Structured Clinical Management (SCM) was developed in the late 00s, by a process of expert consensus. It was conceived as a mechanism by which to structure and deliver services treating patients with Borderline Personality Disorder (BPD), using practitioners with generalist or diverse expertise and skill-sets. It was developed by Professor Anthony Bateman and Professor Peter Fonagy at St Ann’s Hospital in London, primarily as a comparator general psychiatric treatment against which other specialised protocols could be tested in research studies. SCM, even though it is not strictly a type of psychotherapy, has developed into a set of psychotherapeutic organisational principles in its own right. It was developed using the principles outlined within the 2009 NICE guidelines for recognition and management of BPD-CG78.
SCM was developed to help patients with BPD, and is currently used primarily for BPD and other personality disorders. Within some teams it is used when there are either client or organisational barriers to use of a specialised therapeutic modality – such as MBT, DBT or long term psychodynamic psychotherapy.
SCM emphasises use of a clear, reliable and consistent structure, with unambiguous information sharing with the client, often written. Following assessment, there is a focus on sharing a collaborative formulation to demonstrate understanding of the client’s difficulties, and using this to share a coherent message about the diagnosis. SCM aims to foster a secure attachment by use of a curious, responsive, and optimistic therapeutic stance, and giving validation of mental states. Clinicians then utilise this therapeutic alliance to establish a collaborative detailed crisis plan, to set clearly focussed goals based on a shared therapeutic hierarchy, and then to use problem-solving practices to work towards these goals.
Goals are set collaboratively, and should be prioritised based on importance for the client and urgency. The aim is to make them highly specific and achievable. They will generally fall within one of four key areas of focus:
cognitive distortions (including interpersonal sensitivity which can lead to barriers to service engagement).
SCM as envisaged and researched by Bateman and Fonagy includes hour-long individual and 90 minute group sessions weekly, along with clinician and team supervision. Within individual sessions, there is space for advocacy and practical support as might be expected within case management, but with an emphasis on supporting and helping the client to utilise as much autonomy as possible in dealing with problems in their life (for instance by helping the patient write letters or planning and preparing for meetings). Other non-specific interventions include the use of authenticity and openness, particularly in clinician errors or misunderstandings; empathic validation; and positive regard.
The timeframe for providing interventions can be flexible, depending on service and patient needs, ranging from 6 session “pulses” with reviews in-between the pulses, to a year or longer period of SCM.
Specific interventions are used within the group context, with the group leader ‘in charge’ of managing the group to ensure problem areas are discussed with a balance between providing solutions and developing solutions from patient discussion, with the four areas of focus making up modules which are addressed in turn. Problem solving within both groups and individual work proceeds by defining the problem, generating potential solutions, selecting and planning the solution, and implementing and monitoring the solution to evaluate the results. Within each of the four areas of focus, there is a balance between psycho-education, which can include integration of specific strategies and techniques from other therapeutic modalities, and collaborative problem solving to use this information to apply to a client’s individual situation. Specific interventions include techniques for tolerating emotions, mood regulation, impulse control, managing self-harm, and sensitivity and interpersonal problems.
There is evidence for SCM being particularly effective for BPD within the initial 6 months of treatment, and that compared to more specialist modalities such as MBT, it can be faster at reducing self-harm. It has been shown to be effective across a range of clinical outcome measures, including reducing hospital admissions, and thus also in cost-savings, but has smaller effect sizes at 18 months compared to MBT.
“Over the past two decades considerable progress has been made in developing specialist psychosocial treatments for borderline personality disorder (BPD) and yet the majority of people with BPD receive treatment within generalist mental health services rather than specialist treatment centres. It turns out that this is no bad thing.” -Prof Anthony Bateman
By keeping focus on a specific goal through collaborative problem solving with clients, SCM helps maintain hopefulness for change within both clients and therapists, in the face of what can often seem an insurmountable breadth of complex difficulties. SCM is flexible enough to allow for a broad range of psychological techniques to be used and tailored to the client’s needs, but this flexibility avoids risking a piecemeal approach by always emphasising the agreed goals. I have found it to be a satisfying therapy to deliver as a trainee, as it allows for measurable and rapid improvements in a focussed area. For services, it seems clear that SCM allows a broader range of practitioners to feel confident and empowered in delivering psychological interventions for patients with BPD. -Dr James Edmonds, CT3 Psychiatry trainee
Borderline Personality Disorder: An Evidence-Based Guide For Generalist Mental Health Professionals. Anthony Bateman and Roy Krawitz (2013).
Structured Clinical Management (SCM) for Personality Disorder, An Implementation Guide for Practitioners, Trainers and Supervisors (Stuart Mitchell, Mark Sampson & Anthony Bateman, due for publication late 2020).
Applications of Good Psychiatric Management for Borderline Personality Disorder: A Practical Guide. Lois Choi-Kain and John Gunderson (2019).