PONE-D-20-34071

Service user experiences of community services for Complex Emotional Needs: A qualitative thematic synthesis

PLOS ONE

Dear Dr. Rains,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please consider the reviewer points. 

Please submit your revised manuscript by 14 Janurary 2021. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols

We look forward to receiving your revised manuscript.

Kind regards,

Andrew Soundy

Academic Editor

PLOS ONE

Journal Requirements:

When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

2. Please include your tables as part of your main manuscript and remove the individual files. Please note that supplementary tables should be uploaded as separate "supporting information" files.

3. Thank you for stating the following in the Funding Section of your manuscript:

"This paper presents independent research commissioned and funded by the National Institute

for Health Research (NIHR) Policy Research Programme, conducted by the NIHR Policy Research Unit

(PRU) in Mental Health. The views expressed are those of the authors and not necessarily those of the

NIHR, the Department of Health and Social Care or its arm’s 591 length bodies, or other government

departments."

We note that you have provided funding information that is not currently declared in your Funding Statement. However, funding information should not appear in the Acknowledgments section or other areas of your manuscript. We will only publish funding information present in the Funding Statement section of the online submission form.

Please remove any funding-related text from the manuscript and let us know how you would like to update your Funding Statement. Currently, your Funding Statement reads as follows:

"The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript."

Please include your amended statements within your cover letter; we will change the online submission form on your behalf.

4. We note that you have indicated that data from this study are available upon request. PLOS only allows data to be available upon request if there are legal or ethical restrictions on sharing data publicly. For information on unacceptable data access restrictions, please see http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions.

In your revised cover letter, please address the following prompts:

a) If there are ethical or legal restrictions on sharing a de-identified data set, please explain them in detail (e.g., data contain potentially identifying or sensitive patient information) and who has imposed them (e.g., an ethics committee). Please also provide contact information for a data access committee, ethics committee, or other institutional body to which data requests may be sent.

b) If there are no restrictions, please upload the minimal anonymized data set necessary to replicate your study findings as either Supporting Information files or to a stable, public repository and provide us with the relevant URLs, DOIs, or accession numbers. Please see http://www.bmj.com/content/340/bmj.c181.long for guidelines on how to de-identify and prepare clinical data for publication. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories.

We will update your Data Availability statement on your behalf to reflect the information you provide.

5. Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: N/A

Reviewer #2: N/A

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Thank you for the opportunity to review this timely and important manuscript. The paper reviewed qualitative papers pertaining to the service user experience of using community mental health services in people with experience of personality disorder, or Complex Emotional Needs (CEN). The paper was generally well written and coherent, however there were a few typographical errors or unfinished sentences.

Specific minor comments:

Abstract:

• I'm interested in why only examples of 'good care' was included in the review. Why were bad examples of care not included as this presents an opportunity to learn from less effective models. Also, how were experiences of good and bad care differentiated?

Background:

• "Personality Disorder" and Complex Emotional Needs is being used interchangeably. Whilst this is understandable, given the debates about diagnosis, as mentioned on page 5 lines 93-101. It may be, however, difficult for a reader who is not well versed in these debates to follow the text. Perhaps it may be worthwhile to move the text from page 5 lines 93-101 to earlier in the background section, to set the scene for the reader.

Methods:

• It is reported that studies that describe repeated self-harm, suicide attempts, complex trauma or complex PTSD and emotion dysregulation and instability were also included on a case by case basis. What were the criteria that was used to determine whether this met the criteria for this study?

• Were only studies published in English included in the review or were other languages also eligible? Whilst this is explained in the discussion, clarification in the method section would be helpful to the reader.

Results:

• The results of the thematic synthesis is well written and structured in a way that is easy to understand to the reader. To strengthen the synthesis, an indication of the proportion of studies (and which studies) reported on each of the themes and sub-themes would have been helpful to discern the strength of the themes and sub-themes.

• The identification of positive approaches to care is important. However, I wondered whether the phrase 'positive approaches' is the best term, as some readers may confuse this with positive psychotherapy.

Discussion:

• The inclusion of a lived experience commentary from three individuals with lived experience was insightful and helped boost the reliability of the findings. However, were the people with lived experience provided with the findings of the paper when writing their contributions and were there any comments that were made during the process, which altered the manner in which findings were presented?

General:

• Line 358: repetition of the same idea

• Line 374: Sentence not finished

• Lines 599, 601: references need editing

Reviewer #2: Complex emotional needs synthesis

Overall, a very interesting and worthy paper reporting a qualitative synthesis of the experiences of service users with complex emotional needs (i.e. personality disorders) with community health services

Introduction: lines 50-51: clarify what type of professionals you refer to

Introduction: line 58. You provide a rationale for the use of the term complex emotional needs instead of ‘personality disorder’ later on in the introduction. I would suggest using the term ‘personality disorder’ consistently up until this point because it is unclear whether complex emotional needs is used synonymously with personality disorder until this rationale.

Introduction: lines 65-67. Contextualise the importance of involving service user and carer/family perspectives in service design. This is part of a broader shift in public policy and mental health system development, not limited to the field of complex emotional needs/personality disorders’.

Methods: lines 129-132 who performed the full text screening including double screening and discussion with senior reviewers? Suggest putting the author/researchers initials in brackets after each research activity

Quality assessment and data analysis: 156-157 also indicate the two researchers who performed the quality assessment. The same applies for data analysis/thematic analysis.

Results: line 178-188 reference the relevant papers for each of the sample types e.g. “28 papers reported data from people diagnosed with “Borderline Personality Disorder” (REFERENCES X-X). Although this information is included in the Table 1, it is not ordered as such so it would be useful for the reader to know this from the text. I would suggest the same for the description of the quality assessment domains.

Results: line 236 clarify what you mean by recovery. Does this refer to the concept of personal recovery or clinical recovery or both?

Results: lines 266-269 review this sentence for meaning

Results: lines 356-361 review these sentences for meaning

Results: line 374 ‘the value of peer support’ is an unfinished sentence

Discussion: it would be helpful to clarify what type of professionals (and their training/background) provide ‘specialist care’, given that a key finding is that the quality of care was largely better in these settings.

Discussion: discuss the implications of focusing solely on the perspectives on consumers and not carers, family members and other supporters who often have a central role to play in the support and care of people with complex emotional needs

Discussion: the synthesized literature is mainly from English-speaking countries and all was from high-income countries with the exception of China. Discuss how this shaped the centralisation of the individual in the finding and implications arising from the papers. For example, would you expect these findings to hold in contexts/for people who place less emphasis on the individual consumer and more on the collective sense of self. I’m thinking particularly black and ethnic minority groups in the UK, culturally and linguistically diverse groups in Australia, etc

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: Yes: Teresa Hall

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

Service user experiences of community services for Complex Emotional Needs: A qualitative thematic synthesis

PONE-D-20-34071R1

Dear Dr. Rains,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Andrew Soundy

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: N/A

Reviewer #2: N/A

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Thank you for considering my comments. My comments have been sufficiently addressed and I believe that this paper is suitable for publication.

Reviewer #2: The authors have made a satisfactory response to my original review. The ony query I have is that I still believe the results section would be strengthened by referencing the key findings against the original studies. However, I accept the authors' justification as to why this is not necessary.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: Yes: Teresa Hall