Personality disorder (PD) is a prevalent mental disorder, affecting over 4% of the general population . People with personality disorder suffer high levels of distress, suicide, self-harm, addiction, family breakdown, and social exclusion. Rendu et al.  assessed the costs of treating people with PD in primary care as £3,094 per annum, almost twice the costs of people without PD. A prevalence of PD of almost 5% equates to around 3 million people in the UK, costing around £40 million per annum extra to regular care in primary care alone (at 2002 costs). Furthermore, people with PD place considerable demands upon a range of services, including emergency departments, social services, and the criminal justice system. For those who enter outpatient specialist mental health services, treatment costs are around £135 per treatment session , and treatment for people with PD is often of long duration. People with PD who offend may enter medium secure services, where the cost is around £176,000 per person per year . If a relatively brief and effective treatment can be offered to a broad spectrum of people with PD dwelling in the community, this will have the potential to improve the lives of people with PD, improve access to services, and also reduce health and non-health service costs.
Systematic reviews of outcomes of psychological treatments for people with PD [4–7] have identified few randomised controlled trials (RCTs). The majority of these studies are underpowered, most have multiple outcome measures, and only about one-third measure social functioning, which is agreed to be the most significant clinical problem for this group of patients. We plan to conduct a well-designed and adequately-powered study of one promising intervention, namely psycho-education combined with problem solving (PEPS) therapy, which has become a popular way of working. Enthusiasm for its use does not obviate the need for a rigorous evaluation of the effectiveness of PEPS therapy; indeed, if it is widely used then evidence of effectiveness - or otherwise - is crucial.
Social problem solving is the process by which an individual attempts to identify or discover solutions to specific problems encountered in everyday living . Good social problem solving skills help people to cope with life's stressors, particularly those with an interpersonal component . Impairment in social functioning is a key component of PD [10–12], hence the emphasis on social functioning that underpins problem solving therapy is highly relevant to the treatment of PD. Using the Social Problem Solving Inventory-Revised (SPSI-R) , we have found that people with PD, both community adults presenting for treatment and detained offenders with PD, report greater impairment on all SPSI-R scales compared to a sample of mature students . This information suggests that social problem solving therapy may benefit people with PD.
Meta-analyses have shown problem solving therapy to be effective in improving a range of mental and physical health problems [14–16]. This therapy has not been evaluated with people with PD, nonetheless it is suited to this group because the focus is upon improving social functioning and reducing personal distress. These outcomes are considered to be of paramount importance in the treatment of PD . Furthermore, the aim in therapy is to help people recognise both their strengths and limitations and work with these to learn new skills that will enable them to cope more effectively with life's problems. People with PD have different trait profiles and different problem solving deficits , and problem solving therapy is sufficiently flexible to accommodate these differences. It helps clients to adopt a more realistically positive orientation to problem solving, cope better with the negative emotions that hinder effective problem solving, develop a positive problem orientation, and adopt a rational problem solving style that will lead to outcomes that improve social functioning and reduce distress.
Engaging people with PD in treatment is a major challenge [19, 20]. The social problem solving approach enhances engagement by offering an accessible framework for change (i.e., the approach appeals to common sense), supporting people in the experience of successful problem solving (i.e., increasing the likelihood of reinforcement of the developing skills), and encouraging independence rather than reliance on therapy (i.e., promoting self-efficacy). Furthermore, PEPS therapy has a preliminary psycho-education component which aims to educate, build rapport, and motivate people for problem solving therapy . Personality disorders and their impact are discussed in a collaborative dialogue and problems that may be worked upon in group sessions are identified.
PEPS therapy has been evaluated with community adults with PD in a Phase 2 exploratory trial . At the end of treatment, compared to a wait-list control group, those treated with PEPS therapy showed better social functioning, as measured by the Social Functioning Questionnaire . All aspects of social problem solving improved over the course of PEPS therapy, and, after controlling for baseline level of social functioning, the most important predictor of improvement in social functioning was a reduction in negative problem orientation, i.e., people felt less threatened by problems and more confident in their ability to solve them .
This exploratory study has been identified as important in four ways [25, 26]. First, the intervention was brief and hence is likely to be more acceptable to many patients than lengthier interventions; this decreases the likelihood of drop-out and may also be more acceptable to services with limited resources. Second, PEPS therapy was delivered in clinical settings, hence its likely effectiveness in everyday practice was indicated. Third, PEPS therapy was offered to people with any PD or combination of PDs, so it was inclusive rather than exclusive. Fourth, PEPS therapy was delivered by non-specialist staff, hence it would be possible to deliver it relatively cheaply.
Overall, PEPS therapy has the potential to contribute to the UK National Health Service's (NHS) QUIPP agenda (Quality, Improvement, Productivity and Prevention): it is a brief, innovative intervention in which staff can easily be trained and which could be made widely available to people with personality disorder at a stage where prevention of deterioration is possible. However, a definitive evaluation now needs to be conducted. A trial will permit investigation of aspects of the therapy about which there is currently no information. First, a longer-term follow-up is necessary to provide information about the sustainability of gains made during treatment. Second, a cost-effectiveness evaluation of the intervention is required. Third, there is a need to gather information about the respective contributions of psycho-education and social problem solving therapy. We are now conducting a Phase 3 definitive randomised controlled trial to consolidate and extend our knowledge about the effectiveness of PEPS therapy for people with personality disorder (see http://www.peps-trial.co.uk). If improvements in social functioning can be definitively shown to result from therapy and be sustained over time (72 weeks post-randomisation), then this relatively brief intervention could be used more widely across the NHS.
To conduct a randomised controlled trial to evaluate the effectiveness of PEPS therapy compared with treatment as usual in improving social functioning in community adults with personality disorder.
To assess the costs and cost-effectiveness of PEPS therapy compared with treatment as usual.
To examine intermediate change, specifically the impact of psycho-education on the therapeutic relationship, and the impact of social problem solving therapy on social problem solving skills.
To conduct a qualitative investigation of the application of PEPS therapy in practice to identify the views of participants.
Our primary hypothesis is that, compared with those in treatment-as-usual, those in PEPS therapy will show a greater improvement in social functioning post-therapy and at follow-up 72 weeks post-randomisation. Secondary hypotheses are that, compared with those in treatment-as-usual, those in PEPS therapy will show the following changes both immediately after therapy and at follow-up: (a) a greater reduction in receipt of unscheduled services; (b) a greater increase in receipt of scheduled services; (c) a greater improvement in quality of life; (d) a greater improvement in referrers' ratings of functioning; (e) a greater reduction in anxiety and depression; and (f) improvement on client-ratings of self-identified three key problems. Regarding intermediate changes, we hypothesise that, compared with those in treatment-as-usual, those in PEPS therapy will show: (a) better therapist alliance after psycho-education; and (b) a greater improvement in social problem solving at end of therapy. We also expect PEPS therapy to show an acceptable level of cost-effectiveness, based on thresholds that appear to guide National Institute for Clinical Excellence (NICE) recommendations.