Despite the relatively high prevalence of ‘personality disorders’ in the general population and even higher prevalence within mental health services, this diagnosis has been considered a cause of stigma, rejection, and limited access to health care services (Sheehan, Nieweglowski & Corrigan, 2016). Although some people have found the diagnosis helpful to validate their symptoms, many still find it unhelpful or even detrimental, as some people not only don’t agree with the diagnosis but also struggle to access services because of it.

Different reasons have been associated with these negative experiences, including poor staff knowledge about ‘personality disorders’, frustration, lack of training, and views of this diagnosis being intrinsic to the person, so they are “self to blame” (Ring & Lawn, 2019). To reduce stigma and improve services for people with ‘personality disorders’, some authors have suggested the adoption of a holistic approach that can offer service users support for their mental and physical health, and their social needs (Troup et al, 2022). Although these proposed interventions could represent a positive impact on ‘personality disorders’ service users, most interventions have been developed without the views and inputs of those same users.

To address this, Trevillion et al (2022), conducted a qualitative study, co-produced by a team of researchers and clinicians, many of them with relevant lived experience, with the aim of identifying best practices in community interventions for people with ‘personality disorders’, considering service users’ experiences and perspectives. For this study, the authors decided to use the term complex emotional needs (CEN) when referring to people who have been diagnosed with a ‘personality disorder’, who have been referred to ‘personality disorders’ services, or who have experienced related problems (e.g. self-harm), this in recognition of the considerable stigma attached to a ‘personality disorders’ label.

Methods

This was a co-produced qualitative research study, which included experts by experience (six members), experts by occupation (nine members), and researchers (nine members) who worked in partnership at every stage of the study, including inception, data collection, and analysis.

The authors used a purposive sample, using the following inclusion criteria:

1. Aged 18 and above.
2. Having received a diagnosis of ‘personality disorder’ (PD) or self-identifying as having difficulties that may result in a PD diagnosis; or having used complex emotional needs (CEN) services.
3. Having used community services for their mental health.
4. Being able to participate in an interview in English.
5. Having the capacity to consent.

Additionally, the authors sought to recruit individuals with certain demographic characteristics to capture a wide and diverse range of experiences (i.e. age, gender, sexual orientation, ethnicity, and geographical location), to understand how the intersectionality of identities influenced people’s experiences. Participants were recruited from voluntary sector organisations and online social media networks. Interviews were either online or face-to-face, then they were recorded and transcribed verbatim, and the content analysed using thematic analysis.

Results

In total, 30 people took part in the study. All participants received a diagnosis of ‘personality disorders’ at some point in their life and the majority were female (n=12), heterosexual (n=12), white British (n=19), and located in London (n=17).

The authors identified four central themes: understanding; interpersonal connection; consistency and continuity; and adaptability and accessibility. All these themes were linked by a central theme, which the authors considered best described their findings: relational practice.

The theme understanding included six subthemes that highlighted the need of improving clinicians’ knowledge, as well as address their negative attitudes and behaviours, which can negatively impact service users’ experiences. This theme also highlighted the importance of adopting a trauma-informed care approach, which participants considered acknowledges the impact past traumatic experiences have on people’s lives; and the importance of coordinating with other services to better address the different intersecting factors which negatively contribute to their recovery.

The theme of interpersonal connection included subthemes focused on validation, active/empathetic listening, compassion, and open dialogue. These subthemes suggested clinicians need to improve communication with service users, making sure they acknowledge and validate people’s experiences, always interacting in a compassionate and collaborative way.

The subthemes regarding consistency and continuity highlighted the importance of offering service users consistent and continued support from known staff, in a timely way, meaning being able to receive the right care at the right time. These subthemes also recognised the importance of collaborative work across services and localities to avoid a lack of consistency and disparities in the care offered to service users.

The last theme, adaptability, and accessibility, included subthemes that described the importance of taking proactive steps to encourage engagement with service users; as well as the importance of offering services in a flexible manner and including a wide range of interventions that can suit service users’ complex and different needs.

Conclusions

The authors concluded that adopting a relational approach is the best way to support people with CEN in community services, as this approach prioritises therapeutic relationships over standardised procedures. However, they recognised the difficulty of implementing this approach as healthcare services tend to emphasise the implementation of standardised procedures and measure success based on performance targets. Additionally, the authors also recognised that some organisational factors, such as staff levels, management support, and access to reflective and clinical supervision, can influence the adoption of a relational practice approach. In order to successfully design and develop mental health services focused on relational practice, these need to be co-produced with people with relevant lived experience, along with their carers and the professionals who support them.

