Structured Clinical Management

Supporting generalist mental health practitioners to work effectively with people with borderline personality disorder.

Presenters

Emma Hickey and Rachael Line

Clinical Psychologists

Five Boroughs Partnership NHS Foundation Trust

Email:

mark.sampson@5bp.nhs.uk - Trust PD & SCM lead

emma.hickey@5bp.nhs.uk

rachael.line@5bp.nhs.uk

Aims

To give you a basic understanding of SCM. Share how we have applied it. Prompt you to consider how it could look in your service.

Background to Structured Clinical Management

Organised Case Management specific to borderline personality disorder

What is SCM?

Developed by Anthony Bateman, Peter Fonagy, Rory Bolton and Eric Karas at the Halliwick Unit, London.

Evidenced based. Generalist mental health. Supportive approach with case management and

advocacy support.

Structured Clinical Management

Involves helping the person to:

oProblem solveoManage a crisisoDevelop skills to manage emotions/impulses/interpersonal

interactionoUse medication and services appropriately

NOTE: primary aim of SCM is to reduce unnecessary hospital admissions

Specialist/Generalist treatments: the evidence base

Mentalization based treatment (MBT) ‘v’ structured clinical management (SCM (Bateman & Fonagy, 2009b)

Other generalist treatments, comparable to SCM also shown to be effective (McMain, Guimond, Cardish, Streiner, & Links, 2012)

Borderline Personality Disorder:An evidence-based guide for generalist mental health professionals

Anthony W. Bateman, Consultant Psychiatrist and

Psychotherapist, UK and Roy Krawitz, Consultant

Psychiatrist and DBT therapist, Waikato District Health Board,

New Zealand

Implementing SCM within Five Boroughs Partnership NHS Foundation Trust

Halton, Knowsley, Warrington, St Helens, Wigan and Leigh

An opportunity

Pre-Recovery Teams:

Personality Disorder Hub Co-delivered training (EBEs and EBOs) with focus on awareness

and attitudes. Development of specialist psychological treatments.

Recovery Teams:

Training and implementation of generic treatment (SCM pilot). Increasing range of evidence based treatments.

borderline personality disorder identified

SCM

DBT or MBT

SCM

5BP Personality Disorder Care Pathway

COMPLEXITY

Specialisttreatment

Engagement focus

Generic treatment

SCM pilot

2 day SCM training by Anthony Bateman for:

SCM supervisors/champions. Mental Health workers (3 per Recovery Team). Psychiatrists. EBE and carer consultant.

Piloting SCM within 5BP

Each SCM practitioner to see 3 people over 18 months. Inclusion and exclusion criteria. Frame of SCM – weekly 1:1 session and skills group. Weekly supervision. Measures (see appendix). POD.

Pathway of SCM

FociSetting FrameAssessment

Diagnosis & discussion of

treatment options

Clinical Stance

(Attachment)

Problem Solving

Emotional Regulation

Impulsivity

Crisis Planning

Personal Responsibilities

Identifying

Goals

Interpersonal

Sensitivity

Planning for life without services Transition work

Banked Sessions

Assessment

Up to 6 outpatient sessions (40 minutes). Assessment and diagnosis. Explanation of treatment approach. Building therapeutic alliance.

Clinical stance within SCM

Reliable and consistent. Active, responsive and curious. Realistic expectations. Team work and communication. Hope and optimism.

Expect patients to be active in controlling their life.

Change is expected.

Setting Frame

Socialisation to SCM (up to 3 months) Weekly 1:1 sessions (40 minutes). Development of motivation and establishment of therapeutic

alliance. Focus on:

Clinical stance (attachment). Personal responsibility. Setting goals. Crisis planning.

Setting Frame

Collaborative development of:

• Clinician and patient responsibilities.• Comprehensive formulation and goals.• Hierarchy of therapeutic areas.• Crisis planning – risk assessment and management.• Stabilisation of drug misuse and alcohol abuse.• Involvement of families, relatives, partners and other

Crisis Plans

One of the most important things you can do. Key pointers to an effective crisis plan:

• Not adequate to have to attend A & E. • Collaboratively developed plan.• Use previous examples (three) that led to self destructive.

behaviour/or contact to services. • What can you, friends & family, professionals do and not do.

A quick word about admissions and medication

Admission

Define purpose. Agree aims of admission. Monitor progress. Integrate SCM. BEWARE of setting unattainable

targets.

Prescribing

Consider long term plan Try to avoid crisis prescribing Follow NICE guidance Co-occurring conditions

Foci

Weekly 1:1 (40 minutes). Weekly group sessions (90 minutes). Working on hierarchy of therapeutic areas. Problem Solving underpins.

