The role of sub-acute residential mental health services in recovery

  • Kerry Anne Thomas

    Student thesis: Doctoral Thesis


    This thesis including published works contributes to the knowledge of how a residential mental health service can assist clients with sub-acute symptoms in their recovery journey. It makes an original contribution to this field by advancing the knowledge and understanding of the role a sub-acute mental health service can have as a facilitator of recovery, and the recovery environment that supports a person in their recovery journey. This thesis also provides a multi-faceted account of the similarities and differences in clinical outcomes and recovery support needs of clients who have entered the service directly from the community (step-up admissions) and those who have transferred from an inpatient unit (step-down admissions). The goal of this research was to fill a knowledge gap on the effectiveness of a sub-acute residential service on clinical outcomes and build conceptual understanding of essential elements of the recovery environment and facilitators of recovery that had assisted clients. This research adds to the conceptual knowledge of the needs of people with sub-acute symptoms recovering from serious mental illness and highlights the differing needs of clients, depending on the setting from which they have accessed a residential mental health service. The research achieves this by investigating the clinical outcomes for both step-up and stepdown clients, and by examining the recovery environment and organisational climate of the service from the perspectives of both client groups and the staff. This research used a mixed-methods design that was comprised of six components, including a systematic review of the literature, a detailed service description, a longitudinal quantitative analysis of clinical outcomes, a cross-sectional survey study of the recovery environment, and a qualitative analysis of clients’ perceptions of the facilitators of recovery, including a detailed study of one client who had multiple service admissions. The first component was a systematic review of literature reporting on the clinical outcomes, cost-effectiveness and user-satisfaction of acute and sub-acute residential mental health services. The main finding of this systematic review was that there was considerable evidence supporting the effectiveness of acute residential mental health services, but very little research examining the outcomes of sub-acute residential services. The second component was designed in response to the limited research on sub-acute residential services identified in the first component. The aim was to provide a detailed description of a sub-acute residential service’s philosophy, programs and comparative cost effectiveness, to add to the current knowledge and understanding of sub-acute residential services. The service examined is part of a growing trend toward including step-up/stepdown sub-acute services as part of the mental health continuum of care. In addition to providing a description of the service, this study found that the sub-acute service is a cost effective alternative to inpatient admission for clients with sub-acute mental health problems. The third component was a longitudinal quantitative study of the clinical outcomes for step-up and step-down clients of the residential service. The aim of the study was to examine the effectiveness of the service in providing positive mental health outcomes for clients, evident in improvements in symptoms and psychosocial functioning. Self-report and clinician-report assessments of symptoms and psychosocial functioning at admission and exit were available for 17 step-up and 24 step-down participants. Twelve of these participants completed the follow-up assessment of self-report symptoms, functioning, and quality of life, three months after exiting the service. This study found that both client groups experienced positive clinical outcomes at exit, compared to when they were admitted to the service. At three months post exit, clients had maintained their clinical gains and reported positive quality of life, albeit significantly lower than the quality of life experienced by the general population. The fourth component was a cross-sectional survey of the perceptions of step-up and step-down clients and staff of the recovery environment at the residential service. The aim was to examine client and staff perspectives of the service’s delivery of key recovery elements and the organisational climate of the recovery environment. Nine step-up and 18 step-down clients, and 10 staff completed the Recovery Enhancing Environment Measure. Both client groups and the staff rated each of the recovery elements as important and that the service was performing well in these areas. Client groups and staff differed in the performance gaps they identified in the service, with step-down clients and staff identifying more elements in which the service was under-performing, compared to step-up clients. All respondent groups rated the organisational climate of the service positively. The fifth component was a qualitative exploration of the perceptions of step-up and step-down clients of how the service had facilitated their recovery. The aim was to identify the specific features of the sub-acute residential service that clients reported had helped them in their personal journey of recovery; in particular, the recovery processes of finding hope, redefining self-identity, developing a meaningful life, and taking responsibility for recovery. Four key themes emerged from this enquiry: community context, personal support, the formal programs offered, and assistance in personal recovery processes. This study found that the two client groups had differing views on the ways in which the service had assisted them in their recovery and in their preparation to return to living in the community. The sixth component examined the recovery journey of one woman over an 18-month period and three admissions to the residential mental health service. The aim was to explore the individual recovery process of a client of the service and how the service had assisted her in her recovery journey. The study found that this woman experienced change over time in her focus on the recovery processes and identified a range of features of the residential service that were instrumental in her recovery progress. Repeat admissions to the residential service had assisted this woman to progress in her recovery. This thesis contributes significantly to our understanding of the role of a sub-acute residential mental health service in assisting people in their recovery from serious mental illness. It is the only research that has examined the clinical outcomes, recovery environment and facilitators of recovery of a sub-acute residential service for both step-up and step-down clients. The thesis presents seven key elements contributing to the effectiveness of the subacute service that were identified in the research: social relationships and connection; peer support and client participation; self-management; caring staff; inclusion of physical health care; incorporation of personal needs in service delivery; and integration of systems of care. The implications of these findings for the delivery of sub-acute residential services are discussed in relation to the current climate of reform of mental health service provision in Australia. Extensive system reform has been proposed by the Commonwealth Government, in response to the 2014 Report of the National Review of Mental Health Programmes and Services (National Mental Health Commission,2014). The intention of this system reform is to offer tailored services providing a holistic approach to meet the diverse needs of mental health service users. The role of sub-acute residential services within this framework is discussed and future research directions are suggested.
    Date of Award2016
    Original languageEnglish
    SupervisorDebra Rickwood (Supervisor) & Tricia Brown (Supervisor)

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