Many individuals who are diagnosed with a ‘personality disorder’ often face negative outcomes, such as being stigmatised and excluded from receiving necessary services. To address these concerns and better understand their needs, a more neutral term Complex Emotional Needs (CEN), is used to describe the experiences of individuals who are likely to receive a’personality disorder’ diagnosis.
What do we know?
Around 4.4% of the population experiences needs that align with the criteria for a ‘personality disorder’ diagnosis. This diagnosis is connected to various challenges, including higher rates of co-existing conditions, premature mortality, increased service utilisation, and elevated treatment expenses. Concerns regarding the quality and accessibility of services have been raised, and there is limited evidence available to guide the enhancement of services and the implementation of more suitable, effective, and affordable care models.
What’s the next step?
In previous studies, experts have identified some good practices for supporting individuals with CEN in community mental health services. These practices include providing high-quality, personalised care, building strong and ongoing relationships with healthcare providers, and taking a proactive and collaborative approach. However, there is still more we need to learn about the obstacles and opportunities for providing the best care.
The research team invited 50 mental health professionals working with people with Complex Emotional Needs (CEN) to discuss the current and ideal service conditions, along with the barriers and facilitators of best practice. They employed purposive sampling, yielding a diversity in gender, ethnicity, service types and sectors, and professional backgrounds.
Interviews were analysed using reflexive thematic analysis, guided by a phenomenological framework. A highlight of the study was the co-productive approach. The research team involved 6 academics and 13 experts by experience or occupation, who contributed equally from drafting the protocol to analysing interview data. Research skill training and emotional support were available to ensure study quality and peer researchers’ wellbeing.
Participants acknowledged gaps between the needs of people with Complex Emotional Needs (CEN) and the care currently available. Key barriers to quality care included the stigma associated with the ‘personality disorder’ diagnosis, a lack of collaboration across services, and a lack of training and supervision for staff. A few facilitators were also identified, including co-production with service users and person-centred, trauma-informed care. The authors generated three themes from the interviews.
Theme 1 described the diverse individual needs nesting under the same diagnosis. The ideal care was described as individualised and person-centred, flexible, collaborative across services, and co-produced with service users. Essential to such care are well-managed staff-patient relationships, and keeping clear boundaries while being caring. Valued staff characteristics included being empathetic, compassionate, authentic, flexible, supportive, and having good interpersonal skills. Additionally, while participants emphasised the importance of trauma-informed approaches for understanding and empowering patients, they acknowledged a lack of clarity in its definition, and therefore consensus in its practice.
Theme 2 shifted the lens of focus to the experiences of healthcare providers themselves, who reported a dual-level challenge in working with this patient group. On a personal level, staff members often felt powerless in supporting patients, who they empathise with. This is attributable to structural challenges, including the overarching culture of stigma and inadequate resources for this group of patients in the system. As a result, healthcare providers either (feeling hopeless) resorted to therapeutic pessimism, or avoided these patients out of fear of the perceived risks associated with them.
Well, that’s not going to work for this person, but you’re stuck by the constraints of the service […], their KPIs.
I don’t have the resources to do this. They need to be somewhere else.
Co-produced and co-delivered training, as well as reflexive supervision sessions, were proposed to combat such a stigmatising and pessimistic culture.
Theme 3 delved deeper into the system-wide limitations. Emerging from the participants’ description was a vicious cycle, initiated by stigmatisation and risk-averse attitudes towards individuals with complex emotional needs. Being excluded from support and care, however, would only elevate their risks, further strengthening the associated stigmas. Finally, the lack of training opportunities and poor resourcing and funding made it difficult to break the cycle.
This study reiterates the findings of a previous meta-synthesis on clinician perspectives on good practice in community services for people with Complex Emotional Needs (CEN) (Troup et al., 2020). It reinforces the importance of person-centred and empathetic care. However, what sets this study apart is its focus on uncovering the barriers and facilitators to implementing these best practices.
The study highlights barriers such as stigmatising attitudes towards people with CEN and the need for a coherent service system, long-term treatment plans, and easy access to high-quality care. Clinicians stressed the importance of ongoing training and support to enhance their ability to provide optimal care for individuals with CEN. Notably, clinician perspectives align with service users’ experiences, adding to the importance of systemwide changes. Thus, to deliver the best possible care for individuals with CEN, it is essential to prioritize flexibility, sustainable funding, and ongoing training and support for staff.
