A qualitative evaluation of staff experience in the delivery of a co-produced consultation service for personality disorder

Holly Smith (Department of Hammersmith & Fulham Treatment and Recovery, King’s College London, London, UK)
Chloe Finamore (West London NHS Trust, Southall, UK)
Julia Blazdell (Cassel Hospital, West London NHS Trust, Southall, UK)
Oliver Dale (Claybrook Centre, West London NHS Trust, Hammersmith and Fulham, UK)

Mental Health Review Journal

ISSN: 1361-9322

Article publication date: 22 September 2022

Issue publication date: 2 February 2023

159

Abstract

Purpose

Consultation services are recommended to support mental health staff working with service users diagnosable with personality disorder. However, there is scarce literature examining the impact of delivering and receiving consultation services. This study aims to investigate the impact of a pilot co-produced consultation service aiding clinical teams in the engagement of service users diagnosable with personality disorder.

Design/methodology/approach

This is a qualitative evaluation using a focus group and five semi-structured interviews to explore the experience of delivering and receiving the consultation service. Data were analysed using thematic analysis. Clinical and demographic characteristics were obtained on service users referred.

Findings

The consultation staff focus group produced two overarching themes: “Disrupting the system” and “Mirroring the service and the service users consulted”. The staff consultee semi-structured interviews produced two overarching themes: “Experience of working with personality disorder” and “Experience of the consultation service”. Staff described working with personality disorder as challenging. The consultation process was experienced as a helpful and reassuring space to gain a new perspective on the work. However, the service was felt to be limited; in that, it lacked follow-on treatment.

Originality/value

This study adds to the body of literature on consultation for service users diagnosable with personality disorder and demonstrates its function in service provision. It sheds light on staff experience of delivering and receiving a consultation service, including the use of a co-production model.

Keywords

Citation

Smith, H., Finamore, C., Blazdell, J. and Dale, O. (2023), "A qualitative evaluation of staff experience in the delivery of a co-produced consultation service for personality disorder", Mental Health Review Journal, Vol. 28 No. 1, pp. 46-59. https://doi.org/10.1108/MHRJ-04-2021-0025

Publisher

:

Emerald Publishing Limited

Copyright © 2020, Emerald Publishing Limited


Introduction

Personality disorder and role of consultation

The Consensus Statement on Personality Disorder (Lamb et al., 2018) in 2018 highlighted widespread concern about the quality of care for service users who have difficulties associated with a diagnosis of personality disorder. The statement, chaired by Sir Norman Lamb and Sue Sibbald, drew together a broad coalition of professionals, representative bodies, service users and carers and staff to shine a light on a number of key concerns. These included continued stigma, unequal access to effective local services and poor interagency communication.

The statement led to a push for well-resourced dedicated community service provision for personality disorder. The NHS England Long Term Plan (National Health Service [NHS] England, 2019) has, through the Community Mental Health Framework, set out its approach along with considerable investment. Given the prevalence, variability of severity and pervasiveness of the difficulties associated with personality disorder, the vast majority of care will continue to be provided by mainstream health and social care services which with variable expertise. Consultation approaches which support local systems are critical to the success of the framework, and this project aimed to explore a multi-disciplinary co-produced approach.

Historical context

In 2003, the publication Personality Disorder: No Longer a Diagnosis of Exclusion (National Institute for Mental Health in England, 2003) highlighted inadequate provision of care for those diagnosable with personality disorder. With only 17% of NHS trusts in England providing specialist or “dedicated” services and a lack of clear pathways of care, service users were generally supported through accident and emergency departments and frequent and inappropriate psychiatric inpatient admissions (Bateman and Tyrer, 2004). A lack of appropriate care was considered to contribute to a form of service utilisation which was ineffective and associated with an additional and unnecessary burden on health-care services (Bender et al., 2001; Bateman and Fonagy, 2003). Staff were found to hold beliefs that service users with a diagnosis of personality disorder were untreatable and reported a reluctance to work with this group due to a lack of skills, training and resources. Some perceived these patients as “manipulative” and “attention-seeking”. This led to the call for the development of dedicated evidence-based services (Lamb et al., 2018), alongside a nationwide training programme to upskill staff: the Knowledge and Understanding Framework (KUF.)

