People on acute mental health wards struggle to access talking therapies, research found. This was due to the emphasis on medical treatments, a lack of available psychologists, and ward staff not seeing the value of talking therapy.
Acute mental health wards admit people experiencing a mental health emergency. They might have depression, schizophrenia or an eating disorder, for example, and they are too ill to go home. According to the Royal College of Psychiatrists, these people should receive a talking (psychological) therapy, but most in the UK do not.
This study interviewed staff, patients and carers about access to therapy on acute mental health wards. They found that staff were overworked and lacked the capacity to practice therapy. Staff also thought it may be too difficult for patients to engage with therapy: patients are in hospital for a short time only, they are distressed and might be on strong medications. However, patients often just wanted someone to talk to.
The researchers developed recommendations to improve access to therapy. They suggested that psychologists need to be visible on the ward, and that clinicians need training and encouragement to practice therapy. People need mental health support in the community after they are discharged.
The issue: most people on acute mental health wards do not receive talking therapy
Severe mental illnesses include schizophrenia, bipolar disorder, and psychotic depression. Many people with these conditions experience depression, anxiety, hallucinations, and disordered thinking. The conditions can be distressing and make everyday life difficult. During a mental health crisis, they may be admitted to acute mental health wards.
People on these wards can benefit from a talking therapy, such as cognitive behavioural therapy (which helps people change the way they think and behave). However, most do not receive it.
This study interviewed staff, patients and carers about how to improve access to therapy on acute mental health wards. It was part of a larger programme called Talk, Understand, Listen for Inpatient Settings (TULIPS), which aims to improve mental health support in hospitals.
Between 2018 and 2019, researchers interviewed 26 members of staff, including mental health nurses, psychologists, and others. The study included 22 patients with schizophrenia, bipolar disorder or other severe mental health conditions; all had been cared for on an acute mental health ward. It also included 12 carers, who had looked after people with severe mental illnesses.
The interviews with staff, patients and carers explored barriers to accessing therapy. Four themes emerged.
- Patients were discharged quickly
Staff believed their role was to stabilise patients’ mood with medication (especially those with psychotic illness), and to discharge them quickly: “We need to get the meds stable and get them out.” Patients thought they were discharged too quickly, and ended up back on the ward like “a revolving door.” All groups found wards chaotic and often lacking a dedicated room for therapy. Staff felt that senior staff (head nurses, consultant psychiatrists) needed to promote therapy.
- Care was not joined-up
Psychologists saw patients infrequently or were absent from wards; they were not seen as core team members. Clinicians therefore neglected to refer patients for therapy. All groups thought acute mental health wards were disconnected from other wards and community care. Clinicians did not see value in short-term therapy. One staff member said, “It’s unfair on the service user to actually start [therapy] then be discharged.” Continuing therapy after discharge was difficult due to long waiting lists. Patients and carers agreed that discontinuing therapy in the community was disappointing but were therefore especially keen to access therapy while they were on the ward.
- Patients were distressed
Some clinicians thought that high levels of stress, or side-effects from strong medications (such as difficulty concentrating) would make it unlikely that therapy would produce meaningful improvements. However, often patients just wanted someone to talk to: “It’s more getting stuff off me chest, like with things that have happened, like arguments.” Most wanted therapy, but some did not trust staff and didn’t want to engage with it. They often did not know what therapy would involve. Some feared it would delay their discharge.
- Staff lacked capability and motivation
Nurses who were not trained were reluctant to provide psychological support (such as improving coping skills). One staff member said, “I would feel nervous to do it, ‘cos we’re not used to doing psychology with patients.” Those who had been trained thought it was valuable. Staff were overworked, moved from one crisis to the next, and could feel that it would be difficult to try new approaches. Therapy involves calm, considered reflection, which could be difficult to provide on busy wards.
Why is this important?
Interviewees identified many barriers to access to therapy, but all groups were willing to overcome them. The researchers identified areas to be addressed. For example, increasing the importance placed on therapy, joining up the care provided by psychologists, ward staff and community services, and increasing staff members’ capability and motivation to provide therapy (especially for short-term inpatient care).
They recommend that:
- a cultural shift is made in how clinicians value therapy (especially ward leaders); staff need to actively promote it
- psychologists are based within wards and provide different types of therapy; they need to have dedicated rooms to deliver therapy
- hospitals develop better relationships with community teams so that patients can continue therapy post-discharge
- psychologists support and train clinicians and encourage them to practice therapy as part of their everyday care.
One of the hardest barriers to overcome will be staff members’ negative expectations of therapy, the researchers say. Better staff training is needed to address this. For example, nurses could receive psychological training as part of their degree.
Trusts could implement the recommendations of this paper locally. However, more resources are needed to improve mental health services nationally.
Most interviewees were White. Further research could explore whether people from diverse ethnic backgrounds experience different barriers to accessing support. Most were from the Northwest of England, so further studies could investigate if the findings are similar in other parts of the UK.
The lead author of this paper is now assessing how psychological support affects patient wellbeing and safety, staff burnout, and the atmosphere on acute mental health wards. This research will also assess the value for money of talking therapies.
You may be interested to read
This Alert was based on: Berry K, and others. Exploring how to improve access to psychological therapies on acute mental health wards from the perspectives of patients, families and mental health staff: qualitative study. BJPsych Open 2022;8:e112
More information about the TULIPS programme is available on their website.
A blog summarising the need to improve the provision of therapy on acute mental health wards.
Guidance for policymakers from the Association of Clinical Psychologists to improve psychological services on acute mental health wards.
The Royal College of Psychiatry’s standards of care for the provision of therapy in hospitals.
Funding: This research was funded by the NIHR Programme Grant for Applied Research.
Conflicts of Interest: The study authors declare no conflicts of interest.
Disclaimer: NIHR Alerts are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that views expressed in NIHR Alerts are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care.