RESEARCH ARTICLE Open AccessSeeking to understand lived ex.docx

RESEARCH ARTICLE Open Access
Seeking to understand lived experiences of
personal recovery in personality disorder in
community and forensic settings – a
qualitative methods investigation
Andrew Shepherd* , Caroline Sanders and Jenny Shaw
Abstract
Background: Understandings of personal recovery have emerged
as an alternative framework to traditional ideas
of clinical progression, or symptom remission, in clinical
practice. Most research in this field has focussed on the
experience of individuals suffering with psychotic disorders and
little research has been conducted to explore the
experience of individuals with a personality disorder diagnosis,
despite the high prevalence of such difficulties. The
nature of the personality disorder diagnosis, together with high
prevalence rates in forensic settings, renders the
understanding of recovery in these contexts particularly
problematic. The current study seeks to map out pertinent
themes relating to the recovery process in personality disorder
as described by individuals accessing care in either
community or forensic settings.
Methods: Individual qualitative interviews were utilised to
explore the lived experience of those receiving a
personality disorder diagnosis and accessing mental health care
in either community or forensic settings. A
thematic analysis was conducted to identify shared concepts and
understanding between participants.

Results: Fourty-one individual participant interviews were
conducted across forensic and community settings.
Recovery was presented by participants as a developing
negotiated understanding of the self, together with looked
for change and hope in the future. Four specific themes emerged
in relation to this process: 1. Understanding early
lived experience as informing sense of self 2. Developing
emotional control 3. Diagnosis as linking understanding
and hope for change 4. The role of mental health services.
Conclusions: Through considering personal recovery in
personality disorder as a negotiated understanding
between the individual, their social networks and professionals
this study illustrates the complexity of working
through such a process. Clarity of understanding in this area is
essential to avoid developing resistance in the
recovery process. Understanding of recovery in a variety of
diagnostic categories and social settings is essential if a
truly recovery orientated mental health service is to be
developed.
Keywords: Personal recovery, Personality disorder, Qualitative
research
* Correspondence: [email protected]
University of Manchester, Manchester, UK
© The Author(s). 2017 Open Access This article is distributed
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the Creative Commons license, and indicate if changes were

made. The Creative Commons Public Domain Dedication waiver
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the data made available in this article, unless otherwise stated.
Shepherd et al. BMC Psychiatry (2017) 17:282
DOI 10.1186/s12888-017-1442-8
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1442-8&domain=pdf
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Background
Personal recovery is increasingly recognised as a principle
goal for mental health services [1]. Understanding in this
area is by its very nature idiographic, however efforts have
been made to synthesise pertinent themes into framework
conceptualisations [2] and to develop measures through
which recovery orientated clinical practice may be enacted
[3, 4]. So far, most research into the recovery process has
been conducted with individuals with psychosis and the
application of this developed understanding to the
experience of individuals with other diagnoses requires
further exploration.
Conceptualisation of personal recovery in relation to
the experience of personality disorder is complex, given
the underlying proposed nature of these diagnoses
affecting areas of emotional regulation, the formation of
personal relationships and maintenance of social roles
[5], which can be seen as interacting directly with many
of the domains outlined by Leamy, Bird et al. [2].
Despite this complexity a recent systematic review iden-

tified only three qualitative methods studies specifically
focussed on the experience of recovery in relation to
these diagnoses [6], in contrast to 89 studies identified
through systematic review in relation to recovery in
schizophrenia [7]. Understanding the recovery process
with regard to personality disorder is further compli-
cated by the high prevalence of the diagnoses within
prison and other forensic settings, where approaching
two-thirds of men and half of women are proposed as
having a diagnosable personality disorder [8], in com-
parison with estimated rates of between one in 20 and
one in six in the general community [9]. Within forensic
settings particular issues and tensions can be seen as
arising in relation to issues such as autonomy and em-
powerment that are crucial to understanding the process
of recovery [10, 11]. While recovery focussed frame-
works have been developed for care provision within
forensic settings [12] there has been little exploration of
the theoretical underpinning, or lived experience, of this
process [13].
Research into the recovery process is essential in order
that therapeutic support needs can be recognised and
appropriately met through structured interventions [14].
Research can also facilitate the development of shared
understanding between clinicians and patients - a neces-
sary step if new interventions are to become standard
for clinical services [15].
Therefore, with this background framework, the
current study aimed to better map the lived experience
of those receiving a personality disorder diagnosis,
focussing on their understanding of personal recovery
and the experiences of individuals accessing mental
health care in either community (general community
mental health and hospital) or forensic (prison and

secure hospital) settings. Comparison is made between
the experience of individuals accessing support in
relation to their recovery in both settings, in order to
consider in greater detail the particular complexities
discussed above.
Methods
Findings are drawn from a doctoral research project
supported by funding from the National Institute for
Health Research, registered with the UK Clinical Re-
search Network (Reference 15,934). A qualitative meth-
odological approach was adopted to adequately address
the aims of the project; qualitative methods studies offer
the opportunity for in-depth exploration of the personal
aspects of health experience and illness narratives [16, 17].
Individual interviews were conducted with mental health
service user participants - with participants initially identi-
fied based on their having received a personality disorder
diagnosis. Subsequent rounds of recruitment were
conducted in a purposive manner to address emergent
themes and varying experiences of clinical care in different
settings (forensic versus community).
The research was conducted in community and foren-
sic clinical settings in the North of England – specifically
within community hospitals, community mental health
team bases, local prisons (Category B and Women’s
prison), probation approved accommodation settings
and regional secure hospitals. Participant anonymity is
protected through anonymization, including the removal
of any personal, or geographically identifiable informa-
tion from interview transcripts.
Individual interviews: - participant recruitment and
interview process