NICE guidelines (National Institute for Health and Clinical Excellence [NICE], 2009a, 2009b) reinforced the recommendation in the NIMHE report (National Institute for Mental Health in England, 2003) that trusts should use a “hub and spoke” multi-disciplinary team (MDT) as their model for dedicated personality disorder services. The “hub” refers to a therapeutic base developing an expertise via direct clinical interventions to service users with the greatest levels of need. This expertise is filtered through the “spokes” to support staff in non-specialist external settings to improve the capacity for staff in other settings to work effectively. This commonly takes the form of outreach providing consultation, training, reflective practice and supervision to staff in general services across mental health, social care and criminal justice services (Bender et al., 2001; Bateman and Fonagy, 2003; Crawford et al., 2007).

A 2008 Delphi survey (Crawford et al., 2008) investigated how dedicated personality disorder services should be configured. Consultation services providing expert guidance to clinical teams was reported highly across all services. A recent RCPsych position statement on services for people diagnosable with personality disorder reinforced the role of consultation in improving care and promoting appropriate transitions (Royal College of Psychiatrists, 2020).

Despite a fivefold rise in dedicated personality disorder services within NHS trusts in England (Dale et al., 2017) engagement of individuals diagnosable with personality disorder remains a significant challenge (Jinks et al., 2012). Interpersonal dynamics between staff and service users can lead to negative attitudes with the potential for reduced empathy and motivation to engage the service user (Morris et al., 2014). A crucial aspect of effective engagement and subsequent treatment outcomes comes down to the quality of the therapeutic relationship with staff and the organisation of care (NHS England, 2019; Bateman and Fonagy, 2013).

Even with increasing specialist provision of dedicated services, most service users are supported by mainstream services where staff may not have the expertise to effectively manage their care (Price et al., 2009). With 59% of dedicated personality disorder services and 25% of general services reporting they delivered consultation, there is room for growth; however, there is little literature evaluating consultation approaches.

Currently, only two studies explore the impact of consultation approaches in non-forensic settings. Lee et al. (2008) evaluated the experience of care coordinators working with service users diagnosable with personality disorder through semi-structured interviews. They found staff felt consultation supported them in their work, were able to work with increased flexibility and assertiveness and that there was the “added value” of having space to reflect on complex service user dynamics (Lee et al., 2008).

The evaluation (Lee et al., 2008) also identified tensions between specialist and general services. The specialist team could be experienced as prescriptive, divisive, advising more work and under-appreciative of the expertise of non-specialist staff. Staff reported frustration, wanting the specialist service to take over clinical responsibility and viewed the consultative approach as too “hands-off”.

More recently, Dhanjal et al. (2018) evaluated a pilot MDT complex care consultation service based in an NHS specialist psychotherapy department for those with chronic interpersonal problems. The service aimed to support staff in the local community mental health teams via consultation. Through the use of a quantitative tool, the authors found reduced levels of anxiety and stress in staff, improved understanding of psychotherapy within care plans and reinforced the importance of providing a reflective space for staff.

Finally, a consultation approach to case-management, more widely used in forensic settings, has supported probation officers in their understanding of the needs and behaviours of offenders diagnosable with personality disorder and found a significant reduction in recalls to prison (Clark and John Chuan, 2016).

Co-production and its role in personality disorder services

The co-production model, i.e. the incorporation of practitioners explicitly used because of a lived experience, within MDTs, is considered a crucial element in the delivery of personality disorder services (Lamb et al., 2018; Crawford et al., 2007). Co-production is considered to help challenge stigma and negative staff perceptions through greater understanding of the patient’s needs (Yakeley, 2019). A prominent example of co-production is the co-developed and co-facilitated personality disorder training package the “Knowledge and Understanding Framework” (KUF). The programme aims to improve staff confidence and challenge stigma surrounding the diagnosis (Lamph et al., 2014). It has been demonstrated to improve understanding and lessen staff burnout (Finamore et al., 2020). While co-production has been central to the model of KUF and anecdotal evidence supports such approaches, more research is needed so that the approach can be refined and lived-experience practitioners and colleagues supported in their roles.

Co-produced consultation service for personality disorder

In June 2019, a novel co-produced consultation pilot service was developed to provide consultation for non-specialist clinical teams working with service users diagnosable with personality disorder who were in a protracted acute admission or frequently presenting in crisis. The consultation service comprised a consultant psychiatrist, group analyst, service user consultant, modern matron and peer support worker. The team members were drawn together specifically for this task as an additional duty to their other roles within the organisation. They all had previous experience of co-produced projects. The consultation service was a standalone intervention, and there was no dedicated service available for onward referral.

