It is estimated that 4% of people have a personality disorder.
Reference Coid, Yang, Tyrer, Roberts and Ullrich1
Personality disorder has a significant impact on individuals, their
families and society at large. Despite this, people with personality disorder
have historically been overlooked by mainstream mental health services. Many
people with personality disorder are dissatisfied with the care they receive
and some clinicians are reluctant to work with this group.
Reference Lewis and Appleby2,Reference Ramon, Castillo and Morant3
Concern about the quality of personality disorder services prompted the
Department of Health to recommend the development of dedicated community-based
services in England and fund 11 new ‘pilot’ personality disorder services.
Although evidence about the effectiveness of specific treatments for
people with personality disorder is beginning to emerge,
Reference Binks, Fenton, McCarthy, Lee, Adams and Duggan5
there is little information to guide the development of such services.
We therefore conducted a Delphi study to develop a consensus on how dedicated
community-based services for people with personality disorder might best be
Delphi studies involve sequential rounds of questionnaires in which
participants are given feedback summarising the views of others and asked
whether they would modify their views in the light of this feedback.
Reference Murphy, Black, Lamping, McKee, Sanderson, Askham and Marteau6
We developed a 49-item questionnaire on the organisation and delivery of
dedicated personality disorder services based on in-depth interviews with
service users and providers, and recommendations from the study team.
Reference Crawford, Rutter, Price, Weaver, Josson, Tyrer, Gibson, Gillespie, Faulkner, Ryrie, Dhillon, Bateman, Fonagy, Taylor and Moran7
Each question comprised a statement and an accompanying Likert scale
ranging from 1 (disagree) to 9 (agree). Two additional items asked panellists
to rank 11 priorities for service development and 6 measures of service
outcome. Panel members were also encouraged to provide suggestions for
additional items to be included in the subsequent round.
The panel comprised service providers (from the 11 national pilot services),
service users (recruited via the Department of Health's national personality
disorder programme, a mental health charity (the Mental Health Foundation) and
a national service user group (‘Borderline UK’)) and academic experts. Academic
experts were identified from an electronic search of bibliographic databases of
all those who had published at least one peer-reviewed paper on personality
disorder services in the UK in the past 10 years. We aimed to recruit equal
numbers from each group; the final panel comprised 34 service providers, 34
service users and 31 academic experts. Three rounds were carried out. In the
first round, eight additional statements were suggested, which led to five new
statements in the second round of the survey. This meant that a total of 54
items were rated, plus the two ranking items.
For analysis, the 9-point scale was divided into bands of disagree (1–3),
neutral (4–6) and agree (7–9). Consensus was judged to have been reached when
75% of panellists responded in the same 3-point band. Feedback on the results
of the previous round was given to participants in rounds two and three,
including the person's previous response, the median rating and information
about differences between stakeholder groups where applicable.
Eighty-eight people (89%) responded to the first-round questionnaire, 85% in
the second round and 82% in round three. Expert authors and service providers
included 21 (34%) psychiatrists, 13 (21%) psychologists, 12 (20%)
psychotherapists, 8 (13%) nurses and 2 (3%) social workers.
Consensus was reached on 21 items (39%), which are listed in the online Table
DS1. Ten items were endorsed in round one, five in round two, and a further six
in round three. Consensus was not reached on most items, including: whether
services should work with people with a history of violent offending; the role
of assertive outreach; whether people should be assessed in their own homes;
use of medication; whether teams needed to have medical input; use of
compulsory treatment orders; and whether dedicated out-of-hours services should
Details of items endorsed by each of the three groups of stakeholders are shown
in the online Table DS2. Major differences between stakeholders were not found.
However one item, ‘It does not matter if personality disorder services do not
have a clear treatment model, as long as there are positive outcomes for
service users’, was rejected by expert authors and service providers, but it
was endorsed by over 40% of service users.
Priorities for service development were rated by 88 (89%) panellists. Four
types of service scored consistently highly: those aimed at reducing stigma and
discrimination associated with personality disorder and community-based
services providing psychological treatments (median score=8), and dedicated day
services and consultation services providing expert guidance to colleagues
working with people with personality disorder (median score=7). Two types of
service, therapeutic communities and in-patient units for people with severe
personality disorder, were rated lower (median score=5). All measures of
service outcome were scored highly. Quality of life was ranked highest by all
three groups. Expert authors and service providers placed social function as
the next most important outcome, with service users opting for reduction in
symptoms of mental distress. All three stakeholder groups rated user
satisfaction with quality of care the least important outcome measure.
Consensus was reached on only 39% of items, which is lower than that achieved
in previous Delphi studies examining general and dedicated mental health services.