Participants were selected on the basis of their having
been identified as having received a personality disorder
diagnosis and having sufficient spoken English language
skill to enable them to participate in the interview
process.
Potential participants were initially identified through
approaching clinical teams with information relating to
the study. Teams were asked to identify potential partici-
pants, and to provide them with information describing
the role of participants in the study. Initial contact with
participants by the researcher was therefore mediated
through clinical teams.
No specific steps were taken to verify the personality
disorder diagnosis and no specific subtype of diagnosis
were sought. For the purpose of this research project it
is argued that, on the basis of recent discussions of
personality disorder diagnostic criteria [18–20] and
possible future changes [9, 21–23], the present adminis-
tration of any specific diagnosis is uncertain. Specifically,
the recent revision of the DSM-5, from the previous
Shepherd et al. BMC Psychiatry (2017) 17:282 Page 2 of 10
edition, proposed a ‘hybrid’ system of personality dis-
order classification (combining categorical and dimen-
sional considerations), that was ultimately proposed as
needing further research; while the proposed changes for
the next edition of the World Health Organisation’s
diagnostic criteria (ICD-11) have suggested that most
categorical distinctions (emotionally unstable versus
dissocial personality disorder for example) be dropped in
favour of an overarching personality disorder diagnosis,

classified according to the severity of accompanying
impairment [9]. Therefore, a pragmatic approach to
diagnosis was adopted with no specific exclusion criteria
set. A recruitment strategy was utilised where partici-
pants were being supported by their clinical team ‘as if’
they had a personality disorder diagnosis, and that the
participants themselves identified with the diagnosis, as
indicated through their consent to participate in the
project. Participants were not excluded because of any
co-morbid diagnoses. Therefore, no specific exclusion
criteria were applied, excepting that participants were
required to be able to offer informed consent for
participation.
Participant recruitment was conducted in two waves;
the first concentrating on community mental health
settings and the second with a focus on potential partici-
pants with experience of accessing care within forensic
settings. During the forensic recruitment wave a focus
on individuals with experience of prison incarceration
was developed such that all participants in the second
wave had experience of prison incarceration in common.
While only four participants were interviewed specific-
ally in secure hospital settings the majority of forensic
participants also had experience of hospital care within
secure settings.
Interview recruitment and analysis were conducted in
a parallel and iterative fashion; such that recruitment
was informed in a theoretical manner. For example,
early references to adverse inpatient experiences and the
importance of consistent therapeutic contact led to
participants being identified with varying lengths of
contact with the mental health services and experience
of contact in a variety of clinical settings (inpatient open
ward, psychiatric intensive care unit, community care,

prison and secure hospital). Recruitment continued until
data saturation had been reached. The applied definition
of saturation is discussed in the analysis section below.
As described above, potential participants were
approached with information relating to the study by
members of their clinical team. After expressing interest
participants were then contacted by the first author and
an appointment was arranged for the interview to be
conducted. Interviews were conducted at clinical loca-
tions with which the participants expressed familiarity
and comfort in attending. Prior to commencing the
interview proper further opportunity was provided for
participants to ask questions relating to the research.
Consent for participation in the study was then obtained
with a consent form being signed at this stage - although
the consent process was viewed as being dynamic in
nature, continuing throughout the period of the
interview and beyond. Consent and interview were both
undertaken at the same appointment to minimise dis-
ruption for participants.
Interviews were conducted in an open style, with ini-
tial questioning conducted in a fashion that encouraged
the elaboration of personal story [24]. Semi-structured
interview schedules were developed but were used only
for participants who indicated they desired more
prompting to elicit their experience. Specific topics iden-
tified for discussion within the interview schedules
included: The experience of mental distress, first contact
with mental health services, treatment and support
accessed, understandings of treatment goals, conceptua-
lisations of recovery, sources of support, experience of
change since contact with services, and hope for change
in the future. Interviews were audio-recorded and then

stored, electronically, in an encrypted file format in
keeping with NHS data protection standards.
Analysis
Analysis was theoretically informed by a contextual con-
structivist approach to knowledge generation [25]. In
this manner responses to questions were taken as
representative of the participants’ understanding, but
with consideration being given to the emergence of
discourse as being a co-constructed phenomenon be-
tween researcher and participant.
The first step in the analysis process began with the
writing of reflexive journal entries following each indi-
vidual interview meeting. Journal entries allowed the
capturing of significant themes based on initial reflection
on the interview such that these could be explored in
more detail during subsequent interviews, and during
subsequent analysis steps. These initial themes were de-
veloped through reflection on subsequent interviews and
further transformed throughout the analysis process.
Data saturation was defined by the emergence of no
novel themes within these journal entries over the
course of sequential interviews.
Transcription of interviews was completed by the first
author and represented the second phase in the analysis
process, allowing an ‘immersion’ in the data [26]. The
third step in the analytic process involved a coding
strategy conducted in a manner so as to ‘fragment’ the
transcribed data allowing horizontal comparison be-
tween interviews [27]. Memo-writing [28] was used to
capture descriptions and links between coding and to
allow the development of emergent themes [29]. Data

analysis was supported using qualitative data analysis
software (NVivo - QSR International version 11). The
fourth stage of the analysis process involved the
construction of thematic maps [30], which allowed the
relationship between themes to be reviewed. Descriptive
writing was then also incorporated into the analysis
process.
Four randomly selected transcripts were coded by the
second and third authors in a process of comparison
and to prompt additional discussion. Any disagreement
between coding, or in the interpretation of themes, was
resolved through discussion and agreement during re-
search meetings; as no disagreement emerged in relation
to the underlying coding process research only a small
minority of transcripts were coded by all authors to
allow a greater focus on the elaboration and discussion
of overarching themes. Themes were also discussed at
meetings with a mental health service user advisory
group throughout the research project. In this way
analysis was reviewed from a variety of standpoints
regarding theoretical experience and role. Issues of re-
flexivity, that is the impact of the role of the researcher
on the research process [31], were also discussed during
supervision and advisory group meetings in order to
allow that they be sufficiently addressed.
Ethical approval
Ethical approval was sought from the National Research
Ethics Service East of England - Essex (Reference [14]/
EE/0029). Access to prisons was approved by the Na-
tional Offender Management Service, National Research
Committee (Reference 2013–282); specific Prison

