Barnet, Enfield and Haringey Mental Health NHS Trust

Dr Tom Pennybacker

IAPT SMI Stakeholder Event: Haringey Personality Disorder

Service

Halliwick Unit

Tottenham

Haringey

The Team

The Team

• Specialist assessment and treatment for people with personality disorder

• Team based in local psychiatric services with clear referral pathways from primary and secondary care

• Nurse-led liaison service• Introductory group (i-MBT)• Treatment program: Mentalisation Based Treatment

(MBT) or Structured Clinical Management (SCM)

What do we do?

Organisational support at all levels

• Explicit theoretical approach

• Structured care and therapist supervision

• Long-term psychological interventions (typically 18 months)

• Treatment and service is data driven

Guiding principles

• Mentalisation is the capacity to understand oneself and others in terms of mental states

• Sense of self, constructive social interaction, mutuality in relationships, sense of personal security

• We are all vulnerable to collapses in our mentalising ability, people with personality disorder especially so

• Aim of treatment is to increase the person’s capacity to recover and retain mentalising

How do we do it?

Implicit-Automatic

Explicit-Controlled

Mentalinterior focused

Mentalexterior focused

Cognitiveagent:attitudepropositions

Affectiveself:affect statepropositions

Imitativefrontoparietalmirror neuronesystem

Belief-desireMPFC/ACCinhibitorysystem

Impression driven

Appearance

Certainty of emotion

Treatment vectors in re-establishing mentalizingin borderline personality disorder

Controlled

Inference

Doubt of cognition

Emotional contagion Autonomy

• Standardised assessment (SCID) with identification of severity to determine treatment pathway: MBT or SCM

• Introductory group (3 months) leading to structured treatment program with regular consultant-led CPA reviews

• Active service user group combined with Patient Experience feedback and Quality Assurance system at Trust management level

Service Practicalities

Predictive Recovery by Axis II Pathology

• Focus of current developments in service

• IAPT minimum data set

• Patient Owned Database - POD

• Historic and current data

Data collection

Percent with Clinical Episode (Attempted Suicide, Self-harmed, or were Hospitalized in Last Six

Months) N=62 2011-2012

0

20

40

60

80

100

120

Baseline Six Months Twelve Months EighteenMonths

Per

cen

t w

ith

In

cid

ent

MBT

.

Percent with Clinical Episode (Attempted Suicide, Self-harmed, or were Hospitalized in Last Six

Months) N=74 2011-2012

0

20

40

60

80

100

120

Baseline Six Months Twelve Months EighteenMonths

Per

cen

t w

ith

In

cid

ent

SCM

• It’s good!

• Patients in trials do better than patients with same treatment given in general services

• Impact of individual therapists

Routine data collection – why?

• 6,499 patients seen by 71 therapists

• therapists had to see at least 15 clients (average 92)

• Mean number of sessions: 8.7

• Equivalent clients in terms of disturbance & presentation

• Recovery curves monitored

Impact of individual therapists in routine practiceOkiishi et al. 2006 (J Clin Psychol 62:9, 1157)

Clients of Some Therapists Improve Faster or Slower Than Others

Session number

Score on OQ 45

recovered improved deteriorated

top 10% therapists

22.4% 21.5% 5.2%

bottom 10% therapists

10.6% 17.4% 10.5%

Outcomes for Best and Worst Performing Therapists

• estimates are that 5-10% of therapy clients deteriorate• across all orientations, client groups, modalities• in RCTs of ‘empirically supported treatments’

• rates higher in active treatment than in control groups – NIMH reanalysis13/162 (8%) deteriorated, all in active

treatments

• therapists tend to be poor at: – predicting who will do badly– recognising failing therapies

Incidence of Harmful Effects

MBT introductory group data

Grouped data on POD

Individual data on POD

• Comparative severity data

• Site visits: starting 16th April – BMJ Experience day– Future dates: 9th May, 13th June, 11th July– Further dates will be arranged according to demand

• Regional days with PD commissioning tool

Next Steps

• Organisational requirements• commitment, management support

• Service framework• clinical pathway, multiagency agreement

• Treatment framework• defined programmes, coherence, structure

• Quality monitoring• therapist competences, adherence, supervision, outcome monitoring

PD Service Commissioning Tool

• Commissioners, managers, clinicians, service users• Local completion of commissioning tool • Identify and map organisational and service requirements• Links with local service user groups

• Benchmarking local services• Define principles of clinical treatments for people with PD• Quality document• Introduce generic clinical skills for treatment of PD in mental

health teams

Regional meetings – for whom?

Thank You

The End