Clinician perspectives on what constitutes good practice in community services for people with Complex Emotional Needs: A qualitative thematic meta-synthesis

Abstract

Introduction The need to improve the quality of community mental health services for people with Complex Emotional Needs (CEN) is recognised internationally and has become a renewed policy priority in England. Such improvement requires positive engagement from clinicians across the service system, and their perspectives on achieving good practice need to be understood. Aim To synthesise qualitative evidence on clinician perspectives on what constitutes good practice, and what helps or prevents it being achieved, in community mental health services for people with CEN. Methods Six bibliographic databases were searched for studies published since 2003 and supplementary citation tracking was conducted. Studies that used any recognised qualitative method and reported clinician experiences and perspectives on community-based mental health services for adults with CEN were eligible for this review, including generic and specialist settings. Meta-synthesis was used to generate and synthesise over-arching themes across included studies. Results Twenty-nine papers were eligible for inclusion. Six over-arching themes were identified: 1. The use and misuse of diagnosis; 2. The patient journey into services: nowhere to go; 3. Therapeutic relationships: connection and distance; 4. The nature of treatment: not doing too much or too little; 5. Managing safety issues and crises: being measured and proactive; 6. Clinician and wider service needs: whose needs are they anyway? The overall quality of the evidence was moderate. Discussion Through summarising the literature on clinician perspectives on good practice for people with CEN, over-arching priorities were identified on which there appears to be substantial consensus. In their focus on needs such as for a long-term perspective on treatment journeys, high quality and consistent therapeutic relationships, and a balanced approach to safety, clinician priorities are mainly congruent with those found in studies on service user views. They also identify clinician needs that should be met for good care to be provided, including for supervision, joint working and organisational support.

Service user experiences of community services for complex emotional needs: A qualitative thematic synthesis

“…This reinforces the need to include people with lived experience of CEN and of using services, as well as their families and friends, in the development and assessment of services and care pathways. The perspectives of clinicians, investigated in an accompanying review [75], as well as those of family and friends, also need to be understood to ensure plans to improve care are feasible, and to develop approaches to reducing stigma and improving understanding and attitudes. Furthermore, we note also that trials of therapeutic interventions to date have tended to focus on testing effects of specific therapies over relatively short durations [76].…”

Service user perspectives of community mental health services for people with complex emotional needs: a co-produced qualitative interview study

“…Our team recognises the considerable stigma attached to the label ‘personality disorder’, and the considerable associated harms identified by both service users and clinicians (6, 7). Many people find it unhelpful and do not identify with it.…”

“…Mental health services are found to marginalise service users with CEN and, compared with other mental health conditions, the provision of timely, well-resourced interventions and good quality care for this service user population appears to lag behind (7–10). Our recent meta-synthesis of the international evidence on service users’ experiences of mental health services identified several areas for which there is a strong consensus on what kind of care is needed (6).…”

“…support that addresses service users’ psychological, social, and physical needs), delivered by skilled and compassionate staff who understand the need for a long-term perspective on treatment. Our complementary meta-synthesis of international clinician perspectives highlights that some staff, especially in generic mental health services, hold ambivalent, pessimistic, and stigmatising views about people with CEN and may lack the knowledge and skills to effectively support people (7). Access to specialist services and longer-term treatments are also reported to be impeded by a lack of clear referral pathways and accessible services for people at various stages in recovery journeys (7).…”

“…Our complementary meta-synthesis of international clinician perspectives highlights that some staff, especially in generic mental health services, hold ambivalent, pessimistic, and stigmatising views about people with CEN and may lack the knowledge and skills to effectively support people (7). Access to specialist services and longer-term treatments are also reported to be impeded by a lack of clear referral pathways and accessible services for people at various stages in recovery journeys (7). Clinicians call for better organisational support, more joint-working practices and clinical supervision to assist them in delivering better care to service users (7).…”