Governor approval was granted for prisons from which
participants were recruited. Access to hospitals and
community mental health team bases was negotiated
through NHS Trusts.
Results
A total of 41 individual interview participants were re-
cruited. Most participants self-identified as having been
diagnosed with an Emotionally Unstable, or Borderline
Personality Disorder, with some (principally in forensic
settings) also reporting a diagnosis of Dissocial Personal-
ity Disorder. A minority of participants indicated that,
while they agreed to participate in the study and had re-
ceived a diagnosis of personality disorder they disagreed
with the diagnosis. Demographic details of interview
participants, together with the location of the interview
are summarised in Table 1. The length of contact be-
tween the participant and mental health services
ranged from less than one to 43 years (average length
12 years). The length of contact was roughly equal
between community and forensic participants. Most
community participants were not currently working at
the time of their participation; examples of previous
employment included armed forces service, manual
labour, retail managerial positions, and healthcare. In
Table 1 Participant codes and description
Code Interview Setting Age (as range) Gender
Int001 Secure hospital ward 41–50 Male
Int002 Secure hospital ward 22–30 Female
Int003 Prison 41–50 Male

Int007 Prison 31–40 Female
Int015 General Community 31–40 Male

Int024 General Community 31–40 Female
Int027 Community inpatient ward 51–60 Male
Int028 Community inpatient ward 41–50 Female

describing their ethnic background all but five partici-
pants self-identified as White. The other five did not
comment on this question. Individual interviews
lasted between 15 and 79 min (mean 53 min, stand-
ard deviation 16 min).
In discussing their understanding of recovery, partici-
pants described an overarching process involving a bal-
ance between developing an ‘understanding of self ’
together with ‘looked for change’ or hope for the future;
this process was not simply an individual act however
but involved a close negotiation of understanding be-
tween the individual, their host social network and other
agents, such as professionals, with whom they developed
contact. Within this overarching process four specific
themes emerged as representative of the work under-
taken in ‘recovery’: 1. Understanding early lived experi-
ence as informing sense of self 2. Developing emotional
control 3. Diagnosis as linking understanding and hope
for change 4. The role of mental health services. Each of
these four themes is explored in greater detail below; il-
lustrative quotations are used for the richness of their
description and, where possible, to represent counter-
arguments or statements. The number of participants
endorsing specific themes is not presented below, in
keeping with the qualitative epistemology, however
words are employed to imply quantity at times in the

following fashion; many (approximately 75% or more),
most (more than 50%), minority (less than 50%).
Understanding early lived experience as informing
sense of self.
Most participants framed their understanding of their
experiences within a description of their early life within
their family, particularly their sense of belonging and the
interpretations of their behaviour made by key family
members.
“I always felt there was a lot of pressure on me to do
very well, because my brothers are both very bright
and had done well at school and I always felt
compared to them [brothers]when I went to primary
school..”
Later in the interview this respondent reflected on her
current sense of self:
“It’s difficult because I sometimes feel like my illness
has kind of defined who I am, I’m just like the one
who’s got all the problems and I’ve not really found
who I am yet.” [Int036].
For other participants, early life experience was char-
acterised by a sense of alienation from their family, lead-
ing to them struggling to develop a sense of their own
‘place’ within the social unit:
“I had a lot of depression and down days, when I
think back now just not fitting in even the foods that
I liked were totally different I had nothing in common
with the family that I lived with and brought up with.
Not in the food, nothing.” [Int038].

Within the context provided by their social networks,
participants saw some elements of behaviour as consti-
tuting a destructive aspect of themselves. These ele-
ments were conceptualised as emerging in response to
experiences of violence and pain, with many participants
referring to early experiences of emotional and physical
abuse. This impacted on their ability to trust in others
and form relationships:
“I won’t let many people in, I choose my circles… who
I speak to even smaller… I still choose not to speak to
a lot of people about it. Just mainly because I kind of
deal with it, or I’ve dealt with it and I don't feel like
bringing it up.” [Int019].
Participant accounts of their experience were therefore
intimately framed within the understanding of their so-
cial networks, often reaching back to early life experi-
ences of family life - accounts which were often
coloured by experiences of violence or abuse within the
family environment.
Developing emotional regulation
Many participants, when discussing hoped for change,
described their wish for greater control over their emo-
tional life, as a process of developing a more coherent
understanding of their experience. This then became an
intimate part of the ‘recovery process’ - a greater sense
of stability, or ‘self-control’:
“I think in terms of, like, recovery, in terms of being
able to have a degree of self-control and being able to
think ahead about the consequences of things so that
rather than having a big blow up.” [Int033].

Participants engaging in acts of self-harm, or suicidal
behaviours, positioned these as emerging directly from
experiences of trauma, or distress, and representing a
potential relief from conflict; linking their emotional dis-
tress to a sense of embodiment – that is, they developed
an explicit link between ‘somatic’ and ‘mental’ under-
standings of distress and pain [32, 33]:
Interviewer: “What type of things lead to you feeling
you need space”.
Participant: “because my emotions go up and down
where I’m angry and then really really mad, then I feel
suicidal it’s like a volcano with me. At the moment
I’m like level but let anything change tonight and it
goes.”
Interviewer: “What makes it change, what type of
things set off the volcano?”
Participant: “It’s when I don’t feel safe and stuff I just
don’t feel like I can do it no-more and basically at the
end of the day, it’s just like, like I said before, I just
wish I was dead, because it would stop all the arguing
with everybody.” [Int040].
Diagnosis as linking understanding and hope for change
For most participants, the application of a personality
disorder diagnosis represented an important step in the
understanding of their experience. An appreciation of
diagnosis allowed them to begin a process of engage-
ment and to develop a sense of hope for the future:
“That helped knowing a little bit and then I didn't

really get a lot of support with regards to what I had, I
did an awful lot of research myself […] But then by
having that that opened up other avenues, other
courses of treatment and having regular CPN
[Community Psychiatric Nurse] was great, really but it
was good to be diagnosed with something anyway,
because I knew it was something worse [than
depression].” [Int023].
“They gave me the diagnosis of emotionally unstable
personality disorder. So I was put on, obviously,
several antipsychotic drugs and antidepressants which
were linked with an anti-anxiety as well and I started
going to a hearing voices group, which was near
where I lived, so that made things a lot easier knowing
that I was with like-minded people.” [Int025].
For a minority of participants however the diagnosis of
personality disorder was seen as unhelpful - representing a
direct comment on them as a person, or as a representation
of their previous behaviour, not a ‘mental illness’ per se:
Participant: “It felt like a bit of an attack to me own,
everything about me, you know, everything that I am
do you know?”
Interviewer: “That your personality is who you are?”
Participant: “Yeah” [Int003].
“Well the doctor said I’ve got an antisocial personality
disorder, I’m not antisocial so where do they get that
from? […] Well technically, that could be right I
suppose, you know, it’s like antisocial burgling and
crime, stuff like that isn't it but you know does every
Tom, Dick and Harry who’s in [prison] now have an
antisocial personality disorder just because they’re in?”
[Int013].

