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Barriers and facilitators to the implementation of a stepped care intervention for personality disorder in mental health services

MELISSA PIGOT1, CAITLIN E. MILLER2, ROBERT BROCKMAN3 AND BRIN F.S. GRENYER2, 1School of Psychology, University of Wollongong, Wollongong, NSW, Australia; 2School of Psy- chology and Illawarra Health and Medical Research Institute, University of Wollongong, Wollon- gong, NSW, Australia; 3Institute for Positive Psychology and Education, Australian Catholic University, Sydney, NSW, Australia

ABSTRACT Background – Individuals with personality disorders—particularly borderline personality disorder—are high users of mental health treatment services. Emergency service responses often focus on crisis management, and there are limited opportunities to provide appropriate longer term evidence-based treatment. Many individuals with personality disorders find themselves in a revolving cycle between emergency departments and waiting for community treatment. A stepped care approach may help to triage clients and allow access to interventions with minimal client, clinician and system burden. This study aims to understand the facilitators and barriers to real- world implementation of a stepped care approach to treating personality disorders. Methods – Managers and clinicians of health services engaged in implementation were interviewed to obtain accounts of experiences. Interviews were transcribed and thematically analysed to generate themes describing barriers and facilitators. Results – Participants identified personal attitudes, knowledge and skills as important for successful implemen- tation. Existing positive attitudes and beliefs about treating people with a personality disorder contributed to the emergence of clinical champions. Training facilitated positive attitudes by justifying the psychological approach. Management support was found to bi-directionally effect implementation. Conclusions – This study suggests specific organizational and individual factors may increase timely and effi- cient implementation of interventions for people with personality disorders. © 2019 John Wiley & Sons, Ltd.

Personality disorders are of high prevalence in the general population1,2 and in mental health set- tings.3–6 Borderline personality disorder (BPD) is characterized by an instability of emotions, self- concept and relationships.7 Individuals with per- sonality disorders are high users of mental health treatment services8,9 and often present in crisis to

emergency departments.6,10 However, inpatient admissions may have iatrogenic effects11 and have a high economic burden.12 An alternative treat- ment approach is needed for people with personal- ity disorder presenting in crisis.13 Long-term outpatient treatment has the best evidence for re- covery from personality disorder14; however, in

Personality and Mental Health 13: 230–238 (2019-11) Published online 14 August 2019 in Wiley Online Library (wileyonlinelibrary.com) DOI 10.1002/pmh.1467

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budget-constrained, time-constrained and resource-constrained services, the opportunity to provide evidence-based treatments can be lim- ited.15 The reality for many mental health services is individuals with personality disorder being involved in a revolving cycle between emergency departments in crisis or sitting on long waiting lists for treatment and attempting to manage intense emotional experiences in the interim alone. Fur- ther, individuals experiencing BPD report they need interventions that support both symptomatic remission and functional abilities.16,17 There is a need for interventions that focus on the individual need for the client and provide care in the space be- tween crisis management and long-term treatment.

A possible solution to this revolving door cycle and differential needs of clients is a stepped care approach. Stepped care approaches are an evidence-based, staged system comprising a hierar- chy of interventions, from the least to the most in- tensive, matched to the individual’s needs.18,19

Given the heterogeneity of personality disorder presentations and the high variability in out- comes, a model of stepped care within community health systems may be able to better account for clients who need minimal intervention for recov- ery.20 Our approach to stepped care involved a whole of service re-design so that staff working at all levels of acuity were implementing evidence- based approaches, with an initial focus on care planning within specific personality disorder stepped clinics, to support reducing suicide rates,21

emergency department presentations22 and in- crease compliance with follow-up.23

We have evaluated this stepped care approach in a cluster randomized controlled trial in mental health settings for personality disorder presenta- tions.24 The stepped care model followed three pro- cesses: intake, brief intervention25 and the option of psychological therapy in the community. The whole of service approach centred on a relational model and was informed by relevant clinical prac- tice guidelines.19,26,27 In the site where the stepped care intervention was implemented, there was a 22% reduction in presentations to emergency

departments over the 18-month follow-up period and a significantly larger reduction in days spent in inpatient wards. While this work provides early indication of intervention success, it is also crucial to evaluate the process of implementation and modify as necessary.

A pressing issue in mental health care is the gap between empirically based treatment and treat- ments provided to clients in typical care settings.28

One strategy for successful implementation in- cludes identifying barriers that may hinder imple- mentation progress and strengths that increase effective implementation.29 The purpose of the current study is to explore the barriers and facilita- tors towards implementing a stepped care inter- vention for personality disorder presentations in mental health settings. The experience of clini- cians and managers implementing the approach were studied using qualitative methods to under- stand factors impacting implementation.