The pilot service was advertised to clinical teams on the Trust’s intranet and via word of mouth. The service processed referrals received using the referral criteria outlined in Table 1. The team offered a series of consultations with the clinicians involved in the care of the referred service user. These consultation meetings were held in the local team setting and were organised as a 60-min facilitated case conference. Between one and three consultation meetings were offered for each referral. In addition, the option of two 1 h consultation meetings was offered by the service user consultant to the care coordinator and service user only. The purpose of the consultations was to create an integrated, team-based formulation of the situation around the patient to help form recommendations. The service user perspective was incorporated into the formulation drawing on both the lived experience of the team members and the consultation with the service user and care coordinator.

Rationale and aims of the study

This is a qualitative study using semi-structured interviews and a focus group to explore a co-produced consultation service for personality disorder. The study aims to investigate the experience of both receiving a consultation as well as the experience of staff delivering it.

Methods and materials

Design

To provide a descriptive understanding of the participants’ experiences and meanings of their involvement with the service, we elected to take a qualitative approach to collecting data. Given our interest in understanding the impact of receiving such a service and of delivering it, we decided to explore the experience of both the staff delivering the consultation service, as well as those receiving it. A further reason for incorporating both the experience of those delivering and receiving the consultation was the a priori assumption that similar themes would arise in parallel between consultation team and consultee groups.

As the team delivering the service were working as a group, we adopted a focus group approach for the consultation staff. This enabled us to consider group and team-based processes. Data gathered in the group were analysed using thematic analysis (TA) to identify themes occurring from delivering the service.

For consultees, an individual semi-structured interview approach was adopted to explore themes which may be less likely to be expressed in a professional group setting. Data collected in these individual interviews were again analysed with TA to explore emerging themes from the experience of receiving the service.

Given our aims of incorporating findings from both those receiving and delivering the intervention, as well as the expectation of many themes being generated, TA was selected as an approach to data analysis due to its flexibility as a method (Smith, 2003).

A convenience sample was used to obtain NHS Trust staff consultee participants. Staff consultees were invited via email by a consultation staff member to participate in semi-structured interviews (N = 24). Staff consultees who responded were recruited resulting in a sample size of five. Due to time-constraints and the need for a pragmatic approach to recruiting staff, a convenience sampling was selected as a simple and efficient method (Jager et al., 2017), until the minimum sample size of five was met as a small-scale TA evaluation of individual interviews and a focus group (Horgan et al., 2020).

Quantitative data were obtained from electronic patient records in the form of clinical and demographic characteristics of service users (see Table 3).

Participants and data collection

All staff members of the consultation service were invited to take part in the focus group. Four of the five staff members from the service participated. See Table 2 for participant details. The primary researcher (HS) attended two consultation meetings to familiarise themselves with the service. The clinical supervisor (OD) of the research project and a secondary researcher (JB) were members of the consultation service. Data analysis and research supervision were supported by a researcher (CF) not involved in either the service or the data collection, which provided an opportunity to address bias in the interpretation of the data.

All participants were emailed an information sheet and consent form. Due to the restrictions of the COVID-19 pandemic, the focus group was held online. The focus group lasted 50 min and was audio-recorded and transcribed. The interviews lasted approximately 40 (33–53) min and were audio recorded and transcribed.

The focus group for consultation staff focused on the experience of developing and delivering the service, while the staff consultee semi-structured interviews explored the experience of receiving it. Both focus group and semi-structured interviews were guided by an interview schedule and prompts. The interview schedules were developed by the primary and secondary researchers. It followed a loose chronological structure to aid participants in their recall of events and focused on eliciting participants’ opinions on co-production as a key aspect of the service model.

Data analysis

Data from the audio recordings of the focus group and interviews were transcribed. Analysis followed a six-step process in-line with TA (Smith, 2003), including: familiarization of individual transcripts, coding an imported transcript on NVivo (version 12), collating codes into themes, reviewing themes, defining and naming themes and finally the write up. Analysis was completed by the primary researcher with extracts of coded transcripts reviewed by secondary researchers.

Ethics

Data obtained from participants were anonymised by using a pseudonym and stored securely. Participants were informed and consented to these procedures prior to participating in the evaluation via a consent form. Patient identification numbers for service users were used as alternatives to other patient identifying information. Ethical approval was not required due to the evaluation not involving randomisation, was not generalisable, and the research did not involve service user contact nor did the research influence treatment decisions. The project was registered as a service evaluation with West London NHS (Project No: 1805).

