‘He just would not accept being on no medication. Of course I could just not prescribe, I could just say it doesn't matter what you say, I am not going to prescribe anything. I just didn't feel able to do that. It seemed that if he didn't get that, he wasn't going to engage’ (P10).

‘It just felt to me that the projection was so strong to the point that the person was telling me that they thought I had the same eyes as their abusive father. It was just getting corrosive really so I asked for that person to be taken over by someone else’ (P6).

‘Sometimes they will be really angry or upset if they are not getting what they want, they storm out of your office or start shouting at you or things like that’ (P4).

‘They see you as a doctor, they see you as a prescriber. They know you are a psychiatrist. Patients come to see you knowing that you can prescribe’ (P2).

‘It is difficult, you are in a team aren't you, you feel an obligation to protect your nursing staff but you have got to do what is best haven't you, and your first responsibility is to your patient and you have got to do what is best for them regardless of [the] kind of other pressures that come’ (P8).

‘If she wants to talk about medication, we get lots of staff who stand very close and I stand very, very far away because she has already kicked me once and I am not making that mistake again’ (P11).

‘There is something really sad when you have got someone sitting in front of you saying please help me, but it is a long-term problem that you can help in the long-term but you can't do anything there and then. They are so used to being told in prisons particularly, well try this pill, and it hasn't worked. So that is really difficult - that sense of helplessness at that point’ (P11).

‘What can you offer to them? Well I can refer you to the [psychological therapy] group, but it is a group and you have to be assessed and there is a few months’ waiting list. It doesn't fit with the need of the patient at the time. There is something about containing the situation here and now, which you think is all there on your shoulders' (P1).

‘They are expecting to be given a prescription because they are seeing a doctor. When you tell them “no” then they say, well why did we come here, what was this appointment for, are you doing your job properly, you don't understand what is going on’ (P4).

‘I think that personally I have found it incredibly difficult because I have felt that I have failed; as a doctor I have failed to alleviate someone's distress and in many regards maybe I have made it worse’ (P2.)

‘On occasions I don't actually need to do anything. And that is actually quite a hard lesson for a medic. I think you know that you can end a consultation and say, “Well I am sorry you feel like this; hopefully things will change. I am going to see you again in 2 months”. That is actually very hard for medics to do, because what we want is for people to actually be able to say, “Well thank you doc, I feel much better”, and go’ (P2).

‘At one level I am responding to a request for help and often the request comes in a language - I don't really care what you do, just make things better for me’ (P7).

‘I think some clinicians in some places are keener to call something psychosis perhaps when it doesn't look like that to me, so that they can then prescribe safely… and I can sort of understand that approach from clinicians really that a severely personality disordered individual with impulsivity or whatever might, with a particular type of voice which might be normally thought of as a personality type of voice, might be called psychotic, so that you can then prescribe for it’ (P8).

‘For me, personality disorder is much more symptom led - it is much more about level of disability by symptoms, severity of symptoms and then going with a means to an end, [prescribing] as an adjunct to get them into a psychological treatment so it is not diagnostic led, I don't think, prescribing in [personality disorder]’ (P5).

‘They often produce very polarised views among staff, and sometimes among doctors as well about, well, what is this: is it schizophrenia, is it borderline personality disorder, how should we be managing this, surely we should be taking them off their medication, sending them away and saying they have responsibility for themselves, etc., etc.? And other staff will say, “No, this person is psychotic, they need our paternalistic medicalised care’” (P3).

‘Patients tend to come in on a huge raft of different medications because they tend to have failed elsewhere, by which time they will have accrued six or seven different kinds of medications. They don't know which one is helpful, they don't know if anything is helpful in the least anyway’ (P11).

‘Well I suppose they will be on medication from every group - antidepressant, mood stabiliser, antipsychotic. That is often the case, with not a very clear rationale. If you were not the one who did this prescribing, then it is hard to actually see by retrospectively searching through the notes, what was started at which point and why. Things seem to be just added and I think it reflects that people felt that we just need to do something… well this doesn't work so I'll add this, or this doesn't work so I'll add another’ (P1).

‘When [patient care] gets chopped up and broken into different people making all the decisions I think it leads to quite a bit of anxiety and lack of containment that can put people into crises and lead to inappropriate prescribing […] We know that consistency is probably the most important thing, and that is something that has been very much lost in our services’ (P3).

‘When patients have been misdiagnosed and been given lots of different medications, then to try and gradually work in the idea that this is a longstanding problem ingrained into their personality and maybe we should look at other treatment options. I suppose trying to focus on other treatment options is, umm, is that they don't really like to be told that. If they have just been told that medication is the only thing for them and you are taking it away, it may feel as though you are taking all help away from them and there are no sort of alternatives’ (P4).

‘If that person goes from one to another service, to another psychiatrist then gets very different views, that can make life very hard for the people. They feel very uncontained, they don't know what's right, what's wrong, and they'll much more often be attracted to the more medical model of their care because of the potential, the ongoing potential for instant rewards’ (P3).

‘It was very difficult to not give him medication, because he wanted it so much and it seemed to be all linked up with “If you don't give me medication then you don't believe that I am ill and so you are rejecting me” […] I think medication is like the milk, the mother's milk, and we have to wean him off quite slowly’ (P9).

‘It is just an issue when you are trying to reduce it, because if their view of themself is that they are ill, and they need to be ill to get care and they see a reduction in their medication as a sign that everyone thinks that they are not ill, then I think that causes them panic and can destabilise them’ (P10).

‘Making the doctor feel that they have actually done something, so everyone briefly feels better, although ultimately the patient doesn't benefit from that. What the patient may have benefitted from in the short term at least is being heard, yeah, and that prescribing might be part of that process I guess. But what I am saying is that if we can work with them consistently, that sense of them needing to be heard by giving them medicine needs to be removed from the equation. We need to hear them, and the way we hear them is by spending long enough with them to not give them medication’ (P2)

‘I think by giving people tablets if you are not careful you do remove that sense of responsibility. It is almost like, these tablets aren't working therefore it is the doctor's fault that I hit that person’ (P1).

‘On the one hand you are saying you should be responsible for your actions and you have got to work in this way, but on the other hand you are giving them a slightly mixed message which is we'll put you on these tablets so you have got an illness, you know, that sort of conflict. I think it is much more complicated if you are prescribing and the patient had got a prescription because of the power, the powerful symbolism of that and the fact that self-harming can arise from that […] It feels different if someone self-harms with something you have given to them, than with something you haven't given to them […] I think that can be a very powerful thing between the doctor and the patient if they are potentially going to self-harm with what you are giving them’ (P10).

‘She does become very dissociated and it is difficult for us to have any kind of conversation. If we do have a conversation she often can't respond to me - it's me just being with her really and trying to talk to her but then often after the event she can't remember an awful lot of what I have said to her […] I can't negotiate any kind of care plan with her because she is so distracted she can't really talk. So when people are that kind of distracted and dissociated I think that medication can be useful so you can just start to even think about a plan together’ (P10).

‘My approach to prescribing is that in order to get them into the psychological therapy, get their, reduce their level of arousal, reduce their level of paranoia, reduce their level of kind of emotional dysregulation, I will prescribe some medication to get them into the treatment and then I will start to, as they acquire psychological skills, I will then tail off the medication’ (P5).