough, C. & Wearden, A. (2009). A pilot study
investigating the use of psychological formulations to modify
psychiatric staff perceptions of service users with psychosis.
Behavioural and Cognitive Psychotherapy, 37, 39-48.
Endley, L., & Berry, K. (2011). Increasing awareness of
Expressed Emotion in Schizophrenia: An evaluation of a staff
training session. Journal of Psychiatric and Mental Health
Nursing, 18, 277-280.