Department Of Psychology, Brigham Young University, Utah, United States
One out of 10 children is abused before the age of 18. They are often abused by parents or family members, demonstrating that elementary school faculty should be enlisted to help recognize and report childhood sexual abuse. Trainings should be provided to educators on how to best help children in this situation. Once teachers report abuse, children can receive the help they need through CBT, TF-CBT, art therapy, and group therapy. If sexually abused children receive help, they are more likely to decrease the negative effects of abuse such as anxiety, depression, and disassociation, which are connected to personality disorders in adolescence. If children do not get the help they need, they can be susceptible to acquiring personality disorders such as BPD and DID, which can compromise the management of emotions and increase feelings of detachment from oneself. Through trainings and more research in the field of personality disorders, beneficial changes can be made to improve the lives of children and adolescents.
Borderline personality disorder; Dissociative identity disorder; Faculty members; Sexual abuse; Therapy
Enlisting School Faculty to Help Identify Childhood Sexual Abuse in Elementary Students and Prevent Personality Disorders in Adolescents
Peter, a 7-year-old child who experiences sexual abuse at home, gets dropped off at school. He feels alone and does not know where to go for help and support. The very people that he should be able to turn to when in trouble (his parents) are the ones who are inflicting great harm. He turns the corner to go to class and runs into a faculty member who regularly strives to have a close relationship with him. This is one of the few people Peter feels he can trust, and a rush of relief rolls over him, knowing that he can confide in someone and hopefully receive the help he so desperately needs.
Peter is one of many children who are sexually abused by parents or close relations. This is an especially common issue within the United States [1-12]. Approximately 1 in 10 children will be abused before the age of 18 . Multiple studies have also found that around 12% to 35% of women and 4% to 9% of men were sexually abused before the age of 18 [7,13]. Tragically, it is common for the victim’s perpetrator (s) to be those to whom they are closest, especially their parents and siblings [1,14]. Such disturbing evidence highlights the need to better understand Childhood Sexual Abuse (CSA) from an empirical perspective.
Research indicates that 42% of sexually abused children’s perpetrators are biological or adoptive stepfathers, 80% are sexually abused by their parent, and 90% are abused by someone they know [1,14,15]. Of those children being abused by their parent, Salter  stated that it can be very difficult to detect the abuse because the parent is usually in control. In addition, he claimed that children are less likely to tell anyone about the situation due to the shame and fear that they typically feel . These findings indicate that abused children are often put in a difficult predicament and may need assistance to ensure their safety and recovery.
Because it is so common for the needs of abused children to go unnoticed, it is important for faculty within elementary schools to develop a close relationship with the children they serve. When faculty members are trained to look for signs of abuse among children and have a close relationship with them, they are more likely able to help. According to the U.S. Department of Health and Human Services , school faculty play a critical role in helping with and recognizing abuse among children, given that teachers are in close contact with children on a regular basis. This usually allows educators to have the unique ability of creating a secondary support system for these children.
With training to help teachers identify signs of abuse among children, elementary school faculty will likely be able to facilitate student support. This support can often be found through different types of therapy such as Cognitive-Behavioral Therapy (CBT), art therapy, and group therapy. Multiple studies have concluded that CBT is the most common evidence-based therapy that has shown improvement in children’s behavior and overall well-being [7,16,17]. Another way of helping children work through their emotions related to abuse is through art therapy. This allows many children to express their emotions through art rather than through words . Lastly, group therapy allows adolescents to feel supported and related to by their peers . All these therapies are thought to be powerful ways to help children overcome the struggles that they may experience as a result of sexual abuse.
If these types of therapies or interventions are not put into place as soon as possible, children are more likely to develop adverse symptoms. These could include Post-Traumatic Stress Disorder (PTSD), depression, anxiety, and personality disorders. One of the most common personality disorders likely resulting from sexual abuse is Borderline Personality Disorder (BPD) [18,10] found that 57% of the 30 victims they studied were diagnosed with BPD. It cannot be certain if these disorders resulted directly from abuse; however, many similar studies have shown a large correlation between sexual abuse and BPD, especially if the cases of abuse were untreated . Given that children are known to experience sexual abuse at the hands of trusted adults, school faculty should initiate and maintain regular communication with elementary-aged students and acquire skills to notice signs of childhood abuse, because doing so facilitates reporting of abusive caretaker behavior, provides information about what type of intervention may be necessary, and can improve outcomes related to associated personality disorders in early adolescence and young adulthood.
