.Running title: Transition from EIPS

Barriers and facilitators to ‘moving on’ from Early Intervention in Psychosis Services

Sarah Woodward, Sandra Bucci, Dawn Edge & Katherine Berry*

Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology,

Medicine and Health, University of Manchester, UK

Word count (excluding figures, tables, references): 2,922

*Requests for reprints should be addressed to Dr Katherine Berry, Division of Psychology

and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health,

University of Manchester, 2nd Floor, Zochonis Building, Brunswick Street, Manchester, M13

9PL, UK. Katherine.Berry@manchester.ac.uk

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Abstract

Aims: Transition from Early Intervention in Psychosis Services (EIPS) to ongoing care can

be challenging for staff and service users. This study aims to explore staff views of the

barriers and facilitators to transition from EIPS.

Methods: Eighteen EIPS staff were interviewed about their experiences of discharge

processes and interviews were analysed thematically.

Results: Four themes were identified: 1) ‘nowhere to go’: illustrated how service users

remained in EIPS because other teams lacked capacity to take them; 2) ‘collaboration

between agencies’ highlights the challenges of working across boundaries; 3) ‘therapeutic

relationships’: reflects the loss service users and staff experienced at discharge; 4) ‘advanced

planning’ relates to the necessity for advanced planning and service user empowerment to

facilitate the discharge process.

Conclusions: This is the first in-depth exploration of EIPS staff views on discharge processes.

To ensure seamless transitions throughout care pathways, services need better inter-agency

collaboration and more adequate preparation for transition.

Declaration

There are no conflicts of interest and this study was not funded.

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Introduction

Large scale research of the long-term impact of Early Intervention in Psychosis Service

(EIPS) interventions (e.g. the OPUS trial; 1) suggests that the positive impact of EIPS on

clinical outcomes was not sustained once service users had left the service. Authors have

noted the potential sense of loss that service users might experience leaving an intensive

service such as EIPS and the consequent negative impact of discharge on service users’

mental health. Moving onto other services following a period of intensive, specialist

intervention may be particularly challenging for people with severe mental health difficulties,

such as psychosis, due to a higher prevalence of previous losses and trauma in their lives 2.

A relatively well researched transition in the mental health literature is transition from child

to adult mental health services (e.g. 3, 4) and within the UK, there are now national guidelines

for transition from children’s to adult services for young people using health or social care

services. These guidelines define transition in terms of a purposeful and planned process of

supporting young people in moving from children’s to adult’ services and acknowledge that

this transition is likely to play a pivotal role in the young person’s life. The guidance sets out

that the young person and their families should be at the heart of the transition process, that

service user choice, involvement and continuity of care are paramount and that staff receive

specific training and support in transition and the needs of younger people. The impact of

moving between different services across the mental health system in adulthood and the

factors affecting the transition process are not as well researched. However, the available

evidence does suggest that better managed transitions are related to better client functioning 5

and that effective continuity of care can be achieved with adequate attention to the discharge

process, good communication between different teams, and dove-tailed working 6, 7.

Internationally, EIPS are offered to people experiencing a first episode of psychosis (FEP 8).

Within the UK these services are based on a model of assertive engagement and multi-4

disciplinary team working. EIPS offers a more intensive model of care than traditional

secondary care services, with care coordinators taking a smaller caseload, and having greater

opportunities for offering psychologically informed care, and psychosocial interventions. At

the end of EIPS care, service users may be either referred back to their General Practitioner

(GP) or if requiring further support, they can be referred to appropriate secondary care

services (e.g. Community Mental Health Teams, CMHTs). Recent research suggests that the

majority of service users are discharged to GP (55%) or CMHT (32%; 9). This means that the

majority of service users are discharged from EIPS to services that offer less intensive

support than EIPS offers. Research examining how service users experienced the transition

from EIPS to other services suggests the care received from EIPS is excellent, but difficult to

replicate in other services 10. As such service users may overestimate the level of care that

can be offered by other services, which may negatively impact on the experience of

continuity of care. EIPS has been shown to be more effective than standard care in CMHT

over a three year period 11 and in order to maintain this efficacy, it has been recommended

that CMHTs and other secondary care services continue to offer similar interventions to EIPS

such as a greater emphasis on relapse prevention and social inclusion; 12

Due to the paucity of research examining discharge from EIPS, the current study focussed on

staff views with the aim of gaining an overview of the discharge process. It was felt that

EIPS staff would be most likely to be able to provide this overview due to having knowledge

of service structures and decision making processes. A qualitative approach was the most

appropriate method as it enabled a more in-depth exploration of relevant issues for each

individual staff member that is not confined by a limited set of predetermined questions. 13

The research question was what barriers and facilitators exist to smooth transition from EIPS.

