1. IAPT SMI Stakeholder Event: Haringey Personality Disorder Service
Barnet, Enfield and Haringey Mental Health NHS Trust Dr Tom Pennybacker

2. Halliwick Unit

3. Tottenham

4. Haringey

5. The Team

6. The Team

7. 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)

8. 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

9. 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

10. 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

11. 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

12. Predictive Recovery by Axis II Pathology

13. 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

14. Data collection Focus of current developments in service
IAPT minimum data set
Patient Owned Database - POD
Historic and current data

15. Percent with Clinical Episode (Attempted Suicide, Self-harmed, or were Hospitalized in Last Six Months) N= .
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

16. Percent with Clinical Episode (Attempted Suicide, Self-harmed, or were Hospitalized in Last Six Months) N=
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

17. 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

18. Impact of individual therapists in routine practice Okiishi et al
Impact of individual therapists in routine practice Okiishi et al (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

19. Clients of Some Therapists Improve Faster or Slower Than Others
Score on OQ 45
Session number

20. 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%

21. 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

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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

30. The End
Thank You