Reporting Of Abusive Caretaker Behavior
Because many children experience sexual abuse by a parental figure, it is important for school faculty to look for signs of abuse. Teachers, advisors, and school faculty have the unique opportunity of being with children every day. This opportunity may allow them the increased ability to notice and identify suspicious activity and potential abuse of children. They can do this through observing changes in children’s behavior and noticing how their families function together [3,4]. Close proximity of faculty grants them the key responsibility to report any sexual abuse suspicions. By law, most states require public, private, and daycare schools to report any kind of suspected abuse [2,3]. Not only are faculty members supposed to fulfill this role of reporting, but they are also in a position to help these children, especially if no other trusted informant is available. If educators watch for signs of abuse in the children they care for, they can likely make a measurable difference in the lives of maltreated children.
Even though elementary school faculty members can have a major impact, many do not know how to recognize or report sexual abuse among children. Studies show that only 18 states require school district training on CSA awareness and prevention, and out of the 2,793 schools surveyed, only 51% of staff felt adequately trained to report child abuse [3,4]. Discovered that schools that provided trainings mostly focused on reporting requirements rather than preventative strategies for sexual abuse (Figure 1). Alvarez et al.  further found that many schools frequently excluded sexual abuse from their maltreatment trainings. These statistics show that society would likely benefit from better enforcing school and faculty training to help children who are sexually abused. By doing so, teachers would likely feel more prepared to use preventative strategies and report sexual abuse.
Figure 1: Number of states requiring awareness and prevention training on sexual abuse of students by school personnel, by topic
Note: This graph demonstrates the different types of prevention training that school faculty are required to take and how many states require this type of training. Adapted from “Federal Agencies Can Better Support State Efforts to Prevent and Respond to Sexual Abuse by School Personnel” .
Another reason why it is important that faculty know procedures on how to help and report sexual abuse among children is because abusive situations are not all experienced the same way. The U.S. Department of Health and Human Services  gave an example of a case study of a student named Frank. Frank confided in his coach, told him he was being sexually abused by his brother, and asked his coach not to tell anyone. The coach was unsure what to do, so he told the principal. The principal said that this needed to be reported, and before Frank could be warned, the report was made. Consequently, Frank denied that he had any problems and then had a hard time trusting anyone else. The case was subsequently dismissed. This example shows that if each case is not handled carefully, issues may go unresolved and young people may continue to suffer.
One way faculty members can more effectively help students like Frank is by developing close relationships with their students and their students’ unique circumstances. This may allow children to have more trust in faculty members and allow teachers to better judge how and when to proceed. As disclosed in Frank’s story, the main reason he opened up to his coach was because he trusted in him. The U.S. Department of Health and Human Services  emphasized that a close and positive relationship with a trusted adult may help to increase the child’s resiliency. Wang et al.  found that teachers who formed trusting relationships with students are also capable of being a role model for them. Wang et al.  further observed that positive teacher-student relationships developed when teachers took the time to ask students about their opinions, personal life, feelings, and struggles. These findings suggest that if faculty members take the time to make connections with students, children will be more likely to trust the faculty member and disclose potential sexual abuse.
In addition to underscoring the importance of developing trusting relationships with children, faculty trainings can teach educators how to recognize signs of CSA. Some common signs of abuse include nightmares, obsessive cleaning, inappropriate sexual behavior or knowledge, quick attachment to strangers, frequent conflict or aggression, and even strange drawings [4,20]. Children who draw genitalia or sexual acts and who forget to draw mouths or other body parts in their drawings may have been sexually abused [4,21]. Faculty would also likely benefit from trainings on how to report sexual abuse. Gardner et al.  found that faculty who received training on how to report abuse felt more confident and knowledgeable in completing the task. They also found that if trainings were repeated, teachers’ knowledge in reporting persisted over time, and those who did not hear the trainings more than once had a substantial decrease in knowledge . This evidence suggests that by training faculty repeatedly on how to recognize and report abuse, teachers may become more confident and be better able to help in the fight against CSA.
