Continuity of care and therapeutic relationships as critical elements in acute psychiatric care
Authors: Torleif Ruud, Svein Friis
Journal: World Psychiatry (2022)

In their comprehensive review, Johnson et al1 emphasize that acute psychiatric care consumes a substantial part of the resources available for mental health services, but that evidence on which models are associated with the most positive patient experiences and outcomes remains surprisingly limited. It is well documented that continuity of care and therapeutic relationships are regarded as important factors by patients in mental health services2, 3. There is also evidence that these factors are important in acute psychiatric care. Continuity of care has been shown to be positively associated with outcomes in acute psychiatric services4. Regarding therapeutic relationships, the majority of service users identify emotional support as a core component of crisis resolution team care, and emphasize the need to be given enough time and opportunity to tell their story and talk about their feelings and difficulties5. Building and maintaining a therapeutic relationship is difficult in inpatient acute psychiatric care, but has been shown to be possible and to contribute to lower use of coercion, higher patient satisfaction and better adherence to medication6. There is a need to adapt professional training in building and maintaining therapeutic relationships to the typical acute care setting, with limited time available and other restrictions. Research methods assessing ther­­apeutic relationships also need to be adapted to acute psychiatric care, where the patients have personal contact with their responsible clinician as well as with other staff members. Organization of acute care tends to focus on ready access to the services during a mental health crisis. Less attention is often given to building a therapeutic relationship during the acute care and to securing continuity of care in the transfer of contact to further services. In psychiatric inpatient units, this may result in short inpatient stays, with emphasis on medication and little time available to develop a therapeutic alliance and interacting with the patient as a person, as well as lack of securing adequate personal contact in the process of transfer to the following services. Too short length of stay or a discharge without appropriate follow-up may lead to repetitive short-term stays in acute psychiatric wards. Both length of stays and securing follow-up by health services in the community after discharge have been shown to be positively associated with reduction in readmissions7. Patients with serious psychiatric disorders may be more likely to keep a stability in their condition when they are allowed a long-term contact with clinicians with whom they have developed a trusting rela­­tionship, and they may need time to develop a similar relationship to a general practitioner or someone else in primary care. An additional problem is that many general practitioners are over-burdened and have limited capacity to follow up patients with mental illnesses. It should also be considered that mental health crises often reflect problems that have developed over time and become gradually more serious. Early interventions may address problems when they are less serious and require less efforts for improvement, and low-threshold services may be provided as part of mental health care or primary care. Brief patient-controlled admission (PCA) to a mental health ward in a community center represents such a low-threshold model, which has been innovated in Norway, and is found useful by patients. PCA stays are typically a maximum of 5 days8. The crisis resolution teams in Norway have emphasized early intervention and low-threshold services in addition to community-based crisis interventions for patients who would otherwise be admitted to an inpatient unit. Compared to those in the UK, the Norwegian teams provide crisis care to a broader patient group, with more psychological interventions and less psychotropic medication management9. This practice also includes longer visits or sessions with more time for psychological help and for developing a therapeutic relationship. Like several other team-based health services, crisis resolution team care is a complex model in which several persons provide a wide range of interventions. Variations among team practices suggest that it is hard to practice all elements or components well, and that sometimes different components can compete, e.g., ensuring rapid response to new referrals vs. providing intensive care with frequent visits to current service users. Local adaptations are often necessary, and this may add to challenges in comparing complex interventions across sites and countries. Johnson et al's overview describes a wide range of acute psychiatric care models used in various stages and contexts. For most of these models, there is a lack of research-based evidence, and achieving evidence for all these models may not be possible. However, a possible path may be to use research models currently under development for complex interventions to study individual elements of acute psychiatric care. If such research could identify which elements are critical for what types of clinical effect, these elements could be applied and studied within various models and contexts. One dilemma of the increasing special­ization and differentiation in mental health services, including acute psychiatric care, is the increasing discontinuity of care for service users who need services through several phases of illness. Models with more generic or integrated teams may secure more continuity in the personal relationships between the service user and the service provider. Efficiency requirements focus on management of disorders, but often leave little room for the interaction of providers with persons with these disorders. We need to know more about which out­comes are most important for service users and what elements of acute psychiatric care contribute to the various outcomes. As a part of this, it is important to better understand how continuity of care and therapeutic relationships contribute to positive patient experiences and outcomes in acute psychiatric care, and how these two critical elements may be provided.