This understanding was particularly pertinent in
prison settings where diagnosis was seen as being used,
through expert witness testimony, to inform the judicial
process, or as a means of excluding some from care
within a hospital setting.
For another group of participants, the recovery process
was seen as being one of radical change, representing an
adaption in self-understanding beyond that offered
within a diagnostic framework:
“I changed quite a lot to be fair, I pretty much did
become a completely different person. […] I gained
empathy, I gained compassion, I gained understanding
these were things that were lacking, even before my
mental health problems really, they were just
accentuated with my mental health problems.” [Int023].
The role of the mental health services
Relationships with professionals in a therapeutic setting were
seen as being crucial in allowing the individual an opportun-
ity to reflect on experience and plan for future change:
Participant: “The counsellor that I saw was the best
person.”
Interviewer: “What was best about the counsellor,
what was it about them?”
Participant: “We had a great rapport.”
Interviewer: “So the relationship with the counsellor
was important to you?”
Participant: “Yeah, very important, and I trusted her
[…] It let me open up more to her and to know that
she cared, and she really did care, and she was very
interested in me and my thoughts…” [Int025].

Others described how their relationships with profes-
sionals had been dismissive, or even bullying, in nature:
“I felt hang on I feel more bipolar, than I do, with that
symptom included, and I look back how I was as a
kid, because sometimes I get quite hyper. I tried
hanging myself at 14 as well so I was suicidal from a
young age and I don’t know it just fits more. He
[psychiatrist] said it was so I could get out of going
under this team at [region] […] which I’ve been
fighting not to go under ‘cause [social worker] I don’t
get on with him, I don’t find him useful, I find him
patronising and not at all good, and I’m not the only
one with that opinion so he was saying I was just
doing it, saying it so I wouldn’t, didn’t have to go
under them and I wasn’t” [Int040].
“But within the illness it’s difficult for me to
understand it I just try and go along I got the
understanding that people don't trust it or they say it’s
a cop out. But I don't care about it I know I’m ill I
know the things I’ve done, I know I wouldn't be in
this service if there was nothing wrong with me”
[Int015].
Within prison settings participants reflected on the
role of prison officers and their interaction with pris-
oners during times of mental distress. Prison officers
were seen as representing the front line of support in
some cases, but also as not appreciating the complexity

of distress that they witnessed:
“…the prison officers and that were pretty good with
me, because they knew I was mentally unwell. So even
though I was locked in my room, because if you don't
go to workshops and stuff in prison you get what’s
called basic salary and you don't get near normal,
amounts, but because they knew I was unwell they
gave me enhanced and they gave me a television even
though I wasn't going to workshops and they took me
out each day to get me a shower and at exercise
times, so they were quite good to me…” [Int001].
“I understand that they’re not emotionally connected
to me, they don't really give a shit, it’s a job -
everything. Well to some extent they do, they’ve got a
duty of care, you know, if I died tonight I’d be forgot
in a week, do you know what I mean, it’s all it really is
nobody gives a shit in here…” [Int003].
Discussion
The present study sought to explore the experience and
personal meaning of recovery in relation to individuals
receiving a personality disorder diagnosis and with ex-
perience of accessing care in either community or prison
settings. Overall, the process was revealed as a negoti-
ation of understanding between those experiencing men-
tal distress, their social networks and clinical (or other)
professionals. In keeping with previous research, recov-
ery was identified not as a discrete outcome but instead
as an on-going process [34]. The way this process was
understood and reflected was determined largely by the
individual’s sense of themselves and their reflection on
their lived experience. Social networks, as in other stud-
ies, were seen as playing an essential role in this ‘sense-
making’ activity [2, 6, 13].
Differences in this process emerged between those

participants with experience of care solely in the com-
munity and those with experience of incarceration in
prison. For all participants, the process involved a
process of ‘fitting’ the diagnosis alongside their sense of
themselves in their personal identity. For those who
were, or had been, classified as offenders however this
process could be seen as being still more complex, as
they contended with feelings of ‘double’ stigmatisation –
making sense of being an ‘offender’, ‘mentally ill’ or ‘per-
sonality disordered’ [35]. Concepts of mental disorder
therefore became incorporated into other understand-
ings of self, for example ideas of rehabilitation [36], or
‘redemption’ [37, 38]; for some the idea of ‘personality
disorder’ was helpful for this process, for others it was
not - and was rejected.
Diagnosis, for the majority, represented a route
through which understanding of past distress could be
linked to current experience, although this was not a
universal understanding with other participants viewing
the diagnosis as inherently stigmatising or as leading to
an exclusion from health service support, a finding con-
sistent with other studies comparing the experience of
those receiving a personality disorder diagnosis with
other forms of mental disorder [39]. In keeping with
this, as stated above, a minority of participants elected
to participate in the study – stating that they had re-
ceived a personality disorder diagnosis but were rejecting
of the classification. This difficulty was perhaps particu-
larly noteworthy when considered in the context of fo-
rensic healthcare settings where a few participants
experienced the diagnosis of personality disorder as be-
ing used to exclude them from care options, such as
hospital transfer. Despite these difficulties when consid-

ered in the light of individual experience many found
the act of diagnosis to be a powerful act allowing an al-
ternative perspective to be adopted and hope for future
change to develop.
Mental health services were seen as supportive in their
ability to offer therapeutic relationships that allowed par-
ticipants to work through their understanding of recov-
ery in a negotiated manner. However, the capacity to
develop these relationships was being impinged upon
by tensions between modes of sense making - with
many participants detecting uncertainty from clinical
staff in terms of their understanding of the diagnosis
of personality disorder; such uncertainty impacted on
the individual’s ability to foster feelings of hope in
relation to change. Within prison settings other
professionals, principally prison officers, were seen as
fulfilling an essential role in the support of those with
experience of mental distress. The impact of this
emotional labour on officers can-not be directly com-
mented on from the findings in this study, although -
given the described impact of such work on clinical
professionals - it can be hypothesised that this will
represent a significant burden. Caution is necessary to
ensure that the well-recognised difficulties of working
with individuals with disrupted attachment experience
[40], as is often characteristic of forms of personality
disorder, does not lead to a process of exclusion for
‘difficult patients’ [41].
Overall, a close articulation can be seen between the
construct of recovery as a developing understanding of