SCM: Non-specific interventions

Non specifics remain key:

Attitude. Empathy. Validation. Positive regard. Advocacy.

SCM: Specific interventions

Problem Solving underpins core treatment strategies:

• Emotion management.• Mood regulation.• Impulse control.• Interpersonal sensitivity.• Interpersonal problems.• Suicidality and self-harm and management of risk.

Content of Group

Psycho-education and problem solving.Incorporating mentalization principles about self and others.Involves:

•Problem Solving/Mindfulness Module •Tolerance of Emotions and Mood Management Module•Impulsivity Module•Enhancing Relationship Skills Module

All sessions to include a skills component and time spent problem solving a relevant issue of the group members choice.

Where are we up to?

Individual SCM. Weekly supervision. Group work – coming soon. POD – coming soon. SCM awareness/skills training for remaining recovery team

staff, inpatient staff, home treatment staff.

Lessons learnt so far….

Competing demands for SCM practitioners. Whole system approach. Highlighting competencies. Positive attitudes towards personality disorder & recovery. Whole system approach. Validation is key!

What are service users saying about SCM?

“ I think that the Agreement is really good idea because it is between both of us and helps me to have some structure and responsibility in my life”

“Learning more about my diagnosis, symptoms and what medication is prescribed and why, helps to give me more insight into my diagnosis and how the diagnosis and symptoms effect my daily life and the risks that come was some of the symptoms”

What are service users saying about SCM?

“The crisis plans helps me to come to an agreement that between us is for my own benefit and to assist me when in Crisis but I feel it needs to have more in it to prevent any more admissions because this is a big anxious issue for me”

The Goals are good because it gives me things to aim for both in the short and long term”

What SCM practitioners are saying

Hope...but realistic Really like the structure Need flexibility so can tailor it to the individual Hadn’t realised how little they understood of their care plan Good to start SCM with someone you already know Seeing the benefits for service users But am I really doing SCM?

References Bateman A, Fonagy P. Randomized controlled trial of out-patient mentalization based

treatment versus structured clinical management for borderline personality disorder. American Journal of Psychiatry. 2009;1666:1355-64.

Bateman,A., & Fonagy,P. (2013). Impact of clinical severity on outcomes of mentalisation-based treatment for borderline personality disorder. British Journal of Psychiatry, 203, 163-164.

McMain, S., Guimond, T., Cardish, R., Streiner, D., & Links, P. (2012). Clinical outcomes and functioning post-treatment: a tow-year follow-up of dialectical behaviour therapy versus general psychiatric management for borderline personality disorder. American Journal of Psychiatry, 169, 650-661.

McMain, S., Links, P., Gnam, W., Guimond, T., Cardish, R., Korman, L., et al. (2009). A randomised controlled trial of dialectical behaviour therapy versus general psychiatric management for borderline personality disorder. American Journal of Psychiatry, 166, 1365-1374.

Measures used within 5BP for SCM

Weekly:• PHQ-9: Patient Health Questionnaire.• WEMWBS: Warwick-Edinburgh Mental Well Being Scale.• WSAS: Work and Social Adjustment Scale.• Service usage over the past week.

Start, 6 months, 12 months and end point:• SAPAS: Standardized Assessment of Personality Abbreviated Scale.• EQ-5D-5L: EuroQol (quality of life).• PTEQ: Perceived Threat from Emotions Questionnaire.

• PEQ: Patient Experience Questionnaire (not used at start).

Crisis Plan - example

 Information for me: Positive things I can do when I am in a crisis:  Things which have not been helpful when I have been faced with crises in the past:

Staying up all night; admitted to hospital; increasing the dosage of my medication as this prolongs my stay in hospital; health professionals concentrating on my past history instead of current problems 

 Specific refusals regarding treatment during a crisis: I do not want to be hospitalised unless it is absolutely necessary; please don’t make decisions about my treatment without including me in the discussion first

Information for healthcare professionals:  My difficulties as I see them now:

I am addicted to cannabis, I often go out of my way to get it (which puts me in danger); I have several worries about family and thinking about them can make me feel very depressed; attempting to deal with the problems in my life can lead to thoughts of suicide Details of any current treatment / support from health professionals:

 Physical illnesses & medication:

Situations which can lead to a crisis:

Things I would like professionals to do which may help me when I am in a crisis:  Things which professionals have said or done which have not been helpful in the past:

 Practical Help in a Crisis:  Agencies or people that I would like to have copies of this Joint Crisis Plan: √ Myself√ My GP, Dr. X√ My Community Drug Project worker√ My CPN√ My partner