IAPT SMI Stakeholder Event:
Haringey Personality Disorder
Service
Barnet, Enfield and Haringey Mental Health NHS Trust
Dr Tom Pennybacker
Halliwick Unit
Tottenham
Haringey
The Team
The Team
What do we do?
• 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)
Guiding principles
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
How do we do it?
• 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
Treatment vectors in re-establishing mentalizing
in borderline personality disorder
ImplicitAutomatic
Impression
Controlled
driven
Appearance
Inference
Mental
interior
focused
Certainty
emotion
Doubt of of
cognition
Cognitive
agent:attitude
propositions
Imitative
frontoparietal
mirror neurone
system
ExplicitControlled
Emotional
contagion
Autonomy
Mental
exterior
focused
Affective
self:affect state
propositions
Belief-desire
MPFC/ACC
inhibitory
system
Service Practicalities
• 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
Predictive Recovery by Axis II Pathology
Assessment
Refer elsewhere
Introductory
Group (i-MBT)
SCM
If 2 or less Axis
II diagnoses
MBT
If 2 or more Axis
II diagnoses
MBT+
Comorbid Drug
use/Alcohol/ED
Data collection
• Focus of current developments in service
• IAPT minimum data set
• Patient Owned Database - POD
• Historic and current data
Percent with Clinical Episode (Attempted Suicide,
Self-harmed, or were Hospitalized in Last Six
Months) N=62 2011-2012
MBT
Percent with Incident
120
.
100
80
60
40
20
0
Baseline
Six Months
Twelve Months
Eighteen
Months
Percent with Clinical Episode (Attempted Suicide,
Self-harmed, or were Hospitalized in Last Six
Months) N=74 2011-2012
SCM
Percent with Incident
120
100
80
60
40
20
0
Baseline
Six Months
Twelve Months
Eighteen
Months
Routine data collection – why?
• It’s good!
• Patients in trials do better than patients with same
treatment given in general services
• Impact of individual therapists
Impact of individual therapists in routine practice
Okiishi et al. 2006 (J Clin Psychol 62:9, 1157)
• 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
Clients of Some Therapists Improve
Faster or Slower Than Others
Session number
Outcomes for Best and Worst Performing Therapists
recovered
improved
deteriorated
top 10%
therapists
22.4%
21.5%
5.2%
bottom 10%
therapists
10.6%
17.4%
10.5%
Incidence of Harmful Effects
• 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
MBT introductory group data
BDI
63
BDI Score (n)
54
45
36
27
18
9
0
Beginning
Middle
Time Point
End
Global Severity Score (n)
SCL-90
5
4.5
4
3.5
3
2.5
2
1.5
1
0.5
0
Beginning
Middle
Time Point
End
Grouped data on POD
WSAS
27
24
21
18
15
12
9
6
3
0
40
35
WSAS Score (n)
PHQ-9 Score (n)
PHQ-9
30
25
20
15
10
5
1
2
3
4
5
6
7
0
8
1
Week
2
3
5
6
7
8
Week
EuroQol VAS
MOAS
100
90
80
70
60
50
40
30
20
10
0
40
35
Series1
MAOS Score (n)
VAS Score (n)
4
30
25
20
15
10
5
0
1
2
3
4
Week
5
6
7
1
2
3
4
Week
5
6
Individual data on POD
WSAS
27
24
21
18
15
12
9
6
3
0
40
35
WSAS Score (n)
PHQ-9 Score (n)
PHQ-9
30
25
20
15
10
5
0
1
2
3
4
5
6
7
8
1
2
3
Week
5
6
7
8
Week
EuroQol VAS
MOAS
100
90
80
70
60
50
40
30
20
10
0
40
35
MAOS score (n)
VAS Score (n)
4
30
25
20
15
10
5
0
1
2
3
4
5
Week
6
7
8
1
2
3
Week
4
5
Next Steps
• 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
PD Service Commissioning Tool
• 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
Regional meetings – for whom?
• 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
The End
Thank You