Table Of ContentStructured Clinical Management (SCM)
for Personality Disorder
Advance Praise
‘Structured Clinical Management is a practical, compassionate, and
highly valued approach to helping people with personality disorder. This
book provides an excellent guide for all those working in mental health
services, whether they are delivering SCM or just want to provide better
care to people with complex emotional health needs.’
Mike Crawford,
Professor of Mental Health Research,
Imperial College London, UK
‘The beauty of this book is that it not only provides a simple and
comprehensive set of evidence-based ingredients of quality treatment for
personality disordered patients, but it also illustrates how to implement
SCM in regular clinical services. A powerful resource for any service with
an interest in providing high-quality generalist treatment. ’
Joost Hutsebaut,
de Viersprong, Tilburg University and
Centre of Expertise on Personality Disorders,
The Netherlands
‘Adult mental health services often struggle to respond to the complex
needs of people with personality difficulties and their care often falls
woefully short. Yet the provision of well-structured care can lead to
tangible health benefits. Structured Clinical Management (SCM) provides
a pragmatic approach to delivering such care and this comprehensive
textbook tells us exactly how to do this. It is essential reading for anyone
involved in the delivery, management and commissioning of adult mental
health services. ’
Paul Moran,
Professor of Psychiatry,
University of Bristol, UK
Structured Clinical
Management (SCM)
for Personality Disorder
An Implementation Guide
Edited by
STUART MITCHELL
Consultant Clinical Psychologist & Trust Lead for Personality
Disorder, Cumbria, Northumberland, Tyne & Wear NHS Foundation Trust,
Newcastle- upon- Tyne, UK
MARK SAMPSON
Consultant Clinical Psychologist, Professional Lead for Psychology
and Psychological Therapies, Lead Clinician in Personality Disorder,
Mersey Care, St Helens, UK
ANTHONY BATEMAN
Visiting Professor, University College London, UK;
Honorary Professor University of Copenhagen, Denmark
1
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Preface
The original manual for structured clinical management (SCM) was first published
8 years ago (Bateman & Krawitz, 2013). Since then, there have been changes in
classification, understanding and treatment of borderline personality disorder
(BPD).1 In parallel to these changes, generalist treatments for BPD such as SCM
have been fully implemented in many organizations across the United Kingdom,
Europe, and elsewhere. However, implementation of treatments and treatment
approaches in clinical services are fraught with difficulties and clinical leads, op-
erational managers, and practitioners alike grapple with how to implement SCM
across complex mental health systems. The aim of this book is to provide guidance
on how clinical teams, services, and organizations may implement SCM in clinical
services. A range of clinical experts, researchers, service users, carers, and practi-
tioners of SCM have contributed chapters from across the United Kingdom and
Europe. Each chapter outlines a core aspect of the SCM model or its adaptation and
delivery in clinical services. Key principles are highlighted in each chapter with
clinical examples of application. A core theme throughout all chapters is a focus on
the problem- solving structure of SCM and the clinical interventions for the core
problem domains experienced by service users diagnosed with BPD or complex
emotional and relational needs.
Generalist practitioners with relatively short additional training, combined
with regular clinical supervision and support, can effectively implement SCM
treatment. It is for this reason that the approach has become increasingly popular
within general mental health services. SCM is a pluralistic and pragmatic approach
that may be delivered and organized in a flexible way without rigid rules on ap-
plication and implementation. SCM is an approach in terms of how a service is
organized, how practitioners focus on the specific problems of service users diag-
nosed with personality disorder, how they are supported to deliver the clinical
interventions, and how they work with other services available to the service user
to effect optimal outcomes. The in-b uilt flexibility is important because within
generalist mental health services there are often competing demands, variations
1 We recognize that not all service users will have received a diagnosis but may still present to mental
health services. The ICD/D SM classification schemes have moved towards dimensional trait-b ased ap-
proaches, making the personality disorder types less relevant. It is likely that in future, trait- domain
based schemes will be used more widely as they become adopted into clinical services. For the purposes
of this book, we will write ‘diagnosed with borderline personality disorder/ personality disorder’ whilst
recognizing this may not always be the case.
vi Preface
in cultures around care, as well as significant capacity issues related to both staffing
and demand that affects their state of ‘readiness’ to embrace change. It is worth
highlighting that although SCM is permissive and flexible this does not equate to a
drop in quality of the care delivered. Any SCM programme should have high levels
of coherency, consistency, continuity, and collaboration, the four Cs underpinning
SCM as outlined in Chapter 1.
