Individuals diagnosed with ‘personality disorders’, of which borderline personality disorder (BPD) is the most common type seen in mental health services, often experience significant relational difficulties, mental health issues, and reduced quality of life (Tyrer, Reed, Crawford, 2015; Bohus et al., 2021).
Long-term psychological interventions are well-established, improving symptom severity, suicidal behaviour, depression and psychosocial functioning (Cristea et al., 2017), and remain the gold-standard NHS treatment (NICE, 2009). However, they require sustained patient engagement (e.g., year‑long group therapy) (Cristea et al., 2017) and place substantial pressure on services due to staffing, time and financial demands (Shadid et al., 2025).
This has prompted interest in short‑term psychological interventions that might offer more immediate, cost‑effective support, either as alternatives, as interim care for those on waiting lists, or to widen access to psychological treatment. Despite this promise, evidence for short‑term interventions remains limited. The PEPS Trial, the first large, rigorous evaluation of brief interventions, found no patient benefit (McMurran et al., 2017), and subsequent systematic reviews highlight a lack of cost‑effectiveness analysis and long‑term follow‑up (Spong et al., 2021), restricting progress in NICE and NHS guidance.
This study evaluated Structured Psychological Support (SPS), a short‑term intervention offering up to 10 individual sessions based on evidence‑based approaches used in longer‑term treatments (e.g., DBT, MBT). Earlier feasibility work has suggested SPS may improve social functioning (Crawford et al., 2020). This trial tested its cost-effectiveness and lasting benefit at 12‑months.
Despite the gold-standard status of long-term psychological treatments, service pressures have driven interest in shorter ‘personality disorder’ interventions.
Methods
This study used a randomised controlled superiority trial of Structured Psychological Support (SPS), with a nested process evaluation and integrated economic evaluation. People with lived experience contributed to the study design, interpretation, and dissemination.
What is Structured Psychological Support (SPS)?
SPS is a short‑term intervention combining psychoeducation and psychological skills training drawn from longer‑term evidence‑based treatments for personality disorders (e.g. psychoeducation, skills practice, mentalising). Staff followed a treatment manual, completed training and an assessment, and received fortnightly supervision. Sessions were tailored to participant preferences, typically delivered fortnightly for 45–50 minutes, with early sessions introducing SPS ideas and setting plans for the focus of later sessions, including psychological skills practice.
Participants
Participants were recruited from 7 NHS trusts (primary and secondary services). Eligible individuals were aged 18+ with probable personality disorder (score ≥4 on SAPAS) (First, 1994) and consented before eligibility assessments.
Exclusions included psychotic disorders, current or imminent psychological treatment (within 12 months), or participation in other trials.
Randomisation
Randomisation used a dynamic adaptive algorithm stratified by gender and study centre to balance participant characteristics across groups whilst maintaining randomness. Researchers assessing outcomes were masked to group allocation; the trial statistician running the analysis was unmasked due to the unequal allocation ratio.
Trial groups
- Enhanced treatment‑as‑usual (control): usual care plus a single remote crisis‑planning session.
- SPS group: up to 10 SPS sessions plus usual care.
Monitoring
Practitioners completed proformas documenting session type, frequency, and content to support fidelity assessment of SPS.
Outcomes were assessed at baseline, 6 months, and 12 months (except satisfaction measures, which were removed from 6-month follow-ups due to the researcher’s unblinding):
Outcomes
Researchers measured social functioning using the Work and Social Adjustment Scale (Mundt et al., 2002) and looked at mental health-related aspects like whether participants met BPD (SCID‑II; First et al., 1994) or PTSD criteria (ITQ; Cloitre et al., 2018). Rates of self-harm/suicide (NSPM; Thomas et al., 2002), anxiety levels (GAD‑7; Spitzer et al., 2006), difficulties in emotional regulation (Bjureberg et al., 2016), and overall patient wellbeing scores (PHQ‑9; Kroenke, Spitzer, Williams, 2001) were also examined.
Standard demographic data (e.g. age, gender), service use data (EuroQol‑5; Brooks, 1996; Adult Service Use Schedule; Borschmann et al., 2013), and patient experience ratings (Clinical Global Impression–Improvement scale; Guy, 1976 and Patient Satisfaction Questionnaire; Shipley et al., 2000) were also collected.
Results
Participants
The study exceeded its recruitment target, enrolling 336 participants (75% female, 22% male, 3% non‑binary/other). Most were white (84%), with a mean age of 34.8 years. 74% met criteria for BPD, 65% for PTSD, and 62% for complex PTSD. Retention to 12 months was high (84% SPS; 85% control).
SPS Delivery
SPS was delivered mainly by psychologists (34%) and nurses (28%). Practitioners typically worked with two participants, and most (76%) attended supervision except for illness and leave.
