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

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 implementation. 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 efficient implementation of interventions for people with personality disorders