Experiences of crisis care among service users with complex emotional needs or a diagnosis of 'personality disorder', and other stakeholders: systematic review and meta-synthesis of the qualitative literature

Abstract

Background Mental health crises are common in people with complex emotional needs (our preferred working term for people diagnosed with a 'personality disorder'), yet this population is often dissatisfied with the crisis care they receive. Exploring their experiences and views on what could be improved, and those of carers and healthcare staff, is key to developing better services. Aims We aimed to synthesise the relevant qualitative literature. Method Five databases were searched. Eligible studies included service users with a diagnosis of personality disorder and their carers or relevant staff, focused on crisis responses and used a qualitative design. Data were analysed with thematic synthesis. Results Eleven studies were included, most focusing on emergency departments. Four meta-themes emerged: (a) acceptance and rejection when presenting to crisis care: limited options and lack of involvement of carers; (b) interpersonal processes: importance of the therapeutic relationship and establishing a framework for treatment; (c) managing recovery from a crisis: clear recovery plan and negotiating collaboration; and (d) equipping and supporting staff: training and emotional support. Conclusions Our findings suggest that emergency departments have major limitations as settings to provide crisis care for people with complex emotional needs, but there is a lack of research exploring alternatives. The quality of the therapeutic relationship was central to how care was experienced, with collaborative and optimistic staff highly valued. Staff reported feeling poorly supported in responding to the needs of this population. Research looking at experiences of a range of care options and how to improve these is needed.

A scoping review of trauma informed approaches in acute, crisis, emergency and residential mental health care

“…However, if TIC is reducing rates of seclusion and restraint, reducing length of stays, as well as creating a more therapeutic environment (as reported in this review), this may have a positive impact, as conflict is costly (92), while increased patient satisfaction is associated with reduced costs (93). However, there was also a lack of data on carers, perhaps due to our focus on specific settings, and very little evidence on hospital emergency departments (where care may be experienced as traumatising (94)), and on community-based crisis assessment services, home treatment, or acute day units, which future research could investigate.…”

Crisis-focused psychosocial interventions for borderline personality disorder: systematic review and narrative synthesis

“…Although this is broad enough to include people who have presentations that align with a personality disorder, we did not include the terms complex PTSD or complex emotional needs, which are used quite frequently in more recent literature. 10 This may have led to the omission of some studies and should be rectified in future reviews.…”

“…9 This is because these services do not meet the needs of this population, are not trauma-informed and may serve to re-traumatise individuals and reduce the likelihood of help-seeking in the future. 10,11 Frequent presentation to crisis services is a concern for clinicians and policy makers alike. One of NHS England's priorities is to reduce the frequency of crisis presentations of those with complex needs, to reduce service pressures and improve the quality of care provided.…”

It’s time to replace the personality disorders with the interpersonal disorders.

“…Finally, at the level of clinical practice, PD diagnoses often deviate from DSM diagnostic rules and specific criteria (Clarkin et al, 2006; Morey & Benson, 2016). Further, there are many barriers to accessing and maintaining treatment (DeLeo et al, 2022; Lohman et al, 2017; Tusiani-Eng & Yeomans, 2018), most concerning being a lack of insurance coverage for even empirically supported specialized treatment programs for PDs (Paris, 2020; Paris & Black, 2021). Lack of insurance coverage and concern over the stigma associated with a PD diagnosis can lead clinicians to avoid the diagnosis altogether (Sisti et al, 2016; Wright et al, 2022), especially in adolescent patients (Sheehan et al, 2022).…”