Results

Table 3 outlines the clinical and demographic characteristics obtained from the patient record following referral to the consultation service. During the time of the study, the pilot service received seven referrals of which five were accepted. The first referral accepted by the service did not meet the service use criteria. However, the referral was accepted due to significant concerns expressed by the treating team regarding risk.

The consultation staff focus group produced two overarching themes: “Disrupting the system” and “Mirroring the service and service users consulted”. “Disrupting the system” was formed by one theme: “A benignly provocative function”. The overarching theme “Mirroring the service and service users consulted” formed two themes: “Drawn into the need to do something” and “An insecure team structure”.

The staff consultee semi-structured interviews produced two overarching themes: “Experience of working with personality disorder” and “Experience of the consultation service”. “Experience of working with personality disorder” was formed of three themes: “Relentless and overwhelming”, “Chaos in the system” and “Lived experience in services”. The overarching theme “Experience of the consultation service” was formed of four themes: “A fresh perspective for teams”, “Change in the service user”, “Lack of coherence” and “Limitations of consultation” (see Table 4).

Discussion of results

Despite the limitations of the pilot service, the study gives evidence to support the utility and practicality of delivering consultation services to mainstream services.

Key findings on experience of delivering consultation service

“A benignly provocative function.”

The primary aim of the consultation service was to provide a containing, supervisory space to support non-specialist teams in the care of service users via consultation. “A benignly provocative function” explicates the contentious nature of holding a “specialist” or expert function as a dedicated personality disorder service by the team who appeared to perceive their role as persecutory at times: “And I found- I find myself struggling to not be a persecutor and find it very hard, very hard […]” Nevertheless, themes of persecution were absent in the staff consultee interviews.

“Creating complex dynamics in relationships.”

“Creating complex dynamics in relationships” acknowledges the challenges of provoking unhelpful and potentially damaging dynamics with the care-coordinator and service user through short-term involvement: “[…] at best tantalising, but at worst kind of provokes uh you know some sort of attachment that might not be helpful”. Use of individual direct work with service users was felt to change the service’s primary task as a consultative service into providing the link to accessing clinical treatment at the service’s base, a dedicated personality disorder hospital providing a national service: “[…] who am I setting myself up as, you know, for that person. Um. And I think that became [pause] more apparent for those who we thought could actually benefit from coming to [specialist personality disorder service] […]” This seemed to mirror the staff interview theme “Assumptions of taking the service user away”.

“Mirroring the service and service users consulted.”

The results reveal a mirroring dynamic in the consultation team as they described being “Drawn into the need to do something” displaying a desire to “do” and “act” often shown in services and service users as well as offer something beyond a short-term consultation: “[…] I felt very much kind of […] having- try- needing to come up with something […] drawn into, you know, doing”. The consultation team’s intended role of bringing joint-thinking and reflective practice into the consultation room, meant resisting this dynamic, yet they replicated a lack of a secure base from which to manage this tension given the service was a pilot intervention. “Lack of security within the consultation team” exemplifies this mirroring of insecure attachment styles of the service users consulted by the service: “[…] and we never really got our team structure properly going […] to work through the toxicities of the experiences”. Due to funding and the pilot nature of the service, the team structures necessary for the staff were limited. This meant insufficient availability and consistency for team debrief. This theme was understood as a tendency towards “Underestimating the impact of the work” illustrating an assumption that a consultation service would be “far enough away” to avoid experiencing the emotional impact, as well as underestimating the time and resources required to deliver the service: “I felt after the meeting it would have been great if we’d had the space- to be together”. This is comparable to “A reluctance to know” where resistance was observed in the staff consultees in discussing the impact and emotional experience service users were having on them: “[…] it took them a little bit of time to be able to talk about how they were getting a bit annoyed with this patient [laughs]. And we did quite a lot of modelling actually”.

Key findings on staff experience of receiving consultation service

The staff consultee interviews predominantly focused on the difficulties experienced by staff working with service users diagnosable with personality disorder generally over a direct discussion of the consultation service and the individual service users referred. This suggests the scale of the impact service users diagnosable with personality disorder have on staff.

“Relentless and overwhelming.”