Part 1 of the book orients the reader to the model and describes with detail
the ‘what’ of SCM, including detailed clinical examples of ‘how’ to implement
the model clinically. There are contributions from various authors, including
the model originator, Anthony Bateman. In Chapter 1, Bateman resets the
SCM scene and provides an updated model overview. In Chapter 2, Lester and
Sampson go through assessment, diagnosis, and formulation. In Chapter 3,
Sampson and Kayes then provide an overview of the clinical stance and indi-
vidual interactions/ sessions in SCM. Chapter 4 by Bevington and colleagues,
provides an overview on SCM informed safety planning. Finally, in Chapter 5,
Mitchell provides a detailed overview of the group component in SCM including
what can be covered in the content and troubleshooting particular group-
related problems.
These aspects of good-q uality structured care will be familiar to most gener-
alist practitioners working clinically with people with needs consistent with the
descriptive diagnosis of borderline personality disorder. In SCM, an emphasis is
strongly placed on continuity and structure along with highlighting the import-
ance of developing a therapeutic relationship that builds the self-a gency of the ser-
vice user.
Part 2 of the book, different service models for implementing SCM in the United
Kingdom and Europe are comprehensively described and reviewed (Chapters 6
and 7). The authors detail how they adapted and implemented the SCM model, or
a variant of it, within their organizational settings, and the strategic, operational,
and clinical processes involved. In the United Kingdom, Sampson and colleagues
outline the ways in which they have adapted and implemented SCM in three large
NHS Trusts, each with considerable success (Chapter 6). In Chapter 7, Aalders and
colleagues outline the organizational processes in developing and implementing
a variant of SCM in Sweden and the Netherlands, the latter they call Guideline
Informed Treatment– Personality Disorders (GIT–P D). In Chapter 8, Mitchell and
Harrison outline the importance of teamworking and the arrangements between
SCM and the services with which it interfaces if a system to support service users
diagnosed with BPD is to be developed effectively. Nair and colleagues in Chapter 9
describe a thorough review of the evidence around medication and guidance on
prescribing for people diagnosed with BPD. Finally, in Chapter 10 Swift and col-
leagues provide a comprehensive illustration how SCM principles can provide a
supporting framework to help make in-p atient environments more therapeutic for
service users diagnosed with BPD and/o r complex trauma.
Preface vii
In Part 3, guidance is provided on special adaptations to SCM. In Chapter 11,
Quayle and Mitchell provide a model for thinking about the meaning and pro-
cesses of transitions at key points in the service user’s pathway (illustrating this
with clinical examples). In Chapter 12, Chiocchi and colleagues provide examples
of structured family and carer programmes, illustrating how and why these should
link into SCM pathways. In this chapter, John Chiocchi shares his rich, lived ex-
perience from the standpoint of a carer. This illustrates the importance of co-
production and co- delivery of the family programme. In fact, co- production is a
central theme to effective implementation of SCM programmes, as illustrated in
Chapters 6 and 7.
Chapters 13, 14, and 15 of the book explore adapting the SCM model for service
user groups who have additional problems, such as autistic spectrum disorders,
complex trauma, or learning disability. Coexisting needs and complex psychopath-
ology can make it difficult to formulate and determine with the service user what
to prioritize in the treatment. Here, complexity and ‘coexisting’ or ‘co- occurring’
or ‘comorbid’ conditions may become problematic for clinical teams, with conflict
and disagreement over the best fit of diagnosis and/ or formulation. In Chapter 13,
Everett and colleagues provide a rich and thoughtful account of how SCM may
be developed and adapted for people with intellectual (learning) disabilities. They
show, through careful reflection, how SCM may be adapted and delivered in a dif-
ferent way so that people with learning impairments may benefit. The adaptations
extend to training and scaffolding (supervising) the care team staff who support
such service users in residential settings. Graham and colleagues in Chapter 14
describe how services may use the principles of SCM to ‘case manage’ the service
user in order to repatriate them from out of area treatments, and how SCM can
provide a therapeutic model to help a dedicated ‘linkworker’ support people who
struggle to engage in a structured therapy programme. In the final chapter in this
part (Chapter 15), Mitchell looks at how SCM practitioners can work with service
users with BPD who are experiencing problems related to childhood and adult ad-
versity and trauma. The effects of such experiences may frequently be overlooked
or left untreated but may nevertheless exert great impact on the person’s mental
and physical health and daily-l ife functioning. Mitchell describes with clinical ex-
amples how SCM may be adapted for people with additional problems related to
complex trauma and dissociation in order help them increase their mental and be-
havioural stability.