Method

The study reporting is informed by the Standards for Reporting Qualitative Research.30

Design

In order to gain an in-depth understanding of ex- periences, an interpretive phenomenological de- sign (IPA) was adopted.31 Data were collected by individual semi-structured interview. The inter- view was developed by researchers and included open-ended questions reflecting topics related to implementation. Interviews were conducted by re- searchers who were independent of the clinical services provided in the health service sites.

Setting

The health-care system in this study was a publi- cally funded open access provider of health and medical services to the community in a large catchment area. Initially, the area was divided equally into an implementation and a treatment as usual (control) area and matched based on size

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of the population and services provided. Once the treatment as usual area had been studied, it also implemented the model. Thus, there were two study areas that formed the total implementation sample of study. Details of clinical outcomes have been previously published.24

Participants

Purposeful sampling was used to identify key stake- holders involved in multiples aspects of imple- mentation.32 Participants were mental health clinicians and managers actively involved in the intervention. Forty-six potential participants were contacted, and 21 participants completed the in- terview, consisting of 13 clinicians, 7 managers and 1 individual who acted across both roles. In the final sample, 52.4% of participants were female (n = 11) with an average of 5.5 years (stan- dard deviation = 4.6, range = 1–15) of experience in their current role. For 17 participants who pro- vided their age, mean age was 39.5 (standard devi- ation = 9.7). Participant details were de-identified for confidentiality.

Procedure

Participants provided written informed consent fol- lowing approval of the research protocol by the lo- cal Institutional Review Board. Interviews were audio recorded and transcribed verbatim. Interviews were conducted over 2011–2012 when sites had been implementing the intervention for 18 months. The interview included questions regarding overall success of implementation, in addition to perceived barriers and facilitators to the intervention.

Data analysis

Interviews were recorded, transcribed verbatim and entered into NVivo 10 for analysis.33 IPA was used to understand individual experiences, and transcrip- tions were thematically analysed.31,34 Researchers became immersed in the data prior to coding, then initial codes were generated and codes were collated into common themes. Following this, metathemes

and subthemes were defined and named. Three transcripts, representing over 10% of the data, were coded by two independent raters, and discrepancies were discussed until agreement was reached. Re- maining transcripts were independently rated. The success of implementation was also rated categori- cally by researchers. The findings were then tested against a number of informants to validate the re- sults with no further changes made.

Results

Demographic and clinical variables of the sample were collected during interviews and are presented in Table 1. Most clinicians interviewed were trained psychologists or practitioners actively in- volved in delivering the intervention.

Experiences of overall success of implementation

There were five groupings of clinicians across the study area. Following descriptions by clinicians and managers, two groups were rated ‘moderate implementation’ (some evidence of implementa- tion with limited integration) and three rated ‘good implementation’ (evidence the intervention was accepted as a core practice and was routinely

Table 1: Demographic and clinical variables of participants (N = 21)

Variable N %

Profession Psychologist 12 57.2 Nurse 3 14.2 Psychiatrist 1 4.8 Occupational therapist 3 14.2 Social worker 2 9.5

Current role Clinician 13 61.9 Manager 7 33.3 Clinician and manager 1 4.8

Attended implementation training Yes 20 100 No 0 0

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used). For convenience, we have pooled these to- gether and labelled them ‘site 1’ (moderate imple- mentation) and ‘site 2’ (good implementation) in reporting. Table 2 displays typical descriptions of implementation success for each category.

Thematic analysis

Six dominant themes emerged from the data in re- lation to barriers and facilitators of the interven- tion. These themes spanned across both individual and organizational factors.

Training. Training was used to increase knowl- edge and skills of mental health clinicians about personality disorders and their treatment specific to the stepped intervention. Participants’ re- sponses identified four subthemes impacting implementation.

Validation of psychotherapeutic approach Participants reported training justified a psycho- therapeutic treatment approach. One practitioner reported that ‘by having that specialist training and by having that support from the—from the project, it’s kind of like it’s given us the justifica- tion to work like this … being the psychologists in a team’ [14_C].

Engagement and attitudes towards working with the personality disorder population Training increased awareness of effective therapies with the potential to reduce stigma. Participants also noted a barrier to implementation was lack of engagement by key medical staff. One participant described ‘a little bit of a battle to I think, shift some of the thinking of some medical staff … some of the difficulty you know [is] getting the medical staff en- gaged in the training and education’ [15_M].

Practical experience Training alone was perceived as insufficient for practice, but a combination of training and hands-on experience was useful to build confi- dence. One participant stated ‘that could perhaps be a good thing if it was—if everyone saw at least one person through it … they felt comfortable in it, they felt that they could relax … they could ac- tually engage better with the person’ [03_C].