Participants received a median of seven sessions; 12% attended none. Most sessions were in person, with no outcome differences for online delivery. Proformas indicated participants typically received 4 (median) of the following:
- DBT (64%)
- Psychoeducation (39%)
- Behavioural chain analysis (32%)
- CBT (20%)
- Mindfulness (21%)
Enhanced Treatment‑as‑Usual
Most (65%) received a crisis plan or declined one (34%). 16% either withdrew or already had one.
Analysis
Primary and secondary outcomes were analysed using multilevel mixed‑effects regression with intention‑to‑treat and multiple imputation. A full economic evaluation was conducted.
- Gender and treatment allocation were treated as fixed effects
- Therapists nested within the site were a random effect
- Baseline score and age were covariates
SPS did not significantly improve social functioning compared with enhanced treatment‑as‑usual (WSAS: standardised coefficient 0.12 [95% CI –2.14 to 2.38]; p=0.92). There was no evidence that SPS was cost-effective (probability = 0.34 to 0.39)
Sensitivity and subgroup analyses (e.g. accounting for PTSD, BPD, complete cases, exclusion of deaths, therapist effects) did not alter results, demonstrating robustness.
However, SPS participants reported:
- A small global improvement (standardised coefficient 0.70 [0.11 to 1.29]; p=0.020)
- Reduced emotional dysregulation over 12 months (standardised coefficient 4.29 [95% CI 0.96 to 7.63]; p=0.012)
- These did not translate into reductions in self‑harm or broader mental health improvements.
Safety Findings
Two deaths were reported in the SPS intervention group, although analysis indicated they were not related to study procedures, and researchers felt they were unrelated to study involvement.
Structured Psychological Support was no more cost-effective than enhanced treatment-as-usual.
Conclusions
This trial found no evidence that SPS improves social functioning or is cost‑effective. Although small benefits were observed in emotional dysregulation and global improvement, these did not translate into reductions in self‑harm, suicidality, or broader mental health outcomes. Therefore, longer‑term psychological treatments remain the most effective option.
SPS failed to improve social functioning or prove cost-effective, reinforcing long-term psychological treatment as the evidence-based standard for people with ‘personality disorders’.
Strengths and limitations
This was the first fully powered trial of a short‑term intervention for ‘personality disorders’. It exceeded recruitment targets, achieved high retention, and provided robust clinical and economic analyses, with consistent results across different models supporting reliability. Findings align with the PEPS trial (McMurran M et al., 2017), strengthening evidence that brief interventions don’t produce meaningful improvements and supporting current treatment guidelines. This study extends the evidence base by showing that individually-delivered brief interventions are also ineffective, suggesting delivery format alone does not explain the lack of benefit (McMurran M et al., 2017).
This study meaningfully involved people with lived experience throughout, which is not only best practice, but likely contributed to high follow‑up rates (Iliakis, Ilagan, Choi-Kain, 2021), and ensured the key metrics used to evaluate SPS matched patient priorities. This makes this study very effective at evaluating the benefit (or not) of SPS from the viewpoint of patients.
Another strength was the inclusion of participants with a broader range of personality difficulties than earlier studies, which focused primarily on BPD. This increases the applicability of the findings to services working with diverse personality‑disorder presentations. As results also did not differ in models accounting for comorbid PTSD or complex PTSD, the lack of benefit from SPS also appears consistent regardless of trauma‑related comorbidities.
The sample was predominantly white and female. While this reflects most individuals with diagnosed ‘personality disorders’ presenting in mental health services, it makes it difficult to generalise findings to other groups, like men who could experience short-term therapies differently.
Data from proforma also suggested practitioners often needed longer to build therapeutic relationships than anticipated, leaving less time for skills practice during sessions. This may have reduced SPS effectiveness and makes it difficult to say whether, had trust been established quicker in longer initial sessions, or with previous contact with patients, short-term interventions might be of greater benefit, necessitating further research.
High staff turnover also meant most practitioners delivered SPS to only one or two participants, raising the possibility that limited experience delivering interventions affected intervention quality and impact. More training might have improved SPS delivery, and it is unclear whether this would have increased benefits.
This is a well-designed, inclusive trial with robust findings, though limitations around sample diversity and implementation quality temper the generalisability of the findings.
Implications for practice
Long‑term interventions remain the gold standard. However, further research is needed to determine whether short‑term interventions can offer meaningful benefits if used appropriately, given service pressures. Barriers such as time required to build trust, limited practitioner experience, and the complexity of presentations may limit effectiveness, but research could explore these barriers as opportunities to increase the benefits of short-term interventions through developing structured trust-building exercises or other targeted strategies.