self, as described by participants here, with concepts
such as ‘Connectedness’ and ‘Identity’ [2] or ‘Existential
Recovery’ [42]. It is also apparent that ‘recovery’ should
be conceptualised as occurring within a ‘social space’
involving work not just by individuals but also by their
social networks and mental health care services [43]. In
this manner, the current findings serve to strengthen the
role of existing recovery frameworks in terms of their
applicability to individuals receiving a diagnosis of per-
sonality disorder, while also illustrating the challenges
for this process in different clinical settings and diagno-
ses – that is the complexity of moral understanding
inherent in ‘offender recovery’ and the challenge around
clarity of understanding in relation to the nature of the
diagnosis of personality.
Strengths and limitations
Systematic review has revealed the limited amount of re-
search conducted in relation to the concept of recovery
in personality disorder; what research has been
conducted has generally focussed on the experience of
participants accessing care within community settings.
By focussing on the experience of individuals across a
variety of setting this study builds on, and adds to, this
previous knowledge and understanding.
Reflexivity represents the manner in which the re-
searcher teams’ own theoretical experiences and under-
standings interact with the analysis of the available
material [31, 44]. All interviews and much of the analysis
process for this study were undertaken by the first au-
thor; at the time a higher trainee in forensic psychiatry
and doctoral research fellow. The author’s role as a
psychiatrist was known to all participants in the study
and may have impacted on the emergent discourse [45].
This impact was considered during research supervis-

ory meetings with the remaining authors together
with coding approaches and emergent themes.
Themes were also discussed and developed through
meetings with a service-user advisory group recruited
at the outset of the project. In this manner interpret-
ation of findings was considered in a multi-
disciplinary fashion, acknowledging the impact of the
researcher role on the investigation and moving to
prevent a one-sided reading of the data [46].
The majority of participants within the present study
self-identified as White; this is significant as it is known
that race and ethnicity are factors that influence the un-
derstanding of personality disorder diagnoses [47, 48].
Additionally it is recognised that cultural heritage
may produce different appreciations of the recovery
process [2, 4]. A decision was taken in this study not
to focus on race or ethnicity within the purposive
sampling strategy: - on the basis of the complexities
outlined further research is required specifically
focussing on the experience of race in relation to
personality disorder and personal recovery and with
particular attention paid to issues of reflexivity.
Future work
A significant theme emerging from this study is the way
understandings of recovery are negotiated between the
individual with experience of mental distress, their social
networks and clinical staff or other professionals –
emphasising the importance of similar claims made in
other settings [49]. An intimate sensitivity to the
language used is apparent in this process and further
understanding relating to the dynamic nature of this
process is required. Studies focussing on the develop-
ment of dialogue and discourse between agents are

therefore required to explore and map this process.
As discussed above the experience of Black and Ethnic
Minority individuals with a personality disorder diagno-
sis need further exploration - studies should be
developed to capture this missing experience in an in-
depth fashion.
Finally, the role of prison officers in supporting
individuals experiencing mental distress within prison
settings was also highlighted. Further research should be
undertaken to explore the nature of this process in
greater detail - focussing particularly on the impact of
such emotional labour on officers and the availability of
appropriate support, or supervision, to allow this role to
be fulfilled.
Conclusion
The recovery process, in relation to the experience of
those diagnosed with a personality disorder, was revealed
to be one of developing self-understanding in relation to
one’s biographical experience - with an emerging sense
of greater control in relation to emotional experience.
This understanding involved negotiation between the
individual and their host social networks, as well as clin-
ical professionals and other agents providing support.
This negotiation proved particularly complex for those
faced with the work of also coming to terms with classi-
fication as having ‘offended’ against society, adding a
moral dimension to the process. For some however this
process was seen as being disrupted by the varying
attitudes of clinical staff that were at times perceived as
being almost hostile in their manner, an experience that
was seen as particular to the diagnosis of personality
disorder. The understanding and support for the process
of personal recovery in relation to mental disorder is

complicated by varying understandings of its implica-
tions among professionals [50, 51].
The findings from the current study highlight the poten-
tial difficulty in the development of a negotiated under-
standing between clinical professionals and individuals who
receive a personality disorder diagnosis. Emergent tensions
in relation to the understanding and communication of
diagnosis further complicate this process. A lack of clarity
in this area risks the development of stigmatised narratives
leading to a sense of exclusion and hopelessness. The cen-
tral role of social networks in the recovery process also re-
quires attention from mental health services; this may
represent a problem for those offering care within forensic
settings where individuals may be divorced, or separated by
great distances, from original networks.
Research into the process and meaning of personal re-
covery is crucial for the continuing development of clin-
ical mental health services. This understanding may be
particularly complex in the case of personality disorder.
The current study highlights the importance of attention
to communication and collaboration between profes-
sional and patient to allow the development of mutual
understanding. Developing understanding of recovery in
a variety of diagnostic categories and social settings is
essential if a truly recovery orientated mental health
service is to be developed.
Acknowledgments
With thanks to the members of the project advisory group for
their time and

discussion relating to the reported findings.
Additional thanks to the peer reviewers for their valuable
comments on
initial drafts of the manuscript.
AS is funded by an NIHR Doctoral Research Fellowship award.
Application for
this award was subject to peer review and feedback, however
the funder
was not directly involved in the production of the final study
protocol. The
opinions expressed here represent those of the Authors and not
necessarily
those of the NIHR or Department of Health, UK.
Availability of data and materials
Interview transcripts are stored in an encrypted fashion with all
personal
identifiable information removed, in keeping with the
requirements of the
ethical approval process. However, owing to the nature of the
material
participants are still readily identifiable when transcripts are
considered in
their totality. As such, for access to this data please contact the
corresponding author to discuss the option of arranging ethics
committee
approval.
Authors’ contributions
All authors contributed to the design and conduct of the
reported study as
well as the drafting of this manuscript.
Ethics approval and consent to participate
Participant consent was sought prior to conducting the
individual interviews.