Although faculty can benefit from learning how to recognize, help, and report abuse, controversy remains regarding when it is appropriate to report. Many faculty members disclose that they do not want to report because they do not know if doing so would cause greater conflict within the family unit [2,3]. Faculty members also may not feel the need to act on maltreatment because it does not seem to fall within the school domain; abuse is often thought to be a family matter that lies outside the boundaries of school responsibility . These findings suggest that a gray area may exist regarding when reporting child abuse is appropriate. With proper training of faculty members, this can become much less of an issue, and teachers can be better prepared to know how to handle the abusive situation.
Information about What Type of Intervention May be Necessary
If teachers are successful in recognizing and reporting CSA, children are more likely to receive the help and support that they need. One of the most common therapies known to help is CBT, a non-specific therapy that covers a variety of treatments using cognitive and behavioral techniques . These techniques can involve problem-solving, changing irrational beliefs, using exposure, and learning coping skills. Some unique factors about CBT are the activities used as compared to other therapies. Patients may be encouraged to do homework, skills training, and other procedures to complete future plans [6,24]. Currently, CBT is shown to be the most capable type of CSA intervention and is found to have positive effects on a variety of psychosocial issues such as distorted thought-processes and self-images [6,8]. When CBT is used to help children, studies have found a considerable amount of improvement in the patients, and children may learn skills to process the abuse they endured [6,8]. These capabilities not only allow them to overcome the trauma in the moment but also to combat issues they may have in the future [6,8]. CBT is usually very effective because it covers a large variety of potential issues. These findings suggest that by using CBT as quickly as possible within children that have been sexually abused, victims of abuse are more likely to avoid psychosocial issues in the future.
A subtype of CBT, Trauma-Focused Cognitive-Behavioral Therapy (TF-CBT) focuses on trauma in that it engages in gradual exposure by introducing the feared stimulus to the patient while demonstrating that it will not cause them harm; this in turn allows the child to reduce their negative behaviors caused by the negative stimulus [8,25]. TF-CBT adds the component of educating not only the abused child but also their parents and parental figures. By adding a parental figure, this form of therapy allows adults to learn how to effectively offer support when a child is practicing skills they learned in therapy. Later in the process of TF-CBT, parental figures and children have sessions together to increase open communication [8,25]. Even though this type of therapy generally requires a parent, it is assumed that the non-abusive parent will take part in the therapy . If that is not an option, it could be useful for the child to have a parental figure or role model participate, so the child can gain trust in adults and receive support.
Sometimes when a child is abused, they do not want to talk about it, or they may have a very difficult time expressing their emotions about the abuse vocally. When this is the case, therapies such as play or art therapy are frequently used. Art therapy is a way that children and adolescents can express themselves without words. It includes many mediums such as music, art, dance, drama, sand play, and more [5,9]. Because very young children are often incapable of abstract thought, it is necessary for them to be able to express themselves through these different mediums; this becomes their way of communicating . In addition, children are frequently told not to tell anyone when they are abused, which can cause children to experience anxiety when they do talk about their trauma . Through art, they can portray their thoughts in a relaxed and non-stressful way. Pifalo  found, after a 10-week art therapy session, that children reported having less dissociative symptoms, anxiety, and PTSD . If children are not capable of verbally portraying how they feel or what happened to them, art or play therapy may be an effective option for them. These forms of therapy may allow the child and others to determine what happened but in the child’s own timing.
One last common way that adolescents can receive help after being sexually abused is through group therapy. Studies show that group therapy may help decrease negative psychosocial effects such as dissociation, PTSD, anger, and behavioral problems; it can also prevent other issues from occurring in the future [6,8]. In this type of environment, people who are abused can feel understood because they are with a group of people their age who have gone through similar circumstances. By being with empathetic peers, they are less likely to feel alienated and are more often capable of gaining trust in others . Even though this kind of therapy is frequently helpful, it usually is more suited for adolescents. Additionally, some research shows that it is better for small children to participate in individual therapy rather than in a group . One downside to group therapy is that some adolescents might not want to discuss their situation in a group setting [6,8]. However, group therapy usually has high outcomes for those that would feel comfortable in participating because it generally allows adolescents to feel supported and not alone during the process of recovering.