Strengths and limitations

The main strength of this study is that the authors adopted a real co-production approach, by including people with lived experience at every stage of this study, and by providing a clear and comprehensive description of how everyone involved in the study contributes to its design and development. Another strength was the adoption of a purposive sampling approach to recruit participants from a broad range of characteristics to illustrate intersectionalities, which could influence people’s experiences with community health services. I also found the proposed use of the term CEN sensitive, as the ‘personality disorders’ diagnosis has been associated with stigma and discrimination, and is often incorrect or harmful.

Despite its strengths, there were some limitations to this study. For instance, although the authors tried to purposely recruit participants with different sociodemographic characteristics, they didn’t succeed. So, it is unlikely results really capture the experiences of people from the global majority or the LGBTQI+ community. Another limitation was the lack of information regarding how authors grouped all identified themes in the relational practice central theme; or how authors reached the conclusion that relational practice is the best way to support people with complex emotional needs (CEN). Although the authors offered a short description of relational practice, they did not link their results to current theories, which include considering the relational practice as a way of creating sustained health-promoting relationships with service users, carers, and colleagues (CLPN, 2018); or as a type of practice which allows people to connect and grow, and in which mutual trust leads to empowerment (Emmamally W, et al 2022). Although based on these definitions, we can argue that results support the conclusions, the authors did not provide enough information to allow readers to reach these conclusions on their own.

Implications for practice

Despite its limitations, this is a very interesting study with important implications for practice. Firstly, this is a good example of coproduction. Although funding bodies require the inclusion of Experts by Experience (EbE) in the research team, sometimes it’s not clear how they were involved, or if they were invited as a box-ticking exercise. Other authors can imitate the active involvement of EbE and the written account of their contribution to dissemination.

Secondly, this study confirms people with complex emotional needs (CEN) are not finding current community services useful or able to meet their needs. However, this study shows people with CEN can identify how services should be designed to care for them. Current and future services not only need to look into the evidence, but they also need to conduct service development research and consult with service user panels. Equally important is to remember that like people with any other diagnosis, service users with CEN should be treated in an individualised, non-stigmatising, kind and compassionate way, all elements, part of a relational practice approach.

Finally, practitioners can reflect on these findings to better support service users with CEN. Like anyone else, people with CEN want to feel included, understood, and seen in a non-judgemental and non-discriminatory way. Also, clinicians need to reflect on their own negative beliefs regarding people with CEN, and on how these beliefs can affect the way they treat patients so as to not perpetuate stigma. Clinicians can also offer support in other areas such as housing issues or benefits, as they can liaise with other services or offer support letters stating the impact of these issues on someone’s mental health. We need to actively advocate for our patients, as we know how social determinants affect people’s physical and mental health. Not offering support to address these issues, can be a barrier to their recovery.

Statement of interests

Working in a crisis team I have seen many patients with complex emotional needs, who unfortunately have had negative experiences with healthcare services, experiences that have led them to feel frustrated and even hopeless about getting the right support. The characteristic of our service, which focuses on providing rapid and intense care, but does not provide long-term support, can contribute to these negative experiences due to the lack of consistency and continuity. However, the feedback we often receive includes comments regarding how we help people by providing immediate care, as well as validation, understanding, and compassion. We know there is still much more that needs to be done, but this study reminded me of the importance of always putting people at the centre of every decision, and always treating them in a kind and compassionate way, which can be the most valuable elements of any crisis intervention.

Links

Primary paper

Trevillion, K. et al. (2022). Service user perspectives of community mental health services for people with complex emotional needs: a co-produced qualitative interview study. BMC Psychiatry; 22:55. https://doi.org/10.1186/s12888-021-03605-4

Other references

College of Licensed Practical Nurses of Alberta (2018). Relational Practice, Beyond Introductions and Interviewing. study-guide.pdf (studywithclpna.com)

Emmamally, W., Erlingsson, C., Brysiewics, P. (2022). In-hospital interventions to promote relational practice with families in acute care settings: A scoping review. Health SA; 27:1694. doi: 10.4102/hsag.v27i0.1694

Ring, D., Lawn, S. (2019). Stigma perpetuation at the interface of mental health care: a review to compare patient and clinician perspectives of stigma and borderline personality disorder. Journal of mental Health; DOI: 10.1080/09638237.2019.1581337

Sheehan, L., Nieweglowski, K., & Corrigan, P. (2016). The Stigma of Personality Disorders. Curr Psychiatry Rep; 18:11. https://doi.org/10.1007/s11920-015-0654-1

Troup, J., et al. (2022) Clinician perspectives on what constitutes good practice in community services for people with complex emotional needs: A qualitative thematic meta-synthesis. PLoS ONE; 17:5 https://doi.org/10.1371/journal.pone.0267787

Zou, P. (2016). Relational Practice in Nursing: A Case Analysis. Nursing Health Care; 1:1. https://doi.org/10.33805/2573-3877.102

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