“Relentless and overwhelming” describe different aspects of this impact, such as the challenges of managing crisis: “we were just running- [exhales] [pause] just dealing with crisis”. Moreover, feelings of burnout are present throughout from the overwhelming and demanding nature of the work: “[…] you’re carrying about 25 cases or 30 cases and then suddenly you have 3 or [pause] 5 clients with personality disorder on your caseload, so you feel overwhelmed”. The stigma and negative attitudes often held by staff towards services users diagnosable with personality disorder (Lamph et al., 2014) were not present within the interview themes. Instead, a sense of wanting to help but feeling stuck and needing support to achieve this was present, outlined in “At a loss and running out of ideas”: “[…] what on earth are we doing, you know, what is our role? You know we don’t seem to be seeing any significant change or improvement […]”

“A fresh perspective for teams.”

“A fresh perspective for teams” suggests the intervention created a confidence to approach the therapeutic relationship in a different way, such as by being more boundaried and giving clearer communications with greater transparency to service users: “[…] being honest with the client […] explaining the whole care plan to them […] sharing what- what has been observed […]” Furthermore, “Hope” and “Reduced self-harm” display positive changes in the service user and a belief in recovery found in staff: “[…] she will benefit from that. And it may be one of those ones that recovers from their personality disorder. I am not too sure. And I can only say [pause] positively, it will have an impact on her recovery”.

“Being dropped.”

“Being dropped” demonstrates a sense consultees had of being left behind and abandoned. This may be driven by a feeling the team were “intellectualising” the dilemmas the staff and patient were facing and partly due to an expectation of a specialist intervention or onward referral. This suggests the consultation service inadvertently replicated the experiences service users often report receiving from services in that the team were left with a question of what next: “[…] but I don’t really know in all honesty, because she, you know she was discharged not long after um the meeting from what I remember- or that’s the way I remember it. So, I don’t- I don’t really know we never had another HICS meeting or any follow up or anything like that”.

“A divide between services.”

Similarly, “A divide between services” outlines the frustration staff consultees felt over the separation and lack of continuity between services in teamwork and communication, particularly between inpatient and community services: “[…] what would happen on the ward would happen without the community team or any other team would be consulted […]”. The importance of this relational continuity between hospital and community settings when working with personality disorder has recently been highlighted (Crawford et al., 2007).

“Lack of coherence.”

Conflict between the role of consultation and the wishes of teams was evident. “Lack of coherence” portrays the desire staff held for the consultation service to transfer the service user to their care: “[…] my initial thought was oh you know you are referring this client to them. To this group. And that client is going to be under their care […]”. “Thinking more, doing less” illustrates a resentment felt by staff and a desire for more than consultation: “[…] they almost intellectualised doing nothing was a better strategy”.

“Hard to implement recommendations.”

Furthermore, “Hard to implement recommendations” sheds light on the difficulty of working in pressured environments where holding a formulation informed approach is challenged by the high levels of stress and trauma in both the service user and staff: “[…] and it can be quite hard to, you know, treat them in that sort of you know more sort of compassionate understanding way, unfortunately”. This likely impacts the capacity for reflective thinking due to the demand for reactive and time-pressured responses: “[…] so you do not have the time scale to implement all those- maybe the HICS group are geared towards that type of approach. Whereas we work very very differently”. This may contribute to a culture that reinforces a focus on “doing” to function within the service. Therefore, it suggests a clash between the approach of the consultation team and the realities of the services.

Key findings on staff experience of co-production

Co-production as part of the service model was not well understood by consultees. This was demonstrated by a focus in “Lived experience in services” on staff members’ experience of service user involvement prior to the consultation service. Echoing “A reluctance to know”, the consultation team expressed the feeling that lived experience is not widely accepted or perhaps acknowledged in services: “[…] I still think it’s very new that […] [sighs] that people would […] accept that someone who’s got- you know lived experiences, is there to be able to add something to the conversation”. Therefore, it is unclear whether lived experience within the consultation service contributed to challenging prejudice around personality disorder as suggested by Yakeley (2019).

“Provoking reflection and an understanding.”

Co-production was, however, described by consultees to be valuable in its contribution to services generally. “Provoking reflection and an understanding” outlines lived-experience staff holding a capacity to prompt in colleagues a different questioning of their role, practice and understanding of personality disorder: “[…] makes you question yourself so maybe that’s a good thing then in your attitude, you know to it, and whether you know you are being compassionate and you are [pause] you know you’re in the right job, you know […]”.

“Providing relational insights.”

“Providing relational insights” details the value of the perspectives given by staff with lived experience and how these may be more readily accepted by both service users and other staff: “I think they’re very important because my sense is they could probably maybe point some of those dynamics out and say, “Well, maybe this was my experience” and- and maybe it’s then less threatening for people”. Seemingly, lived-experience practitioners had a different authority, which the researchers believe is linked to the experience consultees had of developing greater confidence in working with their service users.