The current study aimed to explore staff views and attitudes to the discharge process from

EIPS and the barriers and facilitators to transition from EIPS to other services including both

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primary care (General Practice; GPs) and secondary care mental health services (typically

Community Mental Health Teams; CMHTs).

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Method

Design

The current study used a qualitative descriptive design. Analysis followed an inductive

thematic analysis approach.

Sampling and procedure

Participants were purposively recruited 14 from EIPS teams across the North West of England.

Inclusion criteria were: (i) employment in EIPS; (ii) experience of supporting a service user

during discharge; and (iii) willingness to be audio-recorded. Thirty-two staff expressed an

interest in completing the study, of which two declined due to having insufficient time, four

were ineligible, due to lack of involvement in the discharge process, and eight failed to

respond after the initial inquiry. This left a sample of 18 staff who gave informed consent to

be interviewed. All interviews were conducted by the first author, were digitally recorded

and lasted between 20 and 70 minutes. The topic guide was based on the research questions,

previous research (e.g. 6, 7) and service user and staff consultation. It comprised a range of

open-ended questions covering: (i) participants’ experiences of working in EIPS (e.g. “Can

you tell me a bit about your experience of early intervention services?”); (ii) general views of

the transition process (e.g. “How do you decide where the service user should be transferred

to?”); (iii) perceptions of changes in care (e.g. “How does care change when people leave

EIPS?”); and (iv) perceptions of helpful and unhelpful factors during the transition period

(“e.g. “what kinds of things do you do to prepare people for the move that seem most

helpful/unhelpful?”). Field-notes were taken during the interviews and were used to guide

the coding process and preliminary analyses 15

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Data Analysis

Interviews were transcribed verbatim, and subject to inductive thematic analysis 16, This

approach was chosen due to its flexible nature, and lack of assumptions regarding

epistemology. All transcripts were read and coded by the first author. Other members of the

research team independently coded three of the transcripts which were discussed and

reviewed for consensus. Where disagreement occurred, further discussion was held, and

where necessary the research team returned to the original recordings to seek clarity. Codes

were grouped into themes and candidate themes were reviewed by all members of the

research team independently to ensure i) they accurately reflected the content of the dataset;

and ii) each theme reflected a different aspect of the data. This ensured that each theme

represented a different concept within the dataset. Whilst apparently distinct, , themes are

linked to form a coherent narrative as illustrated by our thematic map.

Reflexivity

Reflexivity, the process of continually reviewing one’s own perceptions, assumptions,

background and beliefs is particularly important during qualitative analysis due to the degree

of subjectivity involved 17.

Three of the authors are clinical psychologists experienced in working with people

experiencing psychosis. The authors acknowledge that this may have led to the interview and

analysis focussing on issues that they had personally found to be important in explaining the

discharge process. For example, the theme of therapeutic relationships may have gained

prominence in the analysis as the authors’ clinical experience and previous research has

focused on the importance of the strong attachments that service users can develop with

mental health teams. However, the fourth member of the research team is a Mental Health

8

Researcher, and is not a practising mental health clinician, thus bringing a different

perspective to bear on analyses, such as challenging taken-for-granted assumptions and

making explicit tacit knowledge among the clinical psychologist research team members.

For example, the three authors who are clinical psychologists had assumed from the outset

that the quality of therapeutic relationships would be a key factor in determining participants’

views of the transition process. Therefore extra care was taken to ensure that the evidence for

the importance of this theme emerged from the data by checking the coding of quotes that

related to this theme with the author who was not a practising psychologist.

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Results

Participant characteristics

The majority of participants were female (n=12) and the average age was 37.58 years. The

average length of time spent working in EIPS was 4.87 years. See Table 1. Full data on the

nature of the teams and caseloads included in this study were not gathered at the point of

recruitment. However, the teams covered a predominantly urban population, and were multi-

disciplinary in nature. Two of the NHS Trusts from which participants were recruited

covered areas with a large student population.