Part 4 provides qualitative reflective accounts of how services users and prac-
titioners have experienced being in or delivering an SCM programme and how
clinical supervision may be organized. SCM is described as being collaborative and
democratic in giving the service user as much autonomy and control of treatment
as possible. But this clinical aim is not the same as reality for the service user or
practitioner perspective. In Chapter 16, Watts and colleagues provide rich qualita-
tive accounts of how service users have experienced SCM in UK clinical services
viii Preface
and the implications of this for service development, suggesting that the appeal
for democracy between service user and practitioner in SCM is only partially real-
ized. In Chapter 17, Hanmer and colleagues provide qualitative accounts of practi-
tioners’ experiences of implementing SCM, and the implications SCM has had on
their development as practitioners. In many respects, SCM has given practitioners
confidence to work with people diagnosed with BPD, providing them with a struc-
ture for intervention. In Chapter 18, Harrison and colleagues look at supervision
in SCM. They describe how the organization and principles of supervision may
be implemented in services outlining well-k nown models of clinical supervision.
They relate survey data from supervisors and supervisees to the model, including
the use of a specific SCM implementation checklist to facilitate the areas of focus in
supervision sessions. The final chapter of the book is a reflective account from the
book editors summarizing and synthesizing the key aspects for practitioners and
services to remember when they are implementing the model in clinical services.
We also look forward to further research and changes to clinical services where
SCM may be implemented as a generalist approach to treatment.
SCM is well on the way to becoming an evidence-b ased generalist approach
for treating service users diagnosed with BPD or complex emotional or relational
needs and/ or associated problems. We hope this book is a useful guide for you to
implement SCM within your service and organization, and that together we can
help improve the lives of the many people who come forward seeking help with
interpersonal problems, managing emotions, and controlling impulses. It is a priv-
ilege to be able to work with service users and practitioners with the singular aim
of improving the lives of those who have been underserved by clinical services and
society for many years. Good luck with your endeavours.
Stuart Mitchell
Mark Sampson
Anthony Bateman
Reference
Bateman, A., & Krawitz, R. (2013). Borderline personality disorder: an evidence- based guide
for generalist mental health professionals. Oxford: Oxford University Press.
Contents
Contributors xi
PART 1 THEORY, RESEARCH, AND MODEL
1. Introduction and Rationale of Structured Clinical Management 3
Anthony Bateman
2. D iagnosis, Formulation, and Assessment in SCM 18
Rachael Lester and Mark Sampson
3. T he Clinical Stance and Individual SCM Sessions 35
Mark Sampson and Sharron Kayes
4. C risis Work and Safety Planning 52
Rebecca Bevington, Ashleigh McGuinness, and Mark Sampson
5. G roup SCM Sessions 69
Stuart Mitchell
PART 2 IMPLEMENTATION MODELS
6. Models of SCM Implementation—U nited Kingdom 87
Mark Sampson, Christopher Berry, Allyson Jerry, and Catriona Gray
7. M odels of SCM Implementation: Europe 113
Helga Aalders, Peder Björling, and Niki Sundström
8. T eamworking, System, and Service Interfaces in SCM 128
Stuart Mitchell and Julia Harrison
9. P rescribing in SCM: United Kingdom and Europe 141
Rajesh Nair, Peder Björling, Muhammad Abdul- Rahman, and
Gordon Turkington
10. S CM and In-p atient Care 157
Elaine Swift, Louise Roper, Genevieve Quayle, Kathryn Strom, and
Jill Everett