Timing of intervention training The timing of training delivery in relation to im- plementation timeline was reported to be both a barrier and facilitator, depending on the area. Most participants commented on the need for

Table 2: Statements from participants on their perception of implementation success

Rating Site N Description

Moderate 1 10 ‘The mental health service does not—has not really changed its policy around, seeing personality disorders as a serious mental illness.’ [12_M]

‘I do not believe the [intervention] is working. I do not think we are capturing enough people.’ [12_M]

Good 2 11 ‘… there [are] clear strategies and people are seeing that they are having a really good impact.’ [14_C]

‘… we are running five appointments a week … putting them through this different pathway, actually, frees up the access.’ [16_M]

‘It’s increasingly becoming embedded in the culture, I think.’ [21_C]

Note: M, manager; C, clinician.

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ongoing training opportunities to continue facili- tating the intervention implementation.

Clinical champions. Clinical champions were re- ported as key facilitators of change and pivotal to implementation at both sites. A participant re- ported that the stepped intervention ‘was well sup- ported by clinicians who had good intent to make something happen’ [08_M]. However, at areas with limited support from management, cham- pions were restricted from working within the flex- ible treatment model of the intervention.

Management support. Positive experiences of im- plementation were fostered by management support of clinician experience. As one participant remarked, ‘… you know the managers were commit- ted to making it work, they were just kind of leaving it up to us to, try and work out how to do it’ [14_C]. Conversely, a perceived lack of management sup- port was a barrier. Lack of engagement of senior managers at site 1 resulted in a sense of isolation from clinicians and mangers actively implementing the intervention, where ‘it had to get to the point where we just went and did it despite management, rather than with management’ [05_M].

Governance. Governance across both sites had an important impact on implementation. Three subthemes emerged describing relationship be- tween governance and implementation.

Flexibility Practitioners at site 2 consistently reported on how adapting the model to meet the needs of consumers and the service was vital in facilitating implementa- tion; ‘we took ownership of it very quickly. And we saw how it could work within our team, and within our sort of processes’ [16_M]. Conversely, at site 1, a lack of flexibility was a significant barrier to initially commencing implementation.

Perceptions of core business Across both sites, conflicting opinions by staff about their role in working with people with

personality disorders were evident. At site 1, this hampered implementation as the intervention was ‘more seen as like an appendage rather than within the Health Service at times’ [10_M]. At site 2, descriptions of success and sustainability were most positive, including ‘the system works pretty well here, that it’s a little bit more just inte- grated into normal work practice than I think it is at other areas’ [03_C].

High sensitivity to risk of harm Governance within mental health services is fo- cused on minimizing risk of harm to clients. In implementing a crisis intervention, managers and clinicians were reluctant to diverge from this pol- icy, and staff members in acute teams were hesi- tant to increase their workload and take on additional risk. One manager reported ‘clinicians would still refer to the clinic’s acute care team. There was always … a barrier between the [stepped intervention] and the acute care team …. Clinicians were frustrated by that and weren’t happy to be holding risk like that’ [08_M].

Change management. Participants’ perception of change management was an important indicator of implementation. At site 1, the absence of a plan for change leads to confusion from staff and man- agement about goals and logistics of the implemen- tation. One clinician remarked ‘there was just some kind of friction, misunderstanding, feelings of why … bring in trainers in from outside, when they could’ve used their own people’ [07_C]. The size of the area and the level of management support ap- peared to impact perceptions of change manage- ment. At smaller, isolated areas, the lack of a structured process of change did not impede imple- mentation in the context of strong management support. However, at larger areas, the presence or absence of a plan for change was an important factor contributing successful implementation.

Feedback on outcomes. Most participants commented on the importance of demonstrating outcomes for the intervention. One participant

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stated ‘I think the demonstration of outcomes has been the best thing. You know these people would just keep going around and around for a long time without any change … just seeing people—[they] have you know two, three sessions and you don’t hear from them again. It’s good’ [14_C]. Where outcomes were not communicated to the service providers, descriptions of implementation were poorer. For example, one manager commented ‘I’m not saying I’m not positive towards the [stepped intervention], I just haven’t seen any re- sults. I’ve seen very few referrals, I’ve seen confu- sion, I’ve seen staff dwindle away’ [12_M].

Discussion

This study aimed to explore the experiences of cli- nicians and managers implementing a stepped care intervention for personality disorders in mental health settings. Qualitative interviews were used to identify barriers and facilitators of change. Site 1 was rated by researchers as having ‘moderate’ success of implementation with some use of inter- vention model, and site 2 was rated as having ‘good’ implementation where the intervention was integrated into core service practice. Results of thematic analysis elicited six themes in relation to barriers and facilitators, including training, clin- ical champions, management, governance, change management and feedback on client outcomes. Themes can be understood in terms of individual and organizational factors.

