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 Impression driven Controlled Implicit- Automatic Explicit- Controlled Mental interior focused Inference Appearance Mental exterior focused Certainty of emotion Doubt of cognition Affective self:affect state propositions Cognitive agent:attitude propositions Emotional contagion Autonomy Imitative frontoparietal mirror neurone system 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

Introductory Group (i-MBT) Assessment Introductory Group (i-MBT) MBT If 2 or more Axis II diagnoses MBT+ Comorbid Drug use/Alcohol/ED SCM If 2 or less Axis II diagnoses Refer elsewhere

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 . Hospital admissions, suicidal and self-injurious episodes Proportion with episode overall decline or risk per 6 m period 0.28 (0.14, 0.39), differnce between slopes 0.28 (0.13, 0.61) 15

Percent with Clinical Episode (Attempted Suicide, Self-harmed, or were Hospitalized in Last Six Months) N=74 2011-2012 Hospital admissions, suicidal and self-injurious episodes Proportion with episode overall decline or risk per 6 m period 0.28 (0.14, 0.39), differnce between slopes 0.28 (0.13, 0.61) 16

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 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 Score on OQ 45 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 Hospital admissions, suicidal and self-injurious episodes Proportion with episode overall decline or risk per 6 m period 0.28 (0.14, 0.39), differnce between slopes 0.28 (0.13, 0.61) 24

Grouped data on POD Hospital admissions, suicidal and self-injurious episodes Proportion with episode overall decline or risk per 6 m period 0.28 (0.14, 0.39), differnce between slopes 0.28 (0.13, 0.61) 25

Individual data on POD Hospital admissions, suicidal and self-injurious episodes Proportion with episode overall decline or risk per 6 m period 0.28 (0.14, 0.39), differnce between slopes 0.28 (0.13, 0.61) 26

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