Outcomes Related to Associated Personality Disorders
A common detrimental effect of sexual abuse found among children is the onset of personality disorders, such as BPD, in adolescence or young adulthood. Children who are sexually abused and have BPD show worse side effects than those who are not abused with BPD . To understand this issue, it is first important to understand that BPD is a mental illness that negatively affects one’s ability to manage their emotions, have interpersonal relationships, and think clearly before acting impulsively; these effects of BPD commonly arise in adolescence and early adulthood [26,27]. Further research indicates that those who are sexually abused and develop BPD attempt suicide more often, participate in self-mutilation more, are in the hospital longer, and have higher rates of sexual impulsivity than those who just have BPD without having been abused [11,12]. In fact, 70% to 84% of people diagnosed with BPD will try to commit suicide multiple times [11,12]. These findings suggest that CSA and its associated personality disorders present serious issues. Not only could BPD affect one’s emotions, but it could also drive youth to multiple suicide attempts.
Even though BPD involves many negative effects, it can be very difficult to diagnose someone with BPD. The diagnosis of BPD is often challenging because the disorder expresses itself in many different ways; additionally, clinicians often disagree on how valid the diagnosis of BPD is . Moreover, BPD is often misdiagnosed because its symptoms can look very similar to other disorders such as PTSD, disassociation, bipolar disorder, and eating disorders (NEABPD, n.d.). Other disorders may be comorbid, such as anxiety, eating disorders, and other personality disorders, which can also lead to a misdiagnosis, preventing people from receiving the help they, need to recover [29-27]. This evidence indicates that BPD can be challenging to navigate clinically, particularly with regard to diagnosis.
Not only is BPD frequently difficult to diagnose, but it is a disorder often accompanied by social stigma. Warrender et al.  discovered that many BPD patients were refused admittance into hospitals, even when they had serious issues. Individuals with BPD have also been observed to be helped by the hospital only when they were at risk of suicide . Not only can hospitals have biases towards those with BPD but those in society may, as well. Fruzzetti  claimed that BPD is one of the most common mental disorders to be majorly stigmatized. He claimed that because of this, those with BPD were discriminated against, experienced negative judgments, and received undesirable assumptions; these actions led those with BPD to experience suicidality, depression, and even more emotional dysregulation . This evidence demonstrates the apparent societal bias towards those with BPD and suggests that reducing stigma would likely help those with BPD to receive the help and support they need.
Another personality disorder that can come about due to CSA is Dissociative Identity Disorder (DID), or (as it was previously known) multiple personality disorder. DID is generally not as common as BPD but can still be prevalent among those with CSA (Cleveland Clinic, n.d.; NEABPD, n.d.). DID is characterized by two or more distinct identities or personalities; each identity has its own unique background, wants, and dislikes, and the disorder typically involves a disconnect of one’s self from their mind, including a perceived detachment from one’s own actions [30-32]. Those with DID can even have memory problems with day-to-day events, hallucinate, and believe in something they think is real but is not (Cleveland Clinic, n.d.). All of these effects are the body’s way of coping with and forgetting certain traumatic memories [30-32]. DID tends to be a rare mental disorder; however, it is common for those with DID to have been abused as a child . Research in this area identifies a connection between CSA and DID; for example, Beitchman et al.  found that 60% of females with DID encountered CSA. This evidence indicates that even though DID is relatively rare, it is commonly associated with CSA and can be very detrimental to those who have it.
More research should examine DID because it can be difficult to diagnose within patients. Some even claim the validity of the diagnosis, arguing that it lacks empirical evidence . A rebuttal claim was made by Crellin and Temple  who explained that the ability to diagnose patients requires an enhanced knowledge in clinical experience; however, dissociative disorders such as DID do not fall under this kind of training. They stated: “This results in the absence of understanding and therefore ability to appropriately enquire and consider DID within differential diagnostic assessment” . They then claimed that psychiatrists therefore rarely report having seen DID cases . One other difficulty with diagnosing DID is that symptoms generally show up in children between the ages of 5 and 10; however, many teachers and even parents confuse DID at this age with attention-deficit/hyperactivity disorder. Consequently, DID is not usually diagnosed until adulthood (Cleveland Clinic, n.d.). Crellin and Temple  further claimed that even though some believe that DID is a pretend disorder, capabilities of detecting it through neuroimaging biomarkers exist. They discovered that people with DID have different brain imaging and neural responses compared to those without DID . This shows that even though DID might not be as common as other disorders, it is still a present issue.
