Introduction: The Challenge of Managing Personality Disorder
Personality disorders (PD) represent a significant challenge in contemporary psychiatry, characterized by enduring patterns of inner experience and behavior that deviate markedly from cultural expectations. These conditions are associated with substantial morbidity, reduced quality of life, and a high burden on healthcare systems. Traditionally, evidence-based treatments such as Dialectical Behavior Therapy (DBT) and Mentalization-Based Treatment (MBT) have been delivered over long durations—often 12 to 18 months. However, the increasing pressure on mental health services has led to the proliferation of brief psychological interventions. While these shorter programs are easier to implement and less resource-intensive, their clinical effectiveness has remained a subject of intense debate. The Structured Psychological Support (SPS) study was designed to provide a definitive answer regarding the utility of brief interventions for this vulnerable population.
Highlights
No Improvement in Social Functioning
The primary outcome, social functioning measured by the Work and Social Adjustment Scale (WSAS) at 12 months, showed no statistically significant difference between the intervention and control groups.
Lack of Cost-Effectiveness
Economic evaluations indicated a low probability (0.34-0.39) that the brief intervention is a cost-effective use of healthcare resources compared to enhanced treatment-as-usual.
Evidence for Long-Term Care
The trial results strongly suggest that for patients with probable personality disorder, brief interventions cannot replace the comprehensive, long-term psychological programs currently recommended in clinical guidelines.
Study Design and Methodology
The SPS study was a multicentre, researcher-masked, randomised controlled superiority trial conducted across seven National Health Service (NHS) Trusts in England. The trial sought to evaluate whether a brief, structured psychological intervention could improve outcomes for adults with ‘probable’ personality disorder.
Participant Selection
Inclusion criteria focused on individuals aged 18 or older who met the threshold for probable personality disorder, defined by a score of 4 or higher on the Standardised Assessment of Personality Abbreviated Scale (SAPAS). To ensure the study reflected real-world clinical practice, the researchers excluded those with co-existing psychotic disorders or those already receiving psychological treatment. A total of 336 participants were randomized: 180 to the SPS group and 156 to the treatment-as-usual (TAU) group.
The SPS Intervention
The Structured Psychological Support (SPS) intervention consisted of up to ten individual sessions delivered fortnightly. The content was derived from established evidence-based frameworks, including DBT and MBT. Sessions focused on psychoeducation and the development of psychological skills, such as distress tolerance and emotional regulation. The intervention was delivered by staff with prior experience in personality disorder services, ensuring a baseline level of clinical competence.
Endpoints and Analysis
The primary endpoint was the WSAS score at 12 months, which assesses the impact of a person’s mental health on their ability to work, manage a home, and maintain social and private leisure activities. Secondary outcomes included cost-utility analyses and safety monitoring. Data were analyzed using multilevel mixed-effects general linear regression on an intention-to-treat (ITT) basis.
Key Findings: Clinical and Economic Data
The results of the SPS trial provide a sobering look at the limitations of brief therapy for complex personality pathology. At the 12-month follow-up, the retention rate was high, with 84% of the SPS group and 85% of the TAU group completing the assessment.
Primary Outcome Results
The analysis revealed no significant difference in social functioning between the two groups. The standardized coefficient for the WSAS score was 0.12 (95% CI -2.14 to 2.38; p=0.92). This near-zero effect size indicates that the addition of ten sessions of structured support did not confer any meaningful benefit over standard care in terms of day-to-day social and vocational adjustment.
Economic Evaluation
The parallel health economic evaluation mirrored the clinical findings. When accounting for the costs of delivery and the resulting quality-adjusted life years (QALYs), the probability of the SPS intervention being cost-effective ranged between 34% and 39%. This falls well below the standard thresholds typically required for adoption by the NHS, suggesting that the intervention does not provide sufficient value for money.
Safety and Adverse Events
Safety data showed that serious adverse events (SAEs) occurred in both groups (36 events across 17 participants in the SPS group and 16 in the TAU group). Crucially, none of these events were judged to be related to the study procedures. Two deaths occurred in the SPS group during the follow-up period, but neither was linked to the intervention itself.
Expert Commentary and Clinical Implications
The findings from the SPS trial challenge the current trend toward ‘low-intensity’ or ‘brief’ interventions for personality disorders. While brief interventions are often proposed as a pragmatic solution to long waiting lists, these data suggest they may be ineffective for the primary goal of improving social functioning. Personality disorders, by definition, involve deeply ingrained patterns of behavior that are often rooted in early developmental trauma. It is perhaps unsurprising that a 10-session intervention, even one derived from DBT and MBT, is insufficient to produce lasting change in complex social outcomes.
The ‘Dosage’ Argument
Clinicians and researchers have long debated the ‘dose-response’ relationship in psychotherapy for PD. This study reinforces the view that there is a minimum threshold of therapeutic intensity and duration required to achieve clinical stability and functional improvement. The lack of effect in the SPS trial should prompt a re-evaluation of how resources are allocated in community mental health teams.
Generalizability and Limitations
One potential limitation of the study is the use of the SAPAS tool for ‘probable’ PD, which may capture a heterogeneous group of patients. However, the use of the Structured Clinical Interview for Axis II (SCID-II) for borderline personality disorder and the International Trauma Questionnaire for complex PTSD in the baseline assessment added diagnostic depth. The multicentre nature of the trial and the high follow-up rate lend significant weight to the findings.
Conclusion: Shifting the Focus to Longitudinal Care
The SPS trial provides high-quality evidence that brief, 10-session psychological interventions do not improve social functioning for people with probable personality disorder over a 12-month period. For health policy experts and clinicians, the message is clear: there are no shortcuts to treating personality pathology. These data highlight the urgent need to improve access to longer-term, evidence-based psychological treatment programs. Rather than investing in brief ‘stop-gap’ measures, mental health services should focus on providing the sustained, intensive care that this patient population requires to achieve meaningful recovery.
Funding and Clinical Registration
This study was funded by the National Institute for Health and Care Research (NIHR). The trial was prospectively registered under ISRCTN13918289.
References
1. Crawford MJ, et al. Brief individual psychological intervention for people with probable personality disorder: a multicentre, researcher-masked, randomised, controlled superiority trial in England. Lancet Psychiatry. 2026 Mar;13(3):200-212.
2. Bateman AW, Fonagy P. Randomized controlled trial of outpatient mentalization-based treatment versus structured clinical management for borderline personality disorder. Am J Psychiatry. 2009;166(12):1355-1364.
3. National Institute for Health and Care Excellence (NICE). Borderline personality disorder: recognition and management (CG78). 2009.