Ethical approval for the study was granted by the National
Research Ethics
Service East of England - Essex (Reference [14]/EE/0029).
Approval to
conduct the research in prison settings was granted by the
National
Offender Management Service, National Research Committee
(Reference
2013–282).
Consent for publication
All participants provided written consent to the presentation of
anonymised
quotes from their individual interview material.
Competing interests
The authors declare no competing interests in relation to this
project.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional
claims in
published maps and institutional affiliations.
Received: 14 May 2016 Accepted: 24 July 2017
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1

Chapter 7 Leadership
People ask the difference between a leader and a boss. . . The
leader works in the open, and the
boss in covert. The leader leads, and the boss drives. ~Theodore
Roosevelt
Leaders vs. Managers
Obviously, reading the quote above by Theodore Roosevelt
makes sense to many of us.
Throughout my career, I can think of several people who I
thought were leaders and not just
managers. If you think about the differences in leading versus
managing, one can be viewed as
the bare minimum effort needed to get through the day-
managing. While leading may require
extra effort, understanding and time, the difference in the two
can mean success or failure of a
team or objective.
I am often amazed at the U.S. military and how on occasion,
ordinary soldiers, marines, seamen
and airmen do extraordinary things. The mind set of someone
in the armed services is that of
someone being exposed to leadership on a constant basis. I
have always admired and been in

awe of people selected for the Medal of Honor. I take the time
to read the official narrative on
what the recipient did to achieve the highest award possible in
military service. Always given
for valor above and beyond the call of duty, sadly almost all
medals are awarded posthumously.
In reviewing the narratives, at some point, the recipient took
leadership matters into their own
hands and made decisions for a favorable outcome of the group
or team. It is for these reasons
that many companies and industries prefer employees with
military experience. Military training
and leadership always teach to not give up, readjust, adapt and
move on.
Harold Gregory "Hal" Moore, Jr. is a retired lieutenant general
in the United States Army.
General Moore in 1992 wrote a book called, We Were Soldiers
Once… And Young which was
2
Moore’s account of commanding the 1st Battalion, 7th Cavalry
at the Battle of Ia Drang,
Vietnam. The Battle of Ia Drang was the first major

engagement of the Vietnam War in which
U.S. forces and the People’s Army of Vietnam, PAV fought
against each other. The book was
later immortalized in the movie, We Were Soldiers in 2002.
During the battle under General
Moore’s leadership, the engagement included,
pter crash landing
The leadership principles of General Moore during the battle
were the same principles that he
instilled in himself and his troops before deployment. In an
interview with General Moore by
Arm Chair General, the question was asked how to generalize
his leadership style. General
Moore stated, “My leadership philosophy, which I employed in
the military and also for years in
the civilian sector, can be summarized as-power down. I pushed
the authority to make decisions
down to company commanders and told them to push the power

down to their squad leaders and
the individual Soldiers in the ranks. I told my people, if you
feel you are qualified to make a
decision or to take action, do it. Otherwise, move it up a notch
for a decision.” (Moore 2007)
Moore is also credited with creating the what is called, the 4
Principles of Leadership in Battle.
These principles include one of the most famous quotes from
General Moore, “Three strikes and
you're NOT out.” Moore relates that 3 strikes and you’re out
only works in baseball. There is
always something the leader can do to change the outcome of a
situation or problem. In times
when everything is going according to plan is the time when
complacence sets in, and
3
threatening the plan. Moore also agrees that leaders should act
on instinct and believe that it is
easier to ask forgiveness then to get permission.
I am lucky enough to have a family member in the military. I
asked him a few questions when I

was writing this book, and he shared some insight into what
leadership values were instilled in
him. When I asked him the difference between military
leadership and corporate leadership he
told me, “Corporate leadership usually ends when the employee
leaves for the day. Military
leadership revolves around the principle that we must be
accountable for our actions, and that of
our subordinates, 24 hours a day. If a subordinate gets in
trouble on the weekend, the
subordinates’ chain of command is expected to get involved,
and must take time out of their
weekend to resolve the problem. The leaders are questioned on
what they did to prevent the
issue before it became a problem (i.e., safety brief, counseling)
and what their course of action to
correct the problem is. This invests the leaders in their
subordinates professional and personal
lives, while placing a greater emphasis on ensuring subordinates
are capable of
preventing/resolving issues before they become larger problems.
Constant accountability and
responsibility of all subordinates' actions is probably the most
defining characteristics of

leadership within the military.” His statement validates the fact
that subordinates are investments
to the leadership in the military. Does your company look at
employees as an investment?
Thank you Lieutenant. I appreciate your service to our great
country and the freedom you
provide as well as all others who have served at one time or
another.
Leadership Traits and Trust
What makes a good leader? There can be and are many
different answers to this question. The
difference between leading and managing can be strikingly
different. There have been many
different studies on leadership, with five different traits
identified as leadership qualities.
4
People want to work and be led by an honest leader. Honesty,
as well as ethics, played a big role
in the latest economic downturn. The auto industry appeared on
Capitol Hill asking congress for
a loan to float General Motors, Chrysler and Ford Motor
Company. In statements to congress,

all three companies identified increased cost of raw materials
and a slow economy to blame.
Upon further review, Ford elected not to take federal money to
stabilize their business. Both GM
and Chrysler received a combined total of $17.4 billion dollars
in loans. (Wallstreet Journal
2008) Many customers also felt that Ford was extremely
honest, and demonstrated that when
sales of Ford vehicles started to rise in late 2009. By 2010,
sales of Ford vehicles were up by
33% and even posted a 1% gain in market share, as sales for
both GM and Chrysler fell. (Kell
2010)
Honesty in leadership plays an especially big role when
mistakes have been made. During the
BP Deepwater Horizon incident in 2010, then CEO Tony
Hayward created a dishonest
atmosphere, using poor word choices during different
interviews. Before the Deepwater
Horizon incident, BP had integrity issues due to past
catastrophic incidents such as the Texas
City Explosion in 2005 that killed 15 workers. At the end of
the day, people want to work for an

