Sutton and Merton Complex Needs Service

Our service supports adults aged 18+ who meet criteria for a diagnosis of emotionally unstable personality disorder (EUPD), also known as borderline personality disorder (BPD), and frequently engage in self-harm and suicide behaviours.

Some people might describe and understand these difficulties as ‘complex emotional and relational needs’, whilst others prefer the label of ‘personality disorder’. We do refer to the diagnosis of EUPD as this diagnostic label is required to access our service.

We offer two evidence-based therapies: Dialectical Behavioural Therapy (DBT) and Mentalisation-Based Therapy (MBT). For those individuals who have similar difficulties – who do not self-harm or engage in suicide behaviours – there is the option of psychodynamic psychotherapy. 

We are a multidisciplinary team made up of doctors, psychologists, MBT therapists, DBT therapists, and therapists completing training with our team. 

What is Emotionally Unstable Personality Disorder (EUPD)

The diagnosis of emotionally unstable personality disorder can also be known as ‘borderline personality disorder’ (BPD), which is the diagnostic name used in the USA. EUPD is characterised by difficulties in regulating emotions, managing relationships, and experiencing extremely distressing emotions that are difficult to tolerate. These difficulties can cause substantial distress and significantly impact on a person’s life in all contexts: at home, socially, at school and at work. People who struggle with these difficulties may have found unsafe ways to cope with the distress they experience. Many people have experienced traumatic events growing up and so may have developed certain thinking patterns and coping strategies which are understandable in that context. Some of these difficulties start to emerge in adolescence and might persist into adulthood. Therefore, you might not receive the diagnosis before the age of 17/ 18 years of age.

Individuals who meet criteria for a diagnosis of EUPD may typically experience difficulties in the following areas: 

 

 

 

You will have been referred to Sutton and Merton Complex Needs Service (CNS) by your local community mental health team, such as CAMHS or an adult team. Your team may have identified that you experience difficulties with managing emotions, managing relationships and/ or feel suicidal and engage in self-harm. 

What happens after your referral

All referrals are discussed in our referrals meeting to determine whether we are the most appropriate team to meet your needs. If so, you will be placed on our waiting list for an individual assessment with a member of our team and will receive a letter explaining this. As with many NHS services, waiting times can be long. We try to prioritise those referrals from CAMHS, and young adults up to 19 years old, as we acknowledge the challenges of transitioning into adult mental health services. You will be seen as soon as a clinician from our team becomes available. Once a clinician has been allocated, they will be in contact to arrange a first assessment appointment. Whilst on our waitlist, you will continue to be supported by your current team and should access them as required. 

 

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Individual Assessment

Our aim is to understand you and your difficulties more, and whether you meet criteria for a diagnosis of EUPD. There will be general discussion about you and your difficulties, more specific questions regarding the symptoms of EUPD, as well as some questionnaires to complete. We appreciate that it can be anxiety provoking to share personal information with a clinician you have just met. We aim to try and make this process as comfortable as possible. Our assessment consists of individual sessions which covers the above, and then an introductory group where we give you information about the treatments we offer. At the end of this group, we will support you to make a choice of which therapy you want to undertake. 

Within the Trust there are different teams which provide care and support to people with this diagnosis. During our assessment we focus on whether we are the right team for you and your needs. If another team could better meet your needs, we will refer you onto them. During the assessment process we can consider involving family members or carers if you would want and consent to this.

Understanding the family, friends and carers group 

We offer a one-off family, friends and carers session at the end of the group assessment process. It is up to you to choose if and who you want to invite to this group. We understand that some people might not want their families, friends and carers to attend.  

The group covers the same information you will receive during your group assessment sessions. This will include: who we are as a team, the support we offer, what treatments we provide, psychoeducation around the diagnosis of EUPD, and skills teaching to family, friends or carers of people receiving treatment within our team. 

The group is solely for friends, family and carers of our clients. Clients are not expected to attend this session as clients will receive this information in the group assessment sessions. Additionally, as with the group assessment sessions, this space is confidential. 

Everything you did was more than enough, especially by making the session accessible with an interpreter and showing how much you care for the well-being of my child.

Parents of an 18-year-old client

Understanding the pre-treatment process 

The goal of pre-treatment is to make sure you have a good understanding of what your chosen treatment involves, and to establish if you are able and ready to commit to therapy at this time. MBT pre-treatment is an introductory group, and DBT pre-treatment involves individual sessions. During this stage, you have the option of not going onto the next part of the journey. This might, for example, be due to other commitments in your life, caring responsibilities, or not feeling ready to start therapy. 