Key themes

Analysis of the data from resulted in the development of four key themes: ‘delayed discharge:

nowhere to go’, ‘service collaboration and multi-agency working’, ‘staff and service user

relationships’ and ‘empowering service users: involvement and preparation’. These themes

are explored in detail with particular emphasis on the barriers and facilitators that staff

members reported experiencing.

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Theme 1: Nowhere to go

Staff described continuing to provide care for service users well beyond the three years for

which services were commissioned due to inability to discharge people to CMHTs .

“What’s frustrating for us and for the service user is that when they’re due to be

referred on there isn’t the availability, certainly in CMHT, so we’re finding that we

can have people up to five-six years.” (P07, care coordinator)

These delays ultimately resulted in higher caseloads within EIPS, reducing care coordinators’

capacity to offer intensive interventions. In the long run, poorer care in EIPS lead to more

service users requiring CMHT care:

“The idea is you do extensive work to divert people away from CMHT’s but the fact

you can't get anyone in to them means we can’t do the work to do that …. You would

postulate that if our caseload sizes keep going up, so do the number of referrals we

have to make at the end of the three-year pathway to them.” (P02, manager)

Several participants described feeling a sense of powerlessness that their knowledge and

expertise regarding the service user were disregarded by CMHT staff, who were the ultimate

gatekeepers regarding referrals.

“She’s now discharged to consultant only, without the support of mental health team,

but I think she really needs it and they [CMHT] really are the deciding factor in that

because even though I’ve disagreed with decision, our consultant disagreed with the

decision, the team as a whole have disagreed with the decision, there’s nothing we can

do about that”. (P15, care coordinator)

Staff also described the CMHT perceiving EIPS referrals as a low priority, as they were

already care coordinated, therefore any risk was already managed:

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“The clients that we’re working with, because they’re already under the care of a

secondary mental health service, there’s no hurry to, for them [CMHTs] to take those

cases on.” (P14, care coordinator)

Theme 2: Collaboration between agencies

Within this theme, staff described the pressures experienced by services, such as high

caseloads which led to a more inward-looking approach, with services seeking to protect

themselves from outside influences.:

“People just really ring-fence their own workers and their own caseloads and so don't

work really collaboratively” (P10, care coordinator)

Participants described problems with how services communicated during the discharge

process. The perception of this appeared to change depending on the services involved.

EIPS staff described a lack of communication from CMHTs and expressed frustration

regarding this, especially when they requested updates on waiting lists. However, a similar

low level of communication from GPs was discussed this with a greater sense of

understanding. The quotes below reflect EIPS staff experiences of communication with

CMHTs and GPs respectively:

“I had instances where I’ve not known it’s been on the system but there’s not been a

letter or anything so I’ve not known that there’s an appointment so, for example, I’ve

got somebody who is due to be transferred in I think in September, but they didn’t

know about the appointment” (P09, care coordinator)

“GPs never really respond with any difficulties, they always tend to have enough

information once they’re discharged, so they’re at least up to date should any

problems arise. We do invite them to a review, they don’t always attend.” (P17, care

coordinator)

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Staff described differences in the approach of EIPS and CMHTs, and expressed concerns

about how service users would adapt to these changes. CMHTs were seen as lacking in the

assertive outreach approach, which characterised how EIPS related to service users. Some

staff described how EIPS may promote dependence in the service user, and a concern that

they were creating expectations of services that could not be met by CMHTs.

“On one hand I think ‘oh I wonder if I’m actually doing him any favours with all this

kind of assertive approach’ cos he’s not gonna get it when he goes to the CMHT.”

(P08, care coordinator)

Conversely, joint working during the discharge process, where the old and new care

coordinator would co-work for a period of time, was seen to facilitate transfer between

services and promote the handover of the therapeutic relationship:

“I like to think by showing a kind of united approach that helps to kind of just

hopefully embed a sense of kind of trust in the new service and in the new care

coordinator” (P11, care coordinator)

Theme 3: Therapeutic relationships

Participants described developing close relationships with services users, with some staff

describing a sense of loss at the ending of their therapeutic care and ambivalence regarding

service users moving on:

“I suppose there’s a, a sense of like loss, sometimes there’s a sense of loss because

you’ve been in that person’s, and the family’s, life for more than three years, and as

you get to know people, I think they share more about their families, you know,

what’s going on, so there is like a sense of like you’re leaving that person.” (P17,

care coordinator)

