Whose “capacity to change?” Clinical reflections on working with complex service users in secondary care adult mental health services

Purpose The purpose of this paper is to consider service users who struggle to make changes in spite of often-repeated periods of care under secondary care mental health services – who they are, what may be interfering with change and how they can be best supported. Design/methodology/approach This paper summarises the authors’ clinical experience and draws on existing theories of therapeutic change and attachment. Findings The authors reflect on how (and whether) services should identify which service users are ready to make use of psychotherapy in the context of increased demand and limited resources. The role of the therapist in creating a facilitative environment is considered, with EMDR and internal family systems models offered as helpful approaches in particular. The authors also highlight the importance of acknowledging social, economic and systemic contexts as potential barriers to change. Research limitations/implications This paper discusses NHS services that are available in England and, therefore, does not consider broader global community mental health care provision. Originality/value To the best of the authors’ knowledge, there is little written on this issue, and our hope is to stimulate further discussion.