“Emotionally challenging for the lived-experience practitioner.”

Staff expressed a concern for what it might be like for a lived experience practitioner to work in the presence of stigma: “[…] how people feel about patients and they’ve been obviously a patient and a lot of them are ongoing patients in services […]” While this may illustrate a potential for cultural change within services, it illustrates the leadership challenges of such work and the need for robust support. It also mirrors what the consultation team were seeking in reinforcing their own structures to understand their experiences in providing the consultation through their own debriefing and reflective practice.

“Reinforcing negative perceptions.”

“Reinforcing negative perceptions” describes how some consultees reported negative experiences of previous service user involvement. This related to isolated examples whereby the reinforcement of negative attitudes towards service users diagnosable with personality disorder had occurred: “[…] admitting that, you know, that they could be a lot of trouble on the wards just because they enjoy making trouble […] that they could make peoples shifts a nightmare if they wanted to […]”. Additionally, some of these previous activities involving service users were perceived by staff as tokenism.

“Cynical and tokenistic.”

“Cynical and tokenistic” illustrates the danger of poorly conceived and managed co-production projects: “[…] they find someone that you know will come to job interviews or says the right things or, you know, praises them, and then they’ve you know they’re quite useful to have around when you need a service user to wheel out”. Consultees expressed concern that “using” lived-experience practitioners in this way was exploitative and “Emotionally challenging for the lived-experience practitioner”. This demonstrates the importance of having a mindful approach to co-production, such as having a systematic approach involving guidance and standards to support staff (Jager et al., 2017).

Limitations

The most significant limitation is the small sample size. Nevertheless, the findings provide insights into the experience of running a consultation service and guide future research. The convenience sample operating on a first-come, first-served basis for staff consultee participants may have limited the breadth of experiences captured. Additionally, using teleconferencing approaches may have influenced the participants in ways which are not quantifiable at this time. Finally, this was a small team with three of the authors involved in the delivery of the service; this may have introduced bias in the interpretation of the results and data collected.

It is worth highlighting that some consultees introduced themes of working with lived-experience practitioners in other settings and projects, and so it was difficult to disentangle these previous experiences from the actual experience they had of co-production with this particular project.

Conclusions

This qualitative evaluation highlighted the emotionally challenging experiences of staff consultees in working with people diagnosable with personality disorder. Staff expressed feeling overwhelmed and a sense of therapeutic nihilism towards the service users referred. The consultation service was experienced as a helpful, reassuring presence where staff received a new understanding and fresh approach. It was anecdotally considered to produce positive change in service users, including reduced self-harm and a sense of hope. However, staff consultees experienced consultations as limited in role and wanted the service user to be offered a clear onward referral to a specialist service.

Some data on the experience of co-production is described. Staff perceived benefits of a lived-experience perspective through introducing new perspectives and building hope and confidence in staff consultees. The study also cautions against poorly conceived and delivered co-production through describing the lingering negative perceptions such experiences have on staff.

The absence of persecutory feelings in staff consultees contrasted with the fears held in the consultation team, suggesting instead that consultees were open and grateful for their input. Nevertheless, the need for structure for the consultation team illustrated the emotional burden traveling through the system in a way that appears unsustainable without appropriate structures to support the consulting team.

This study supports the role of consultation in working with people diagnosable with personality disorder. The findings lend weight to the assertion that consultation is a key function of dedicated and specialist personality disorder services and is best offered as part of a wider system with access to specialist interventions.

High intensity consultation service (HICS) referral criteria

Clinical criteria Service user criteria
High levels of risk evidenced by any of the following:
Highly disorganised pattern of attachment Service users with over 27 bed days in the preceding 12 months
Confusing diagnostic picture Service users who have had two or more admissions to inpatient services
Challenges developing coherent clinical leadership and care plans (e.g. through numbers of teams, pathways or agencies involved or contradictory patterns of engagement) Service users who have had more than two crisis assessment and treatment team and liaison psychiatry service referrals

High intensity consultation service (HICS) team and staff consultee participant demographics