Strengths and limitations
The study’s strength resides in its strong collaborative approach, bringing together experts by both experience and profession, thus offering a rich and varied viewpoint in the thematic analysis. This joint effort could bolster the credibility and dependability of the research outcomes, highlighting a considerable advancement towards creating policies based on solid evidence.
However, there are discernible potential shortcomings. The sample is not ethnically diverse, predominantly featuring white participants. This could induce a selection bias, potentially neglecting the unique challenges and experiences faced by staff from other ethnic backgrounds, which is key in crafting a more inclusive mental health model.
Moreover, the study seems to neglect a key facet: integrating patients’ viewpoints directly into the research framework. This omission might restrict the investigation’s depth, failing to uncover potential divergences between staff insights and patient experiences, a vital perspective typically explored to enhance service delivery and satisfaction. Hence, a multi-faceted approach incorporating both qualitative and quantitative feedback from service users could unveil trends and connections possibly missed in a staff-focused study, introducing a potential data bias where the absence of key data (from patients) could distort findings.
Furthermore, excluding perspectives from staff in forensic, crisis, or inpatient settings can be seen as a limitation. These settings cater to individuals with Complex Emotional Needs (CEN), directly affecting community mental health services, and possibly influencing care trajectories and outcomes. Including these viewpoints might yield insights into potential variables affecting results, thus augmenting the study’s breadth and real-world applicability.
Lastly, considering the COVID-19 pandemic, a deeper analysis of its impact on service adaptation seems necessary. Understanding how the pandemic might have served as a confounding variable, influencing both staff experiences and service delivery modalities, could have added a rich layer of data, potentially helping to frame more resilient community mental health models for the future.
Implications for practice
A primary implication that emerges is the necessity to incorporate the understanding of a person’s history into their care regimen, particularly focusing on how past experiences of neglect and abuse might influence their current state. Practitioners should be trained adequately to acknowledge and respond to these, thus developing a more rounded approach to care that considers the individuals’ complete backgrounds. This insight should be a cornerstone in training modules, helping staff to foster empathy and build fruitful, understanding relationships with the service users.
Furthermore, the study underscores the significant role that therapeutic relationships play in effective treatment for individuals with Complex Emotional Needs (CEN). Despite being often undervalued, these relationships stand as a key component in the pathway to positive outcomes. The findings suggest a needed shift in both research and practice, where a heightened focus should be placed on establishing and nurturing therapeutic relationships, steering clear from a one-size-fits-all approach and moving towards tailored and person-centred care plans.
At a systematic level, the ongoing stigmatisation of people with CEN emerges as a significant barrier to best practice care. To foster improvement, future initiatives should strive to reduce this stigmatisation, delving deep to understand and subsequently address both the individual and organisational factors that propagate this issue. An integrative approach that combines staff support and training appears to be crucial. This would not only facilitate a better understanding of CEN but would also provide the staff with the tools and resources necessary to offer effective care, reducing the gap between current practices and the best practices identified in this study.
In addition to addressing stigmatisation, there is a pressing need to tackle the systemic inequities that individuals with CEN continually face. Future efforts should be geared towards alleviating these disparities, with a particular focus on how under-resourcing affects the quality and accessibility of best practice care. Policies should be revisited and revamped, ensuring that individuals with CEN are not marginalised but are instead provided with care that meets their unique needs holistically. Future research avenues should explore the potential of specialist psychotherapies and trauma-informed approaches in crafting high-quality, comprehensive care systems that truly resonate with the needs of the individuals.
Statement of interests
Thanks to the UCL Mental Health MSc students who wrote this blog from the Bisby A student group: Xiaoke Qiu, Dilshard Alam (@Dilshard_Alam), Maya Estephan, and Haneen Hakeem.
UCL MSc in Mental Health Studies
This blog has been written by a group of students on the Clinical Mental Health Sciences MSc at University College London. A full list of blogs by UCL MSc students from can be found here, and you can follow the Mental Health Studies MSc team on Twitter.
Foye, U., Stuart, R., Trevillion, K. et al. Clinician views on best practice community care for people with complex emotional needs and how it can be achieved: a qualitative study. BMC Psychiatry 22, 72 (2022)
Jordan, T., Billie Lever, T., Luke Sheridan, R., et al. (2020). Clinician perspectives on what constitutes good practice in community services for people with Complex Emotional Needs: A qualitative thematic meta-synthesis. medRxiv, 2020.2012.2015.20248267. doi:10.1101/2020.12.15.20248267