Discussion
This is the first UK-based study to our knowledge that explores relational aspects of medical consultations in primary and secondary care settings, in patients with a diagnosis of personality disorder.
This study highlights the complexity that patients with personality disorder face when in consultations with their GP and psychiatrist. Given that prescriptions are discussed and offered within the context of the doctor-patient relationship, and personality disorder is itself a relational disorder and a disorder of attachment,19 it is not surprising that this study found various complex interpersonal dynamics which come in to the consultation room.
We found that patients can become angry and engage in self-destructive behaviours as a reaction to perceived neglect by their doctor. Patients perceived doctors handing over decision making to them as a dismissive act, yet they perceived doctors who quickly turned to medications, as controlling and uncaring. Ultimately, they valued the doctors who showed that they cared by listening, being ‘human’ and who were prepared to enter into a balanced professional ‘relationship’ with them, in keeping with findings in many other patient groups such as medically unexplained symptoms,20 and bipolar affective disorder.21
We found that patients with personality disorder often experienced aspects of the healthcare system as uncaring and invalidating. How the doctor relates and validates their suffering was found to have a vast impact on the way patients subsequently managed and contained their emotions, extending even to moderate the effects of prescribing.
The study found that the nature of the doctor-patient relationship was perceived as having an important role on the outcome, with prescriptions being intimately linked to feeling validated or invalidated. It would therefore be important to acknowledge and improve awareness of emotions that arise in consultation rooms from the clinician and patient perspective. Enhanced awareness of these emotions are likely to impact on various outcomes and satisfaction for both clinicians and their patients. There is evidence that patient-centred communication impacts positively on patient outcomes such as recovery and emotional health.22
The final theme which emerged was perceptions and expectations regarding the healthcare system when different professionals were involved. Participants valued continuity of care and specialist input but felt that professionals did not communicate well with each other leading to fragmented experiences. People with personality disorder often require multiagency input because of their multiple needs and attachment styles.17 19
Despite development of healthcare structures such as the stepped-care model and shared-care agreement to promote continuity, patients might continue to be passed from one clinician to another with nobody taking responsibility for the patient as a whole. Balint captured the inevitable loss of patient trust best by the phrase ‘the collusion of anonymity’ to describe the confusion a patient and their family feel when ‘vital decisions are made without anyone feeling fully responsible for them’, reflecting clinicians’ reluctance to hold responsibility for complex and high-risk patients.23 Thus, a lack of communication between professionals, splits in treatment approaches and differences in levels of training can serve to further alienate the patient from professionals, especially prescribers, who might resort to prescribing as a quick solution to unmanageable distress in times of crisis.
Encounters in the consultation room are known to activate powerful emotions for doctors. A qualitative study of psychiatrists’ perspectives when prescribing for personality disorder, exposed a number of themes such as ‘difficulty in collaborating in emotionally charged consultations’, ‘feeling helpless when unable to relieve suffering’ and ‘the drug as facilitator in the doctor-patient relationship’ among others.14 The authors concluded that ‘prescribing decisions may be powerfully influenced by emotional factors’ in the doctor-patient relationship and emphasise the need for psychiatry to regain the psychotherapeutic perspective that can sometimes be lost in biological determinism and diagnostic pursuits.
Research shows that personality disorders continue to be stigmatised by clinicians themselves. A recent study found that psychiatry trainees in the UK hold more negative attitudes towards patients with personality disorder compared with depression, and hold significantly less sense of purpose when working with personality disorder.24
Clinicians clearly face numerous challenges when in consultations with this patient group. Given the difficulties that they face not least at an emotional level, it would be imperative to improve clinicians’ attitudes towards personality disorder for the benefit of both clinicians and patients. Personality disorders are associated with numerous adverse long-term outcomes including physical health comorbidity3 and prolonged contact with mental health services in both inpatient and outpatient settings.25
Although ‘psychotherapeutic medicine’ is a concept that has been embedded in the practice of medicine for many years,26 it would be important not to lose the human skill of being a doctor in what can be a busy and rushed working environment. The Royal College of Psychiatrists has re-emphasised the importance of ‘psychotherapeutic psychiatry’, ‘from cradle to the grave’, as seen in strategic developments aiming to reinforce psychotherapy skills throughout training and practice.27
Strengths and limitations
The focus group methodology in this study allowed for a meaningful interaction and we believe an in-depth exploration of the subject compared with conducting individual interviews. The sample size of seven service users (three and four in each of the two focus groups) was small. Despite initial stated enthusiasm for participation, fewer individuals than expected participated in the group. It was unclear why this occurred but could be attributed to lack of reward for participants or fatigue at the end of a therapy day. Despite this, we believe the groups still allowed for a rich and meaningful exploration of the subject matter as evidenced by the emerging themes.
Participants in this study were all recruited from a single centre, which would limit the extent to which broader conclusions can be made as their experiences are not generalisable. It is possible that different data might be generated if participants were recruited from a GP or community mental health team setting. However, this study serves as a useful basis for preliminary research in a field which has not been explored in depth previously.
There will be relational aspects between primary care and secondary care, in terms of views of who should prescribe medication, which may form part of primary-secondary care dynamics. These dynamics might interfere with the study design, however they might also reflect patient complexity as already mentioned in the ‘Discussion’ section.
As with any qualitative study, it is important to acknowledge reflexivity.28 This study was designed from a medical psychotherapy perspective and therefore data were approached from a relational perspective, that is, that relational themes are played out in consultations and that prescribing is influenced by the doctor-patient relationship.
Participants were already engaging in group psychotherapy therefore it is possible that there were established dynamics between them, which may have affected responses to discussion and group interactions. We have no reason to believe that this adversely affected their ability to participate fully, as they were all vocal in their opinions. In addition, feedback was later received from staff that this study promoted further medication discussions in their group therapy programme.