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 Mental interior focused Mental exterior focused Cognitive agent:attitude propositions Affective self:affect state propositions Imitative frontoparietal mirror neurone system Belief-desire MPFC/ACC inhibitory system Impression driven Appearance Certainty of emotion Treatment vectors in re-establishing mentalizing in 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
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
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.
Percent with Clinical Episode (Attempted Suicide, Self-harmed, or were Hospitalized in Last Six Months) N=74 2011-2012
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 practice Okiishi 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
recoveredimproved 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
Comparative severity data Site visits: starting 16 th April – BMJ Experience day –Future dates: 9 th May, 13 th June, 11 th 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?