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Some staff also expressed concern that the ending of a relationship could act as a potential

trigger to a relapse in mental health difficulties. This acted as a barrier to transition as

stepdown services would refuse a referral on this basis:

“There are some people who are discharged and towards the end they become more

unwell … the community mental health teams won’t have somebody unless they’ve

been settled for six months actually.” (P08, care coordinator)

Staff were concerned that service users would have difficulty forming therapeutic

relationships with a new member of staff and saw this as a barrier to handover:

“Having to establish a new relationship with somebody, I think that’s a big thing, you

know, meeting somebody new ‘what if I don’t like em? Or what if they don’t

understand me?’ You get that quite a lot; ‘but you understand me, you know, you

know what I’m like. What if they don’t know what I’m like?’ and that stuff that I’ve

heard quite a lot.” (P04, manager).

Several EI staff said that they would remain as informal points of contact for the service users

post-discharge, and in some cases, welcomed taking this role. This was seen by staff as

facilitating discharge as it provided reassurance for both them and the service user. One staff

member spoke about their experience with a service user they had worked with for a long

time:

“She’s told me that she’ll stay in touch with me, let me know how she does, which’d

be nice to see on a personal level.” (P15, care coordinator)

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Several staff felt that it was important to mark the ending of their relationship with the service

user, and did so in a manner that showed their appreciation of the service user as an

individual rather than solely as a patient. There was a sense that this facilitated the ending of

the relationship by providing a positive experience of an ending, and promoting acceptance of

the transition.

“I also think trying to mark the end of your relationship … I’ve got a client at the

moment who is really into like her art and stuff and we’ve talked a lot about her going

to the art gallery … so I was like right shall we how about we do something like that

as a, you know, like a goodbye?” (P09, care coordinator).

Theme four: Advanced planning

The majority of participants spoke about ensuring that service users were informed about the

discharge date far in advance. Reminders where frequently given in 6-monthly care and

treatment reviews. Staff spoke about how these reminders allowed both themselves and

service users to prepare, practically and mentally, for discharge.

“I suppose the most important thing is to be raising in people’s consciousness that

they are going to be discharged. Just because you had the conversation two and a half

years ago, you’re probably not going to remember that … so it should have been on

the table the whole time through” (Participant 02, Manager)

Staff discussed the importance of involving the service users at all stages of the discharge

process. This was perceived to facilitate the process as it gave the service user a sense of

control, and ensured they were aware of what was happening. They also described a process

of preparing the service user for discharge, which in the majority of cases began as soon as a

service user entered EIPS:

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“So from the onset you know the first meeting with the care coordinator that we could

be effectively planning for discharge.” (P02, manager).

Several participants said that in the time approaching discharge, they would review service

users’ progress during their time in the service. Staff felt that this helped to prepare the

service user for discharge, as it would instil a sense of hope and self-confidence, such as the

experience described here:

“One of me [my] clients that went back to GP, ‘cos she was a bit anxious, it was just

instilling, or reminding her of how far she’d come, you know reminding them of the

journey that they’ve actually been on.” (P17 care coordinator)

By instilling a sense of self-confidence, it was hoped that service users would be able to

better manage the reduction in contact and support following discharge.

Staff also spoke about a reduction in contact towards the end of care. By reducing the use of

the assertive outreach approach, it was thought that care would become more in line with

what would be expected within CMHT, thereby smoothing the transition process.

“I think it’s useful to reduce contact, to make it monthly, if you’re referring to CMHT

… so they can get used to us not having as much contact.” (P07 care coordinator)

Discussion

This study examined staff perceptions of the barriers and facilitators of transition from EIPS.

The four themes we identified do not act in isolation, so we developed a thematic map (see

figure 1) to illustrate how they might interact to affect the experience of discharge.

Delays to discharge were both caused by, and resulted in, pressures on CMHTs. Delays

resulted in higher caseloads in EIPS, which ultimately meant that less specialist work was

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conducted and more service users were referred to CMHT rather than to primary care (see

Fig.1). This is consistent with previous observations 18, that community nurses working in

the care coordinator role within CMHTs were prevented from offering specialist

interventions due to service pressures. Delayed discharges acted as a great barrier to smooth

transitions as described in the wider literature (e.g. 3). This has the potential to impact on

long-term outcomes for those leaving EIPS 19.