Staff role Gender Ethnicity Time working with personality disorder
(years)
High Intensity Consultation Service (HICS) team (N = 4)
Consultant psychiatrist Male White British 18
Service user consultant Female White British 10
Group analyst Female Mixed – White British, Black African 38
Peer support worker Female White British 2
Staff consultees (N = 5)
Staff role Gender Ethnicity Caseload diagnoseable with
personality disorder (%)
Time in profession
(years)
Time in current role
(years)
Clinical psychologist Female White European 100 19 10
Occupational therapist Male Unknown 20 12 6
Social worker Female Black African a 24 1
Consultant psychiatrist Male Mixed 30 30 9
Senior nurse practitioner Male Asian Other a 28 9
Note:

a = Unable to say percentage of caseload

Clinical and demographics characteristics of service users accepted to the high intensity consultation service (HICS) (N = 5)

Patient Gender Ethnicity Age Marital status Diagnosis Length of time in service (years)a A&E visitsb Inpatient admissionsb Bed daysb Crisis
team
referralsb
1 Female White
British
54 Single EUPD 28 3 2 179 4
2 Female Asian or Asian
British – Indian
30 Single EUPD;
GAD
6 2 0 0 1
3 Female White
British
42 Single EUPD;
PTSD
21 5 3 111 2
4 Female White
British
25 Single EUPD;
PTSD;
ED
12 4 2 84 4
5 Female White
British
45 Divorced EUPD 9 7 1 38 8

Thematic analysis of the high intensity consultation service (HICS) focus group of staff experience on delivering the service and semi-structured interviews with staff consultees on receiving the service