Fortunately for 7-year-old Peter, who is a victim of CSA, the faculty member he is talking with at his elementary school is someone he can trust. He feels an urge while talking with his teacher to relate what is happening at home after this conversation, the faculty member assures Peter that everything will be all right, and Peter is filled with a rush of relief. With caution and care, Peter’s abuse is then reported by the faculty member, and Peter is put into the proper programs and therapies to help him overcome the trauma that he went through. Just like Peter, there are children who need support from elementary school faculty members to help them overcome issues of sexual abuse.
Because teachers interact with students most of the day, they can generally help students more than other adults. They also have a responsibility as teachers to report abuse [2,3]. However, many teachers do not know how to report abuse . Teachers would benefit by receiving training to feel more prepared and empowered to help. Effective training involves knowing how to gain a close relationship with students and learning how to recognize and report abuse [4,19,20]. Given some degree of ambiguity related to when it is appropriate to report abuse, additional training can help teachers to know how and when to act on suspicious activity.
If teachers are capable of reporting abuse, children are more likely to get the help they need to recover from the abuse. Some common therapies that could help children who are sexually abused include CBT, TF-CBT, art or play therapy, and group therapy. Each therapy has a different approach; consequently, they are uniquely equipped to treat different kinds of cases of sexual abuse. CBT and TF-CBT focus on changing irrational beliefs and cognitive issues [6,8,24,25]. Art or play therapy is a way that children and adolescents can express their emotions without words [5,9]. Lastly, group therapy allows adolescents to feel understood by empathetic peers; however, some downsides to this therapy are that it is not as helpful for children and that some adolescents might not feel comfortable to talk about their abusive situation in a public setting [6,8]. Even though these therapies might not be perfectly suited for each person, they can and do help many children.
If children are not given the help they need to navigate an abusive situation and obtain treatment, they might be subject to certain personality disorders such as BPD and DID. It has been found that a large number of people with BPD and DID were subjected to CSA [10-12]. BPD is associated with the inability to manage emotions, whereas DID is characterized by the disconnection between the self and mind [26,30]. These disorders can be difficult to diagnose because they can look very similar to other disorders such as anxiety, depression, eating disorders, and so on. Consequently, it can be difficult to get these patients the help they need [27-30]. These associated personality disorders can disrupt the lives of those who experience CSA and then continue to suffer with mental health challenges; therefore, it would be beneficial to find better ways to diagnose these disorders so young people can receive the help they need.
While CSA is fairly well understood from an empirical perspective, the correlation between CSA and personality disorders should be researched more extensively. Additional emphasis should also be placed on the diagnosis of personality disorders such as BPD and DID. It would be beneficial for more studies to be done in these areas to help children who have been sexually abused, because they often continue to suffer from personality disorders into adolescence and young adulthood. With improved diagnostic techniques and treatment plans, young people who experience CSA and are able to obtain assistance from a trusted adult may be better able to overcome the negative effects of sexual abuse and lead healthier, happier lives.
- Darkness to Light (2015). Child sexual abuse statistics.
- Alvarez KM, Kenny MC, Donohue B, Carpin KM (2004) Why are professionals failing to initiate mandated reports of child maltreatment, and are there any empirically based training programs to assist professionals in the reporting process? Aggression and Violent Behavior 9: 563-578.
- United States Government Accountability Office (2014) Federal agencies can better support state efforts to prevent and respond to sexual abuse by school personnel. United states government accountability office, Washington, D.C., USA.
- S. Department of Health and Human Services (2003) The role of educators in preventing and responding to child abuse and neglect. U.S. Department of Health and Human Services, Washington, D.C., USA.
- Devlin JM, Hill L, Berry J, Felder K, Wilson C (2019) Therapeutic practices for sexually abused children and adolescents: Resources for marriage, family, and couples’ counselors. The Family Journal 27: 359-365.
- Kim S, Noh D, Kim H (2016) A summary of selective experimental research on psychosocial interventions for sexually abused children. J Child Sex Abus 25: 597-617.
- Putnam FW (2003) Ten-year research update review: Child sexual abuse. Journal of the American Academy of Child and Adolescent Psychiatry 42: 269-278.
- Tichelaar HK, Dekovic M, Endendijk JJ (2020) Exploring effectiveness of psychotherapy options for sexually abused children and adolescents: A systematic review of randomized controlled trials. Children and Youth Services Review 119.