honest company and instill honesty as a value and model for all
employees to follow.
Another trait that is important to being a good leader is to be a
visionary. Forward thinkers are
always looking at how to get to the next level, how to get to the
ideal business state. Forward
thinking is the entire basis of lean manufacturing and
enterprise. Lean enterprise reduces
variation, eliminates waste and improves the process. By
completing all of these tasks,
companies now have time to focus on the future instead of
dealing with the present.
When Henry Ford decided to go into the automobile business,
there were no paved roads, no fuel
stations or repair shops. Ford wrote, “The Edison Company
offered me the general
5
superintendence of the company but only on condition that I
would give up my gas engine and
devote myself to something really useful. I had to choose
between my job and my automobile. I
chose the automobile, or rather I gave up the job—there was

really nothing in the way of a
choice. For already I knew that the car was bound to be a
success. I quit my job on August 15,
1899, and went into the automobile business”. (Ford and
Crowther 1923) To have his vision of
building a car and building it successfully with no infrastructure
in place, clearly required
forward thinking.
When leaders are identified as not being very visionary or
forward thinking, there is a distinct
possibility that the leader may be afraid or unwilling to share
their vision with others. If
someone came to you 15 years ago and told you, “I am going to
start a company that will
produce a new type of phone. I want it to be able to take
pictures, double as a video camera,
send text messages, intercept email, and watch movies on it.”
What would you have thought?
There is also a tendency for leaders not to share visions in the
event that a goal or vision has not
or will not be reached. In some cases, leaders have been seen as
somewhat “flaky” when a
vision is broadcasted and then not achieved. Leonardo Da Vinci
is considered one of the greatest

visionaries of all time. However, if you looked at his work
during the time he was alive, it would
have been quite different.
Employees also want a leader to be competent. By nature,
employees assume you are competent
if you are placed into a leadership position. However, the jury
is still out until a few successful
demonstrations of competency are under your belt. Leaders
must demonstrate competence every
chance they get. There is a fine line to this trait; too much
competence demonstration can led to
thoughts of arrogance by others. Demonstrating competence
also doesn’t mean that leaders have
to inject perspective into every meeting or conversation.
Abraham Lincoln once said, "It is
6
better to remain silent and be thought a fool than to open one's
mouth and remove all doubt."
Intelligence is different from competence, and is another
important trait that employees identify
with leaders. The development of intelligence is always

ongoing, in both formal and informal
settings. Formal setting such as college, give people the
intelligence and understanding of
different subjects. Informal setting such as the workplace, also
offer the opportunity to teach and
learn new knowledge. As a Safety Engineer at Ford Motor
Company, my divisional boss and I
were walking through one of the assembly plants. He turned to
me and said, “I can’t teach you
anything about safety and health that you don’t already know.
What I can teach you is how to
get things done at Ford”. Obviously, this conversation caught
my attention as I believed I was
going to get a magic answer to solve my issues. What he taught
me was how to navigate in the
plant for safety and health issues, how to approach different
departments and sell safety to other
managers. Intelligence will also be demonstrated in how you
handle yourself regarding personal
behavior and attitude. I have met a lot of really intelligent
people who have had horrible
attitudes. Everyone knows someone like this. If you think
about those people, were they good
leaders? Do you feel that if they just had a better attitude, they

would be great to work for?
Inspiration can tie all of these traits together. People in
general, want to be inspired. The writing
of this book was in inspiration to my own passion for safety and
telling my stories. Story telling
is inspirations’ biggest tool. It allows you to use visions and
paint a picture of what you are
trying to say or accomplish. Stories that can connect to
employees and people on an emotional
level will leave lasting impressions. If you have ever gone to
hear a keynote speaker, usually
there will be some storytelling to draw the audience in. The
more emotional the story, the farther
people will go to make the connection on a personal level.
7
Inspiration and passion from a leader can motivate a workforce
if the workforce believes the
leader is honest, visionary, competent and intelligent.
(Leadership 501 2010)
Leadership Standardized Work
When we create standardized work for employees, we create

standard work for all employees
including leaders. Lean is all about change and leaders must be
open to change and create it.
How will management support the lean culture? Leaders are
people too, and we already
established that the human condition is to resist change. This is
why it is important to understand
what role leadership will have to support lean change. What
should be in the leadership
standardized work? Answer is once again, it depends. Mostly,
it depends on where the
organization is in its’ lean journey. If a culture has already
been built and sustainment is an
issue, leadership standardized work will look different from an
organization just to build a lean
culture.
At one facility, the leadership standardized work included the
following identified in Figure 7.1
Insert Figure 7.1
Although Figure 7.1 doesn’t seem like there is much substance
the leadership standardized work
for EHS, each piece or element of work was substantial.
Safety Operating System, SOS-Daily

PFTs, respirator fit testing
needed
reports
-Month)
8
-Month)
GEMBA Walk for Safety-Every Monday
The leadership GEMBA walk occurred every day, Monday
through Friday from 11:00-12:00.
Each day represented a different function of the manufacturing
process. Monday was deemed as
the day the leadership team would review safety. There were
nine critical questions that were
asked regarding safety in the area the GEMBA walk occurred.
Each question had significance to

the overall safety program and culture that was being
reinforced. Figure 7.2 demonstrates the
specific targeted areas that were covered during the GEMBA
walk for safety.
Insert Figure 7.2
Other areas that were included in the EHS Leadership Standard
Work were participating in the
annual EHS audit process. Each leader was assigned as a
champion of a different element
covered in the audit. The champion for a specific audit formed
a cross functional team to ensure
that all departments were working towards sustaining EHS
programs, practices and policies
within the facility. Safety Process Review Boards, SPRB
meetings were also held once a month.
These meetings were overall processes check of the safety
program to make sure everyone was
on the same page and all countermeasures were being addressed.
Leadership standardized work needs to be driven from the top
down. Leaders need to be held
accountable just like all other employees. Leaders lead by
example. In one facility I worked at,
we had a plant manager who came in and jump started the
stalled lean program. When

