When I was first labelled with borderline personality disorder, it wasn’t a proper diagnosis. The term “emerging personality disorder” appeared in my notes without any further discussion. I was eighteen and since my personality was supposedly still too immature and unformed to be officially disordered, the word “emerging” presumably meant that the diagnosis was somehow tentative. They used hesitant language to say I had “features indicative of a personality disorder”, rather than give a definitive diagnosis.
But the harms that came with the label were not “emerging,” “tentative,” nor merely “indicative” of discrimination, prejudice, and abuse; my admission to a “specialist” personality disorder ward was conclusive and decisive; and there was nothing speculative about the way I was dismissed by healthcare staff as “just another PDer.”
In that sense, the euphemistic language made no difference to me. Each clinical letter would use a different synonym for BPD and regardless of how soft they tried to make the language, it was always read in the same way. Of course, it had a profound impact on me to be told at such a young age that my personality was disordered – the words cut deeply. But it wasn’t the name that harmed me the most.
Mental health services employ various euphemisms to label patients with a personality disorder, the current favoured term being “complex emotional needs.” I can’t say exactly who first used the term in this context or how it came about. However, it is clear that a research team from the National Institute for Health and Care Research (NIHR) Mental Health Policy Research Unit (MHPRU) played a key role in legitimising and spreading the use of the term.
According to their website, the MHPRU held a workshop in 2019 as part of research around community personality disorder services with a small group of people with lived experience, researchers, and clinicians. I wasn’t there and I can’t speak for what was discussed, but this workshop is cited as resulting in the decision to title the research the “Complex Emotional Needs Project”. The lead for the project stated that they never intended this to be “a new diagnostic category” but used ‘complex emotional needs’ as a working term to refer to people who may receive a personality disorder diagnosis. They said they hope for more ways to describe the difficulties people experience, but however hesitant they were about the word choice, it was almost inevitable that this would spread pervasively and with significant implications.
Since then, the term ‘complex emotional needs’ has been used by countless NHS mental health trusts (including in child and adolescent mental health services) and third sector mental health services to rename their personality disorder services, as well as being used in a range of policy contexts. Some services use similar variations such as complex emotional and relational needs or complex emotional difficulties. Many of those who use the term describe ‘complex emotional needs’ as a term which “may be more acceptable to users of mental health services”. However, there has been no research or wide consultation of patients’ perspectives beyond select patient groups attending workshops.
In a news piece on Kent and Medway NHS and Social Care Partnership Trust’s website, they discuss the process of renaming their personality disorder services the ‘complex emotional difficulties service’. This decision was based on discussions at a workshop which included patients in attendance (though apparently also included clinicians, police officers, housing officers and others). This raises the first important point: whilst it is of course essential to involve patients within service design, it is also important to recognise the limitations of different methods of engagement. In the case of a workshop with 150 attendees including mental health professionals and police officers, it’s clear that for many patients it would just not be safe to attend, rendering their voices, perspectives and experiences excluded from this conversation.
The article reads:
“What became very apparent during the workshop was that people broadly fell into two categories – those that wanted to change the pathway name and try to move away from the stigma of the diagnosis, and those that were happy with sticking with calling it the Personality Disorder Pathway as it clearly links it to a recognised diagnosis. However, as the day progressed, what emerged was broad agreement that it was less about the importance of the name and more about the attitudes towards working with people with a personality disorder”.
This paragraph clearly positions the action of changing the pathway name as an attempt to move to challenge the stigma of personality disorder diagnoses. Curiously then, although they do recognise that “changing attitudes won’t solely be achieved by changing the name alone”, they do not offer any commitments to taking any other steps towards this. Therefore, despite stating that the attendees at the workshop felt that it was the attitudes towards people diagnosed with a personality disorder which was the most important thing, the conclusion was to change the name – hoping this would lead to attitudinal changes – but not do anything else. It might be an enticing option for mental health services to deploy the latest buzzword, but is this just a smokescreen to allow them to continue to perpetuate – and benefit from – the harms inflicted on those labelled with a personality disorder?
The label ‘complex emotional needs’ is generally used interchangeably with BPD, or sometimes referring to personality disorders more broadly. However, as it is not a diagnosis, the term could easily be applied to patients, by any member of staff, without the clinician giving a second thought. But the label sticks – it’s easy for a term like complex emotional needs or BPD to be used to describe a patient, but incredibly hard to get it removed again. Therefore, terms like ‘complex emotional needs’ risk dramatically increasing the number of people effectively labelled with a personality disorder, exposing them to stigma, discrimination, and harm. So not only does a new name not do anything to address the abuses and violence against those given a diagnosis of a personality disorder, it will surely only spread it further.
As with BPD, the term ‘complex emotional needs’ is applied liberally, but not randomly. Young women, neurodivergent and LGBTQ+ people are disproportionately likely to be given a diagnosis of BPD, as are those who don’t miraculously recover after 6 sessions of cognitive behavioural therapy or who are deemed too complex to respond to the treatment options available. After all, it’s not clear whether the apparent complexity of a patient’s emotional needs relates to the person’s own emotional experiences, or in terms of being needs which are too complex to meet from the perspective of mental health services.
Marking individuals as having complex needs makes it all too easy to pass off neglect as the person demanding too much. In other contexts, the phrase “complex needs” is often used to refer to patients who have health conditions and disabilities which fall under the domain of more than one health service and often have their needs met by none. It raises the question of whether the patients are complex, or whether disconnected and siloed services are ill-equipped to support individuals holistically. Either way, categorising patients’ needs as complex does not absolve services of their responsibility to meet those needs.
I’d argue that people who are given a diagnosis of BPD, who have often suffered significant trauma, don’t necessarily have complex emotional needs. As humans we are all complex beings with fundamental emotional needs; where these are chronically unmet, it inevitably impacts us and can result in chronic distress, illness and disability. So just as with locating disorder within someone’s personality, describing people as having complex emotional needs obscures the wider societal contexts which drive the distress people suffer.
Although a shift towards thinking of individuals as having complex needs rather than a disorder of personality might be well intentioned and hope to shift the negative associations of the diagnosis, this falls short of addressing the prejudice, discrimination and harm associated with it. The term ‘complex emotional needs’ may be viewed by some as more acceptable than personality disorder, but I fear that deploying euphemisms does little more than reinforce the construct further. It obscures the real issues of a harmful construct which is weaponised by mental health services to displace their own failings onto patients who are let down by an underfunded, culturally punitive and uncaring system.
Thank you to Bethan Edwards, Jay Watts, Jee Smith and Nell Aitch for discussions and shared anger on this topic.
Mental Healthcare in a Failing State
This blog is part of our new series, “Mental Healthcare in a Failing State”. All the blogs in the series, when published, will be added here.