Understanding the treatment process 

Mentalisation-Based Treatment and Dialectical Behaviour Therapy are both evidence-based therapies for people who meet criteria for a diagnosis of EUPD. Both are recommended by the National Institute for Health and Clinical Excellence (NICE), a group of experts who oversee research into how best to treat and manage physical and mental illness. 

Both therapies are intensive, in that they involve two sessions a week - an individual session and a group session. They work on emotion regulation and ability to tolerate painful and distressing emotions through increasing awareness of how an individual thinks and feels, as well as how others think and feel. In this way, MBT and DBT are similar to each other. Where they differ is mostly in the style of delivery, in terms of the content and structure of sessions. 

What is Dialectical Behaviour Therapy? 

Dialectical Behaviour Therapy (DBT) is an evidence-based psychological therapy developed by Marsha Linehan, a clinical psychologist from the USA with lived experience of suicidality and self-harm.

DBT aims to work towards a ‘life worth living’, which can look different for different people. Clients work with their therapist to identify personal treatment goals. DBT treatment is 12 months in duration and requires clients to attend: 

• A weekly skills group where clients learn skills such as mindfulness practice, ways to improve interpersonal relationships, how to manage emotions, and coping with distressing situations. 
• A weekly individual therapy where the therapist assists clients in applying the skills learnt in reducing harmful behaviours and improving quality of life.
• In addition, clients also have access to telephone coaching where they are supported by their therapist to apply DBT skills to real life situations outside of group or individual sessions. 

What is Mentalisation-Based Treatment?

Mentalisation-Based Treatment (MBT) is an evidence-based psychological therapy developed by Anthony Bateman and Peter Fonagy in the UK, the latter of which has lived experience of suicidality. 

MBT is based on the theory that people with a diagnosis of EUPD may at times have difficulties understanding the feelings, intentions, desires, and thoughts behind their own and other people’s actions. We call this ‘mentalising’, the ability to think about our own and others’ thinking. Struggles with mentalising can also lead to difficulties with our sense of self. MBT work aims to support clients to understand how their problems have developed through their attachment patterns in both current and past relationships, and what maintains these patterns. This understanding can help clients to find a better quality of life. 

MBT is 18 months in duration which requires clients to attend: 

• A weekly group
• A weekly individual therapy
• Step-down and discharge 

Following completion of full treatment in DBT and MBT, we offer an optional ‘step-down’ stage in which clients have a few sessions over the course of 6 months. For MBT clients, there would be 1 step-down session at 1-, 3- and 6-month intervals. In DBT this is similar, though there can be a bit more flexibility. During stepdown, DBT clients continue to have access to telephone coaching. The purpose of the step-down stage is to support clients to build confidence in the skills they have learnt in preparation for discharge from the team. It can also provide a space to discuss any difficult feelings or concerns about ending therapy. 

What is psychodynamic psychotherapy? 

Psychodynamic psychotherapy is usually a long-term talking therapy that is offered each week, where each session lasts 50 minutes (individual) to 90 minutes (group). The treatment duration is 12 months. In this type of therapy, the therapist does not lead sessions, but rather the client can choose what they wish to talk about. The therapist will give you space to do this, in the individual or group session, and will follow your lead.

This type of therapy works by helping you understand your current struggles and problems by looking to the past and the relationship between you and your therapist. In doing so, we find clients often report their symptoms get better.

Before taking up this type of therapy a consultation will take place so that you can have a taste of what sessions feel like. It also gives the opportunity for us to understand what sort of help you might be wanting and whether this type of therapy matches your wants and needs.

Our service offers this type of therapy to those who are not currently self-harming or experiencing dependence on alcohol or substances (or high usage). This is because talking about the past can stir up painful emotions which then can cause these types of behaviours to escalate.

We know that caring for individuals with complex emotional needs can be difficult and that family members can feel isolated. Research and evidence tell us that the support loved ones provide is important for the recovery journey of our clients. Family Connections™ is a 12-week evidence-based group program that helps your family support you in the changes you are making and learn how they can work with you to meet your therapy goals. The aim of the group is to educate significant others on emotional dysregulation and interpersonal functioning, learn skills to manage their own emotional responses and support their loved ones, as well as provide peer support through group membership. This group is currently only open to significant others (18yrs+) of clients who are 16-25 years old, with emotional dysregulation difficulties with or without a diagnosis of EUPD, and who are under either child or adult mental health. At present, for loved ones to be eligible for the group, clients need to be receiving either DBT informed or DBT treatment from either CAMHS or adult mental health services. It is up to you, the client, to choose if and who you might like to be invited to join this group. We understand that some people might not want their families, friends or carers to attend. This group is a confidential space for clients’ loved ones.

I am very thankful for this opportunity to exist. It facilitated a lot more open and honest conversations with (sibling).

Sibling of a 23-year-old client