Therapeutic relationships can also lead to ambivalence regarding discharge, with some staff

reporting that service users wished to stay in EIPS. This is consistent with previous research,

which suggests that the therapeutic relationship is an important factor in the experience of

transition 5, 7, 20. Staff discussed this ambivalence being in part driven by the close

relationships they built with service users, but also service users’ fear of the unknown and

reluctance to form new relationships. Lack of trust in others and difficulties relating to others

are hallmarks of psychosis meaning that it may be particularly difficult for this service user

group to develop relationships with new staff members 21. Staff also described their own

ambivalence regarding the discharge, and a difficulty relinquishing the caring role.

Participants discussed their own sense of loss at the ending of the therapeutic relationship,

and it is possible that this coloured the way they perceived that service users experienced the

ending.

Collaboration between agencies is described as a key component to discharge in several

policy documents (e.g.22, 23). This was discussed at length by the participants in the current

study. Joint working was described as a facilitator of the discharge process and, to some

extent, appeared to mitigate the barrier caused by service users concerns about developing a

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new relationship with an unknown person (see figure.1). Joint working has also been

highlighted as a key component of an ‘optimal’ transition across other mental health services

3, 6, 7 and in a previous study exploring transitions from EIPS to primary care from service

users’ perspectives 10.

Advance planning was seen as a key facilitator to transition, in line with policy documents

describing the ideal discharge process from EIPS 22. Empowering service users by involving

them throughout the discharge process and preparing them for discharge early on was

regarded as good practice; instilling a sense of hope, optimism and achievement. All these

key facilitators are identified in other transitions literature and guidance 24 and underpin the

Five Year Forward Plan for Mental Health which highlights the importance of moving away

from services working in silos towards more integrated pathways25.

Efforts were made in the current study to recruit a clinical psychologist to the sample.

However, all of the clinical psychologists who were approached stated that they had no

involvement in the discharge process. With the changes in UK clinical guidelines

emphasising the need to make psychological therapy available to all EIPS service users, there

is a consequent drive to train other members of the team in evidence-based therapies such as

Cognitive Behaviour Therapy 13. It is therefore important that clinical psychologists as a

professional group emphasise how their training not only equips them to be skilled therapists,

but also to use psychological theories to inform the ways in which services are designed and

delivered including how processes such as discharge are handled 26. It may be that by

providing specific clinical supervision to front-line staff members such as mental health

nurses and social workers in the period before discharge, Clinical Psychologists could

support these staff to feel more positively about the discharge process, and manage their

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frustrations regarding delayed discharges. It may be that they are also well placed to help

staff manage their own feelings regarding the ending of the therapeutic relationship.

Clinical Implications

The results of this study suggest that services may not be providing a smooth transition from

EIPS for service users. Joint working between EIS and CMHT staff members was discussed

as a particularly important facilitator of the discharge process, as it allowed EIS staff to share

their knowledge and understanding of the service user, and supported the service user to form

a therapeutic relationship with their new care team. Encouraging informal links between

services would allow this process to occur during all discharges, and may also mitigate some

of the communication difficulties that were discussed as barriers to smooth transition. Staff

members were also strongly invested in the therapeutic relationship, and viewed the ending of

this as a loss. It is therefore important that staff are able to access clinical supervision in

managing their feelings about this process.

Limitations and future research

Staff within the current study expressed a great deal of frustration regarding the delays to

discharges. It is possible that some were motivated to take part in the current study in order

to publicise the issues this presented. This may have meant that the views of who did not

perceive the discharge process as problematic were not represented. Similarly, some

professions, for example clinical psychologists and occupational therapists were not

represented within the sample, either due to none being present in the teams, or these member

of staff not meeting the inclusion criteria, due to non-involvement in the discharge process.

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Further research to consider the role of these professions within EIPS in a wider geographical

location would be useful, as well as research to consider the role that they could play within

the discharge process. The three NHS Trusts included in this study represent only a small

proportion of the EIPS operating nationally and internationally. As little information was

gathered on the operating procedures within these Trusts, some caution is required in

generalising these findings in a wider context. It is also possible, for example, that the teams

within the study varied with regards to caseload and sociodemographic make-up, the impact

of which cannot be fully understood within the current study.

Efforts were made to ensure rigor within the analysis (see Method section). However, the

authors acknowledge that additional strategies such as member checking 27 could have been

employed. However, time and resource constraints, including staff redeployment, meant this

was not feasible.

