| Summary: | Policy and professional guidance in England have emphasised the importance of Therapeutic Relationships (TRs) in community mental health care, yet there is no comprehensive model to guide practice or understand the process through which stronger TRs are generated. This thesis investigated TRs in community mental health for individuals with psychotic disorders and was embedded within the CRIMSON trial: a randomised controlled trial of the Joint Crisis Plan (JCP) intervention. JCPs contain service users’ treatment preferences for future care, which are jointly decided with clinicians. Qualitative analyses addressed participants’ views of TRs and JCPs. Quantitative analyses addressed the predictive utility of TRs for outcomes, associations of TRs and the effect of JCPs on service user and clinician-rated TR. Results suggested that significant ambiguity persists regarding what can and should be provided in community mental health, resulting in unhelpful experiences for service users and clinicians. A new model of TRs - Consistent Respect - was developed; it presents TRs as bi¬directional processes, jointly affected by clinicians’ and service users’ experiences of interactions and their roles defined by the wider context; the latter often being a barrier to the development of strong TRs. JCPs significantly improved service users’ appraisals of TRs by providing a structured protocol through which routine role enactments were limited and clinicians could demonstrate Consistent Respect. Positive effects were lost when there were deficiencies in the implementation of JCPs and/or engagement of clinicians. In conclusion, improving TRs through JCPs could facilitate better outcomes and more satisfactory treatment experiences for service users and clinicians. Changes in policy and practice are indicated to facilitate transparent goals and roles for clinicians and respectful interactions with service users.
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