Reference Fiander and Burns8,Reference Heather, Dallolio, Hutchings, Kaner and White9
Although we involved panellists with a wider range of backgrounds than
most previous studies, it is unlikely that this resulted in the low level of
consensus as the more homogeneous subgroups of service providers and expert
authors agreed on even fewer (35%) items. Instead, we think that the lack of
consensus reflects the rudimentary experience of service provision for people
with personality disorder and the limited evidence base that exists to support
their development. The differences between groups that we did find may reflect
a greater interest in the outcome rather than the process of care among service
users, and a tendency to place greater importance on user involvement among
service users and providers than among the expert authors that participated in
Despite low level of consensus, agreement was reached on several statements,
some of which apply equally well to generic mental health services, although
others are more specific. For instance, general mental health services often
need unilaterally to take steps to reduce risk of harm to self or others: in
contrast, panellists agreed that the reduction of risk to people with
personality disorder involves placing a high degree of choice and personal
responsibility with the patient. Panellists stated that most people with
personality disorder should have access to dedicated services. In 2002, only
17% of trusts in England provided such services.
Although dedicated services may reduce the need for in-patient and
emergency medical services,
Reference Bateman and Fonagy10
the financial implications of providing them for all those with
personality disorder would be significant.
Strengths of the study include the range of perspectives that we accessed and
the high response rate. However, all panellists came from Great Britain and
although several factors would seem important in other countries, others are
more closely related to the way that services are currently configured in
Britain. A more fundamental limitation of this, and other Delphi studies, is
that findings are based solely on expert opinion. A consensus based on expert
opinion can be of value, especially when other forms of evidence do not exist,
but expert opinion may still be flawed. So, for instance, we do not know
whether services that adhered to the principles that we identified would be any
more effective than those that do not.
In England, mental health service providers have been asked to ensure that
people with personality disorder have access to dedicated community-based
services. Members of the Delphi panel recommend that such services should
provide psychological treatments via out-patient and day-patient units, and
should work to reduce stigma associated with personality disorder. They stated
that interventions need to be delivered for years rather than months and that
service outcomes should be assessed in terms of improved quality of life and
social functioning, and reductions in mental distress. Findings of this Delphi
study highlight good practice and indicate the need for further research in
Declaration of interest
None. P.T. is the Editor of the British Journal of
Psychiatry but had no part in the evaluation of this paper for
publication. Funding detailed in Acknowledgements.
The project was commissioned by the National Institute for Health Research
Service Delivery and Organisation Programme, which is funded by the Department
of Health. The funder played no role in the design or conduct of the study or
in the writing of this report. We are grateful to Frankie Pidd, Nick Benefield,
Sarah Gillespie and Iain Ryrie for their help in drafting the first round
questionnaire and to all those who took the time to participate in the Delphi
Coid, J, Yang, M, Tyrer, P, Roberts, A, Ullrich, S.
Prevalence and correlates of personality disorder in Great
Britain. Br J Psychiatry
2006; 188: 423–31.
Lewis, G, Appleby, L.
Personality disorder: the patients psychiatrists
dislike. Br J Psychiatry
1988; 153: 44–9.
Ramon, S, Castillo, H, Morant, N.
Experiencing personality disorder: a participative
research. Int J Soc Psychiatry
National Institute for Mental Health. Personality
Disorder: No Longer a Diagnosis of Exclusion.
Department of Health,
Binks, CA, Fenton, M, McCarthy, L, Lee, T, Adams, CE, Duggan, C.
Psychological therapies for people with borderline
personality disorder. Cochrane Database Syst
2006; issue 1: CD005652.
Murphy, MK, Black, NA, Lamping, DL, McKee, CM, Sanderson, CFB, Askham, J, Marteau, T.
Consensus development methods, and their use in clinical
guideline development. Health Technol
1998; 2: i–iv,
Crawford, M, Rutter, D, Price, K, Weaver, T, Josson, M, Tyrer, P, Gibson, S, Gillespie, S, Faulkner, A, Ryrie, I, Dhillon, K, Bateman, A, Fonagy, P, Taylor, B, Moran, P.
Learning the Lessons: A Multi-method Evaluation of Dedicated
Community-based Services for People with Personality Disorder.
National Co-ordinating Centre for NHS Service Delivery
and Organisation, 2007 (http://www.sdo.nihr.ac.uk/sdo832004.html).
Fiander, M, Burns, T.
Essential components of schizophrenia care: a Delphi
approach. Acta Psychiatr Scand
1988; 98: 400–5.
Heather, N, Dallolio, E, Hutchings, D, Kaner, E, White, M.
Implementing routine screening and brief alcohol intervention
in primary health care: a Delphi survey of expert
opinion. J Subst Use
Bateman, AW, Fonagy, P.
Treatment of borderline personality disorder with
psychoanalytically orientated partial hospitalisation: an 18-month follow
up. Am J Psychiatry
2001; 177: 138–43.