Individual factors

Experiences of both clinicians and managers indi- cated individual factors—including attitudes and beliefs—influence implementation. Training in- creased knowledge of psychological therapies. Training was not perceived by participants as resulting in changing attitudes; however, it was seen as an adjunct to hands-on experience to in- crease familiarity and confidence in clinical prac- tice.35 For clinicians with compassionate attitudes towards personality disorder, training

did validate their experience and skills and acted as an incentive to continue change.

The presence of clinical champions was vital to implementation. Mental health services tend to have limited psychologically trained staff mem- bers, which is linked to poor implementation of psychological therapies in public mental health.36

The effect of service wide training that validates a psychological model and gives psychologically trained staff ‘permission’ to use psychological ther- apies may be invaluable to future implementation programmes.

Organizational factors

Organizational factors impacting on implementa- tion were management support or leadership, gov- ernance and organizational values and culture. At site 2 where clinicians experienced support from senior managers, they felt supported in their work and described more successful implementation outcomes. Effective leadership encouraged en- gagement and confidence to work with the popu- lation. A leadership style focused on understanding staff needs is useful for implementa- tion of personality disorder interventions. This is consistent with findings that a transformational leadership approach promotes positive attitudes among staff37,38 and can predict more openness to innovation during implementation of evidence-based treatments.39 At site 1, partici- pants reported the perception that people with personality disorders should be treated by specialist treatment programmes and not by services more generally within a stepped care approach. This culture resulted in a lack of engagement with change, ineffective policy development and ulti- mately poor implementation. Understanding the culture of the organization is vital to appropriately facilitate change.40

Clinical governance was perceived by some participants as a barrier because of conflicting opinions and organizational policies. Conversely, for other areas, formalized policy facilitated imple- mentation by distilling referral pathways and

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clinician support structures. Flexibility in the ap- plication of clinical governance appeared to be the most important theme regarding governance.

Organizational experience in change manage- ment was reported as lacking at site 1. Implementa- tion was perceived as chaotic and unplanned, and managers reported feeling unskilled and unpre- pared for effecting change within the health set- ting. In this context, managers appeared to impede change by not committing adequate re- sources to the implementation, which resulted in clinicians becoming over-burdened and limited success of implementation.41 Organizations should train managers and staff in implementation frame- works and relevant change theory, so they are bet- ter able to influence the implementation process.42

Perceptions of the outcomes of implementing the change were important for engaging in and sus- taining implementation. Feedback on intervention outcomes provided evidence for the change, which prompted action towards change. The importance of transparent outcomes is consistent with models of change,40 and considering the positive experi- ence of informal feedback, future implementation programmes may benefit from incorporating overt evaluation and dissemination plans.

A number of limitations are relevant to this re- search. Firstly, the sample size of this study was small, limiting generalizability of the findings. Fu- ture studies could employ alternate statistical methods to capture a wider breadth of experi- ences. Secondly, the IPA method is limited as in- dividual experiences are not necessarily an accurate representation of the experiences of a sample.43 Additionally, the sampling technique may have resulted in a selection of those with the most positive experiences of change. However, as negative experiences were also reported, it is likely selection and positive reporter bias was minimal.

Conclusions

This study highlights a number of issues relevant to clinical practice. Most importantly, the study

found mental health services have the capacity to implement stepped therapeutic interventions for personality disorders. Further, it provided an opportunity to improve understanding with regard to the key factors for success in implementing such strategies. Management support appeared to be the most important factor, but when not available, ex- perience of training and the role of champions fa- cilitated change in health settings. Demonstration of the impact of change was vital for continued engagement in implementation. Based on these findings, implementation processes could be re- fined to focus on five key factors for success: (1) clear and accountable leadership commitment at the level of senior clinical staff and (2) establish- ing and supporting clinical governance outlining clinical pathways to specific treatment clinics and (3) clinician support structure. Further, im- portant aspects include (4) ensuring sufficient penetration of training to all staff, including ongo- ing training opportunities, and (5) training man- agers and senior clinical staff or clinical champions on how change occurs and factors asso- ciated with success or barriers and development of prospective plans for evaluating and disseminating outcomes of implementation. This study aids in understanding how to implement evidence-based practices in real-world settings for a challenging population. Further research is needed to continue closing the gap between research and practice, thus giving help-seeking individuals with BPD the best possible treatment for their individual level of need.

Disclosures and acknowledgements

Project Air Strategy is supported by the NSW Ministry of Health (no. HEC10/371). The funding body provided the authors with access to collect the data, however, had no role in the de- sign, data analysis or preparation of the manu- script. The funding body gave approval for the manuscript to be published.

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