- Pifalo T (2002) Pulling out the thorns: Art therapy with sexually abused children and adolescents. Art Therapy 19: 12-22.
- Beitchman JH, Zucker KJ, Hood JE, DaCosta GA, Akman D, et al. (2002) A review of the long-term effects of child sexual abuse. Child Abuse and Neglect 16: 101-118.
- Turniansky H, Ben-Dor D, Krivoy A, Weizman A, Shoval G (2019) A history of prolonged childhood sexual abuse is associated with more severe clinical presentation of borderline personality disorder in adolescent female inpatients - A naturalistic study. Child Abuse Negl 98.
- Warrender D, Bain H, Murray I, Kennedy C (2021) Perspectives of crisis intervention for people diagnosed with “borderline personality disorder”: An integrative review. Journal of Psychiatric and Mental Health Nursing 28: 208-236.
- Gorey KM, Leslie DR (1997) The prevalence of child sexual abuse: Integrative review adjustment for potential response and measurement biases. Child Abuse and Neglect 21: 391-398.
- Salter M (2021) New research shows parents are major producers of child sexual abuse material. The Conversation, Victoria, Australia.
- Access Continuing Education, Inc. (n. d.). Perpetrators of child abuse.
- Hanson RF, Wallis E (2018) Treating victims of child sexual abuse. The American Journal of Psychiatry, 175: 1064-1070.
- Ramchandani P, Jones DPH (2003) Treating psychological symptoms in sexually abused children: From research findings to service provision. British Journal of Psychiatry 183: 484-490.
- Mainali P, Rai T, Rutkofsky IH (2020) From child abuse to developing borderline personality disorder into adulthood: Exploring the neuromorphological and epigenetic pathway. Cureus 12 : 9474.
- Wang M, Brinkworth M, Eccles J (2013) Moderating effects of teacher-student relationship in adolescent trajectories of emotional and behavioral adjustment. Dev Psychol 49: 690-705.
- Children’s Welfare Information Gateway (2019) What is child abuse and neglect? Recognizing the signs and symptoms.
- Allen B, Tussey C (2012) Can projective drawings detect if a child experienced sexual or physical abuse? A systematic review of the controlled research. Trauma, Violence Abuse 13: 97-111.
- Gardner SL, Derouin A, Brown R, Johnson AD (2018) At the front lines: Effectively training community stakeholders to recognize and report child abuse and neglect. J Sch Nurs 36: 181-186.
- Münger A, Markström A (2019) School and child protection services professionals’ views on the school’s mission and responsibilities for children living with domestic violence-tensions and gaps. Journal of Family Violence 34: 385-398.
- Bohman B, Santi A, Andersson G (2017) Cognitive behavioral therapy in practice: Therapist perceptions of techniques, outcome measures, practitioner qualifications, and relation to research. Cogn Behav Ther 46: 391-403.
- Cohen JA, Mannarino AP (2015) Trauma-focused cognitive behavior therapy for traumatized children and families. Child Adolesc Psychiatr Clin N Am 24: 557-570.
- de Aquino Ferreira LF, Queiroz Pereira FH, Neri Benevides AML, Aguiar Melo MC (2018) Borderline personality disorder and sexual abuse: A systematic review. Psychiatry Res 262: 70-77.
- National Education Alliance for Borderline Personality Disorder. (n. d.). National Education Alliance for Borderline Personality Disorder. National Education Alliance for Borderline Personality Disorder.
- Garland J, Miller S (2020) Borderline personality disorder: Part 1 - Assessment and diagnosis. BJPsych Advances 26: 159-172.
- Fruzzetti A (2017) Why borderline personality disorder is misdiagnosed. National Alliance on Mental Illness, Virginia, USA.
- Cleveland Clinic (n. d.) Dissociative identity disorder (multiple personality disorder). Cleveland Clinic Ohio, USA.
- Lebois LAM, Ross DA, Kaufman ML (2022) “I am not I”: The neuroscience of dissociative identity disorder. Biological Psychiatry 91: 11-13.
- van Minnen A, Tibben M (2021) A brief cognitive-behavioural treatment approach for PTSD and dissociative identity disorder, a case report. J Behav Ther Exp Psychiatry 72.
- Crellin A, Temple M (2021) What is it about DID? A patient and clinician perspective. BJPsych Advances 27: 99-101.