Authors suggest SPS may be more effective earlier in a person’s contact with services, as participants in this study had first engaged with services an average of 13.5 years earlier. It remains to be seen whether earlier delivery may allow trust to develop more quickly and improve engagement.
Short‑term interventions may still offer small improvements in emotional dysregulation, support individuals on waiting lists, or prepare them for longer‑term therapy, but stronger evidence is required before recommending them.
Future research should explore:
- Whether greater practitioner experience or enhanced training improves outcomes
- Whether structured trust‑building strategies can accelerate engagement
- Whether SPS is more effective earlier in the help‑seeking journey
- How to manage endings of short‑term interventions to avoid the “cliff‑edge” effect reported in interviews.
Could research on trust-building offer hope for short-term interventions?
Statement of interests
Ellie Davis has no conflicts of interest to declare.
Edited by
Dr Dafni Katsampa.
Links
Primary Paper
Crawford, M. J., Leeson, V. C., Evans, R., Goulden, N., Kuhn-Thompson, F., Pandya, S. P., … & Barnicot, K. (2026). Brief individual psychological intervention for people with probable personality disorder: a multicentre, researcher-masked, randomised, controlled superiority trial in England. The Lancet Psychiatry, 13(3), 200-212. https://doi.org/10.1016/s2215-0366(25)00372-4
Other references
Tyrer P, Reed GM, Crawford MJ. Classification, assessment, prevalence, and effect of personality disorder. Lancet 2015; 385: 717–26.
Bohus M, Stoffers-Winterling J, Sharp C, Krause-Utz A, Schmahl C, Lieb K. Borderline personality disorder. Lancet 2021; 398: 1528–40.
Cristea IA, Gentili C, Cotet CD, Palomba D, Barbui C, Cuijpers P. Efficacy of psychotherapies for borderline personality disorder: a systematic review and meta-analysis. JAMA Psychiatry 2017; 74: 319–28.
Shadid J, Ferrari AJ, Bach B, et al. The global epidemiology of personality disorder: a systematic review and meta-regression. Lancet Psychiatry 2025; 12: 932–46.
McMurran M, Day F, Reilly J, et al. Psychoeducation and Problem Solving (PEPS) therapy for adults with personality disorder: a pragmatic randomized-controlled trial. J Pers Disord 2017; 31: 810–26.
Spong AJ, Clare ICH, Galante J, Crawford MJ, Jones PB. Brief psychological interventions for borderline personality disorder. A systematic review and meta-analysis of randomised controlled trials. Clin Psychol Rev 2021; 83: 101937.
Crawford MJ, Thana L, Parker J, et al. Structured Psychological Support for people with personality disorder: feasibility randomised controlled trial of a low-intensity intervention. BJPsych Open 2020; 6: e25.
Mundt JC, Marks IM, Shear MK, Greist JH. The Work and Social Adjustment Scale: a simple measure of impairment in functioning. Br J Psychiatry 2002; 180: 461–64.
Bjureberg J, Ljótsson B, Tull MT, et al. Development and validation of a brief version of the Difficulties in Emotion Regulation Scale: the DERS-16. J Psychopathol Behav Assess 2016; 38: 284–96.
Kroenke K, Spitzer RL, Williams JBW. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med 2001; 16: 606–13.
Spitzer RL, Kroenke K, Williams JBW, Löwe B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med 2006; 166: 1092–97.
Thomas HV, Crawford M, Meltzer H, Lewis G. Thinking life is not worth living. A population survey of Great Britain. Soc Psychiatry Psychiatr Epidemiol 2002; 37: 351–56.
First MB, Spitzer RL, Gibbon M, Williams JBW, Benjamin L. Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II). Biometrics Research, New York State Psychiatric Institute, 1994.
Cloitre M, Shevlin M, Brewin CR, et al. The International Trauma Questionnaire: development of a self-report measure of ICD-11 PTSD and complex PTSD. Acta Psychiatr Scand 2018; 138: 536–46.
Guy W. Assessment manual for psychopharmacology—revised. National Institute of Mental Health, 1976.
Shipley K, Hilborn B, Hansell A, Tyrer J, Tyrer P. Patient satisfaction: a valid index of quality of care in a psychiatric service. Acta Psychiatr Scand 2000; 101: 330–33.
Brooks R. EuroQol: the current state of play. Health Policy 1996; 37: 53–72.
Borschmann R, Barrett B, Hellier JM, et al. Joint crisis plans for people with borderline personality disorder: feasibility and outcomes in a randomised controlled trial. Br J Psychiatry 2013; 202: 357–64.
Iliakis EA, Ilagan GS, Choi-Kain LW. Dropout rates from psychotherapy trials for borderline personality disorder: a meta-analysis. Personal Disord 2021; 12: 193–206.