leadership participation was lacking on the GEMBA walk one
day, he called all managers into
the conference room. He talked about how important lean was
and how the GEMBA walk was a
9
significant part of leadership’s commitment to the lean process.
He then said, “Starting today,
there will be no more meeting scheduled in this facility from 11
a.m. to 12 p.m. This time is set
aside by me for the leadership of this facility to get on the floor.
I expect you to be on the floor
one hour a day helping sustain our lean processes.” Everyone
left the meeting and went about
their business. About 2 days later at 11 a.m., the plant manager
was walking past an office and
saw two managers sitting. He went in and asked what was
going on. Both managers stated that
they were working on a project together. Soon after a
“significant emotional event” occurred,
reinforcing the need and message that leadership was expected
to be visible on the shop floor,

driving lean.
Leadership in EHS
What makes a good EHS manager, director or leader? There are
all kinds of benchmarking tools
on different safety metrics and models for programs and
policies. There is a good chance that
you already know how to write a safety program or at the very
least, how to get one. Here are
some basic concepts and tools that all EHS professionals should
remember. These concepts, we
used properly will form and shape a good EHS leader.
Sell, Sell, and Sell!!!
Selling safety is a huge part of any program. The EHS
professional must be able to sway and
sell the customer in why they should implement new processes
or comply with policy. EHS
professionals should not beat other managers over the head with
standards. At the same time,
when something does go wrong (and it will) resist the
temptation of saying, “I told you so.”
Working with management when things do go wrong will build
team trust and leadership. EHS

professionals need to be visionary and create programs that
everyone can understand and comply
10
with.
Know your Process & Flow
Safety is the same whether you’re building cars or cookies.
With the exception of some different
standards in state run OSH programs, all OSHA standards are
the same. It’s applying the
standard to a specific process that challenges EHS
professionals. You need to spend time on the
floor asking questions and learning the processes of your
location or facility. This knowledge
gives you the creditability to talk to operators, managers and
engineers regarding safety issues
and improvements. If possible, try to do the job task in
question yourself. Someone can tell you
that it hurts to pick up raw material all day, but until you do it
yourself, you will never really
know. At the same time, you will also build relationships and
trust with employees working on

the floor.
I can remember at one facility in my career; we had a new plant
manager start one week. On
Friday, he wanted to have a meeting with all employees to
introduce himself and his vision of
where we needed to go. The past plant manager usually held
two meetings; one for first shift
and one for second shift. At the time, I was over security as
well as safety and environmental for
the facility. About an hour before the meeting was to take
place, I learned that the new plant
manager had decided to hold one meeting for everyone at the
end of the first shift. In his mind,
holding two different meetings was a waste of time and people
would not come to the second
meeting once information got out regarding the first meeting.
I went to his office after he was on the job for one week. I had
explained to him that I had
wished he had consulted me before scheduling the meeting. The
response I got was, “Why in the
world would I consult with safety to hold a meeting with all of
my employees?” I asked him to
come with me to the front door of the facility in the lobby. As
we opened the front door, I turned

11
to him and said, “Because I am one of the few people here that
can tell you our parking lot can
only handle one shift at a time.” Looking out the front door, we
could see a line of cars trying to
get into our parking lot. The plant was built on an elevation, so
we could also see cars stretched
through the industrial park, across the bridge over I-64 and
finally backed up on I-64. The state
police showed up and asked why they weren’t notified of the
meeting. The plant manager
looked at me, and I didn’t say a word to him. I went over the
talk to the troopers and explained it
was a communication issue and we would appreciate help with
traffic once the meeting was
over.
The parking lot looked like a scene from Woodstock. We had
cars blocking other cars because
employees were late and couldn’t find a parking space. Fearing
they would get in trouble for
clocking in late, vehicles were left in the middle of some lots.

Several vehicles ended up in
culverts and drainage ditches attempting to park on wet grass.
I never told the plant manager, “Listen to me or I told you so.”
We moved past that day and
were able to laugh about it years later. The rest of my tenure at
the facility, I was always
included in the decision-making process. The moral of this
story is if you know your processes
and how they work, you bring value to the organization and
leadership to EHS.
Consistency, Do what you say you are doing
To build a strong foundation for the EHS program, consistency
is the key and must be practiced
every day. Whenever I go to different companies for consulting
or benchmarking, I always ask
to see written programs. Understanding that not every
organization is perfect, 90% of the time I
find discrepancies in the written program as to what is
occurring on the shop floor. The whole
reason to write safety programs is to make a program
understandable to non-safety people and
create a program better than the standard.

12
The fastest way to get in trouble during a compliance visit is to
say you’re doing something on
paper, and not doing it in reality. If there is part of the program
that no one is following and can
be omitted from the safety program, omit it. Lean is all about
documenting real life. Safety
programs should also document real life.
Remember your Audience
Always remember who you’re talking to in both content and
meaning. EHS is usually the one
department that will deal with issues from the president to the
janitor. How you communicate
with people will leave a lasting impression. Presidents and
CEOs are usually looking at the
company or organization at a high level. Shop floor employees
and supervisors are dealing with
the here and now. EHS professionals need to calibrate
communication skills to different levels
of meaning and understanding to be successful. If possible,
communicate face-to-face rather
than through email.

Never Stop Learning
Become the perpetual student. If you are a part of a company
that is embarking in lean
enterprise or is already engaged in lean, get involved. Read
books on lean manufacturing,
research and improve your own process. Get on a cross-
functional kaizen team and learn another
part of the business. Participate in DILO studies and get to
know what supervisors go through on
the front lines in production. Formal learning gives you the
foundation; informal learning gives
you the tools.
Works Cited
Ford, Henry, and Samuel Crowther. My Life and Work. Garden
City, New York: Country Life
Press, 1923.
Kell, John. Wallstreet Journal. January 5, 2010.
http://www.aipnews.com/talk/forums/thread-
13
view.asp?tid=11456&posts=1 (accessed February 3, 2011).

Leadership 501. Leadership Traits- The Five Most Important
Leadership Qualities. 2010.
http://www.leadership501.com/five-most-important-leadership-
traits/27/ (accessed March 20,
2011).
Lt Gen Harold G. Moore, US Army (Retired). Battlefield
Leadership.
http://www.lzxray.com/battle.htm (accessed February 21, 2011).
Moore, General Hal, interview by Armchair General. 10
Questions for General Hal Moore
(September 21, 2007).
Wallstreet Journal. Ford Absent From Auto Bailout but May Be
Big Winner. December 19, 2008.
http://www.foxnews.com/story/0,2933,470525,00.html
(accessed January 3, 2011).

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