Overarching theme Theme Subtheme Illustrative quote
HICS focus group (N = 4)
1. Disrupting the system 1.1 A benignly provocative function 1.1.1 Struggling not to be a persecutor “I think actually it ends up feeling very persecutory, I’m afraid. And I found- I find myself struggling to not be a persecutor and find it very hard, very hard…”
“Where at times in all of the meetings was prickly”
1.1.2 Creating complex dynamics in relationships “…we would do these two kind of reasonably discrete pieces work just over two sessions with the service user… at best tantalising, but at worst kind of provokes uh you know some sort of attachment that might not be helpful”
1.1.3 A reluctance to know “…how little was known about some of the- some of the service users that we ended up working with and yet they had- they’ve been in the system for quite a long time”
“…it took them a little bit of time to be able to talk about how they were getting a bit annoyed with this patient. And we did quite a lot of modelling actually”
“…I still think it’s very new that…that people would… accept that someone who’s got- you know lived experiences, is there to be able to add something to the conversation”
2. Mirroring the service and service users consulted 2.1 Drawn into the need to do something 2.1.1 Pressure to come up with solutions “…I felt very much kind of…having- try- needing to come up with something…drawn into, you know, doing”
2.1.2 Starting before working everything out “So I mean I think there are logistic issues…and I think part of that as a reflection of, we did it by the seats of our pants…”
“…I suppose some of the kind of like the teething problems, whether it was, you know, [Peer Support Worker] - receiving treatment within a recovery team- that…you know threw up some issues that we then needed to really think about”
2.2 An insecure team structure 2.2.1 Lack of security within the HICS team “…we never really got our team structure properly going…to work through the toxicities of the experiences”
“…it was very difficult to know whether that resource was going to be available…all those sort of things made it seem quite precarious”
2.2.2 Underestimating the impact of the work “I felt after the meeting it would have been great if we’d had the space- to be together”
“…but I think that there needs to be enough time, I think, not just….for the meeting, for the debrief but also for the report writing…”
Staff consultee semi-structured interviews (N = 5)
1. Experience of working with personality disorder 1.1 Relentless and overwhelming 1.1.1 Crisis “We were just running-[pause] just dealing with crisis”
“…can be quite aggressive and violent and like the self-harming side of thing is really traumatic for, you know, staff and everyone really”
1.1.2 The level of activity and demand “…patients like her, will often then have their moments. So they will then ligature, they will then either copy the same behaviours, you know, they won’t want the attention all on that person you know they’ll want some of it too”
“…you’re carrying about 25 cases or 30 cases and then suddenly you have 3 or 5 clients with personality disorder on your caseload, so you feel overwhelmed”
1.1.3 The family as the patient “…so it is very very difficult to reassure the family. It’s almost like looking after the client [pause] and the family as well”
1.1.4 At a loss and running out of ideas “…what on earth are we doing, you know, what is our role? You know we don’t seem to be seeing any significant change or improvement…”
“Just because we- we’ve ran out of like you know interventions so I guess how to address the psychological needs of these clients”
1.2 Chaos in the system 1.2.1 A divide between services “…what would happen on the ward would happen without the community team or any other team would be consulted…”
“…You know when they’re discharged from us, we don’t know- they’re off the caseload …You know they’re not- they’re not anyone we now have a right to review or look at”
1.2.2 Conflict and competition in teams “…a sense of like, ‘Oh, well you and your setting, you know, you don’t have the challenges that we have in our sector’… because the patient, you know, with this patient, they present differently to different people in different settings and I think also people don’t understand that really…”
“…, they find it very challenging, they get very touchy… feel like ‘oh they’re criticizing me’ or something … It’s often very much like the- the problem is located in the patient but actually this is a systemic problem”
1.3 Lived experience in services 1.3.1 Provoking reflection and an understanding “…makes you question yourself so maybe that’s a good thing then in your attitude, you know to it, and whether you know you are being compassionate and you are [pause] you know you’re in the right job, you know…”
“I think the benefit is about understanding isn’t it? Kind of the same level. Having better understanding what someone is talking about”
1.3.2 Providing relational insights “I think they’re very important because my sense is they could probably maybe point some of those dynamics out and say, ‘Well, maybe this was my experience’ and- and maybe it’s then less threatening for people”
1.3.3 Reinforcing negative perceptions “…admitting that, you know, that they could be a lot of trouble on the wards just because they enjoy making trouble… reinforced some ideas of… where’s the balance of power and that they could make peoples shifts a nightmare if they wanted to…”
1.3.4 Cynical and tokenistic “…they find someone that you know will come to job interviews or says the right things or, you know, praises them, and then they’ve you know they’re quite useful to have around when you need a service user to wheel out”
1.3.5 Emotionally challenging for the lived expert “…how people feel about patients and they’ve been obviously a patient and a lot of them are ongoing patients in services…”
2. Experience of the HICS 2.1 A fresh perspective for teams 2.1.1 Overlooking service user background and history “And also I think when they provided the record. It was very very clear that you know, the- was certain things that we had overlooked before”
2.1.2 Reassurance “Next time I know what to do. I know where to go and know where to go for such services. So it wouldn’t be a kind of frustration of working with someone with PD. And then uh- not knowing what to do. I know where to go now and seek for information”
2.1.3 Gaining knowledge of dedicated personality disorder services “I never know about their existence, until at the point of- we are exchanging emails… then in the meeting I found out that they have about four or five different professionals in terms of the areas of the support they can provide”
“…because it looks like a case that is okay for them. So, yeah- because of her behaviour and impulsiveness and things like that- I was thinking, having that kind of diagnosis, as EUPD, it will be a very good idea for them to work with this client”
2.1.4 Confidence “…I felt a bit more confident. You know, maybe making some references to the past and things that maybe I wouldn’t really have known about”
“…being honest with the client…explaining the whole care plan to them… sharing what- what has been observed…”
2.2 Change in the service user 2.2.1 Hope “…can’t wait for that assessment to continue and to start working with the team. So she’s actually looking forward to it”
“…she will benefit from that. And it may be one of those ones that recovers from their personality disorder.”
2.2.2 Reduced self-harm “But the moment she realized that HICS is going to start working with her, tying of ligatures reduced”
2.3 Lack of coherence 2.3.1 Assumptions of taking the service user away “…my initial thought was oh you know you are referring this client to them. To this group. And that client is going to be under their care”
2.3.2 Being dropped “…you know she was discharged not long after um the meeting from what I remember- or that’s the way I remember it. So, I don’t- I don’t really know we never had another HICS meeting or any follow up or anything like that”
2.4 Limitations of consultation 2.4.1 Thinking more, doing less “Didn’t sound like they were going to offer anything. So I was a bit like oh, you know, there was a lot of talk and no action. What are you actually gonna do? It seems to be they almost intellectualised doing nothing was a better strategy”
2.4.2 Hard to implement recommendations “…but the nature of our work and the intensity of our work, so you do not have the time scale to implement all those- maybe the HICS group are geared towards that type of approach. Whereas we work very very differently”

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Corresponding author

Oliver Dale can be contacted at: oliver.dale@westlondon.nhs.uk

About the authors

Holly Smith is based at the Department of Hammersmith & Fulham Treatment and Recovery, King’s College London, London, UK

Chloe Finamore is based at the West London NHS Trust, Southall, UK

Julia Blazdell is based at the Cassel Hospital, West London NHS Trust, Southall, UK

Oliver Dale is based at the Claybrook Centre, West London NHS Trust, Hammersmith and Fulham, UK

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