The interviews focussed largely on the process of discharge to CMHTs. This meant that the

process of discharge to GP was less well addressed. However, this appeared to be due to the

fact that referral to GP was experienced as a much more straightforward process.

Nonetheless, the understanding of barriers and facilitators presented here would be further

enriched by perspectives from service users themselves and other staff teams such as CMHT

staff and GPs. Eliciting the views of wider group of stakeholders involved in the process

would enrich our understanding of the impact of the transition process. It would also be

useful for future research to further consider the impact of optimal versus suboptimal

transition on long-term clinical outcomes. Research that takes into account the financial,

policy and social context within which EIPS operate may give a better understanding of

factors that affect the capacity of services to manage/facilitate optimal transition.

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17. Jootun D, McGhee G, Marland GR. Reflexivity: promoting rigour in qualitative research. Nursing Standard. 23(23) 42-6.18. Simpson A. Community psychiatric nurses and the care co-ordinator role: squeezed to provide ‘limited nursing’. Journal of Advanced Nursing. 2005; 52: 689-99.19. Catty J, White S, Clement S, et al. Comtinuity of care for people with psychotic illness: its relationship to clinical and social functioning. International Journal of Social Psychiatry. 2011; 20. Pitt L, Kilbride M, Nothard S, Welford M, Morrison AP. Researching recovery from psychosis: a user-led project. Psychiatric Bulletin. 2007; 31: 55.21. Berry K, Drake R. Attachment theory in psychiatric rehabilitation: informing clinical practice. Advances in Psychiatric Treatment. 2010; 16: 308-15.

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Table 1: Participant Information

Participant

number

Age at

consent

Gender Job Title Profession Time in EI

01 --* Male Manager Social Worker 6 years

02 32 Male Manager Social worker 2.5 years

03 50 Male Care Coordinator RMN 6 years

04 36 Female Manager RMN 3 years

05 33 Female Care Coordinator Social worker 4.5 years

06 28 Female Care Coordinator Social worker 2 years

07 35 Female Care Coordinator Social Worker 3 years

08 51 Female Care coordinator RMN 7 years

09 32 Female Care Coordinator Social Worker 5 years

10 34 Female Care Coordinator Social worker 6 years

11 34 Female Care Coordinator RMN 2 years

12 33 Female Care Coordinator Social worker 5 years

13 52 Male Care Coordinator RMN 20 months

14 37 Male Care Coordinator RMN 7 years

15 28 Female Care Coordinator RMN 7 years

16 45 Male Psychiatrist Psychiatrist 7 years

17 48 Female Care coordinator RMN 7 years

18 31 Female Care Coordinator Social Worker 6 years

*Information not provided. RMN – Registered Mental Health Nurse

23

24

25

Communication

Different approach

Joint working

Step down care

Reminders/ early preparation

Review progressMark the endingContinued contact

Trigger

Need to develop new relationship

Ambivalence

Reduced capacity to offer specialist care

More people require secondary care Services shut

down

Increased pressure on

CMHT

Collaboration between agencies

Advanced planning

Therapeutic relationship

Nowhere to go

26

Loss of secure base

High thresholds

Communication

Information sharing

Joint working

Service pressures on

CMHTs

Collaborationbetween

agencies

CMHT as gatekeepers

AmbivalencePrioritization

Nowhere to go

Difficulty forming new relationships

Post-discharge contact

Close therapeutic relationship

Therapeutic relationships

Figure 1: Thematic Map

Empowering service users

Advanced planning

Author contribution and details

Dr Sarah Woodward (BSc, ClinPsyD): Data collection, analysis and write up

Dr Sandra Bucci (BSc, ClinPSyD): Conception of idea, study design, supervision of analysis and commented on write up

Dr Dawn Edge (BSc, MRes, PhD): Study design, supervision of analysis and commented on write up

Dr Katherine Berry (BSc, MSc, ClinPsyD, PhD): Conception of idea, study design, supervision of analysis and write up

Address where work was carried out: Division of Psychology and Mental Health, School of Health Sciences, Zochonis Building, Oxford Road,

University of Manchester, Manchester, M13 9PL, UK

Acknowledgements

The authors would like to thank Tina Perry-Moore for her contributions to the research, and all of the staff who took part in the study reported

here.

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