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Dialectical behaviour therapy for women with borderline personality disorder: 12-Month, randomised clinical trial in The Netherlands

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  • Pro Persona Arnhem, Netherlands; GGNet: Scelta Apeldoorn, Netherlands; Dialexis Deventer, Netherlands

Abstract and Figures

Dialectical behaviour therapy (DBT) is widely considered to be a promising treatment for borderline personality disorder (BPD). However, the evidence for its efficacy published thus far should be regarded as preliminary. To compare the effectiveness of DBT with treatment as usual for patients with BPD and to examine the impact of baseline severity on effectiveness. Fifty-eight women with BPD were randomly assigned to either 12 months of DBT or usual treatment in a randomised controlled study. Participants were recruited through clinical referrals from both addiction treatment and psychiatric services. Outcome measures included treatment retention and the course of suicidal, self-mutilating and self-damaging impulsive behaviours. Dialectical behaviour therapy resulted in better retention rates and greater reductions of self-mutilating and self-damaging impulsive behaviours compared with usual treatment, especially among those with a history of frequent self-mutilation. Dialectical behaviour therapy is superior to usual treatment in reducing high-risk behaviours in patients with BPD.
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BackgroundBackground DialecticalbehaviourDialecticalbehaviour
thera py (DBT) is widely considered to b e atherapy (DBT) is widelyconsidered to be a
promising treatment for b orderlinepromising treatment for borderline
personality disorder (BPD).However, thepersonality disorder (BPD).However, the
evidence for its efficacy publishedthus farevidence forits efficacy publishedthus far
should be regarded as preliminary.should be regarded as preliminary.
AimsAims To compare the effectiveness ofTo comparethe effectiveness of
DBT with treatme nt as usual for patientsDBT withtreatment as usual for patients
with BPDandto examinetheimpactofwith BPDandto examinetheimpactof
baseline severity on effectiveness.baseline severity on effectiveness.
MethodMethod Fifty-eight women with BPDFifty- eight women with BPD
were randomly assigned to either12were randomly assigned to either12
months o f DBTor usual treatment in amonths of DBT or usual treatment in a
randomised controlled study.Par ticipantsrandomised controlled study.Par ticipants
were recr uited through clinical referralswere recr uited through clinical referrals
from both addictiontreatment andfromboth addiction treatment and
psychiatric services.Outcome measurespsychiatric services.Outcome measures
included treatment retention and theincluded treatment retention and the
cours e of suicidal, s elf-mutilating and self-course of suicidal, self- mutilating and self-
damaging impulsive behaviours.damagingimpulsive behaviours.
ResultsResults Dialectical behaviour th erapyDialectical behaviour therapy
resulted in betterretention rates andresulted in better retentionrates and
greater reductions of self-mutilating andgreater reductions of self-mutilating and
self- damaging impulsive behavioursself- damaging impulsive behaviours
compare d with usual treatment, especiallycomparedwith usual treatment, especially
among those with a history of frequentamong those with a history of frequent
self-mutilation.self-mutilation.
ConclusionsConclusions DialecticalbehaviourDialec tical b ehaviour
thera pyis superior to usual treatme nt inthera py is superior to usual treatment in
reducing high -risk behaviours in p atientsreducing high- risk behaviours in p atients
with BPD.with BPD.
Declaration of interestDeclaration of interest None.ThisNone.This
work was supported by ZAOHealthwork was supported by ZAO Health
Insurance Company,Amsterdam.Insurance Company,Amsterdam.
According to the American PsychiatricAccording to the American Psychiatric
Association’s practice guideline, the pri-Association’s practice guideline, the pri-
mary treatment for borderline personalitymary treatment for borderline personality
disorder is psychotherapy, complementeddisorder is psychotherapy, complemented
by symptom-targeted pharmacotherapy ifby symptom-targeted pharmacotherapy if
necessary (American Psychiatric Associa-necessary (American Psychiatric Associa-
tion, 2001). It is stated in this guideline thattion, 2001). It is stated in this guideline that
two psychotherapeutic approaches havebeentwo psychotherapeutic approaches have been
shown in randomised trials to have effi-shown in randomised trials to have effi-
cacy: psychoanalytic/psychodynamic ther-cacy: psychoanalytic/psychodynamic ther-
apy and dialectical behaviour therapy. Theapy and dialectical behaviour therapy. The
guideline has been criticised because it isguideline has been criticised because it is
primarily based upon evidence from uncon-primarily based upon evidence from uncon-
trolled or single case studies and clinicaltrolled or single case studies and clinical
consensus (e.g. Tyrer, 2002). Only fewconsensus (e.g. Tyrer, 2002). Only few
methodologically rigorous efficacy studiesmethodologically rigorous efficacy studies
have been conducted. With respect to dia-have been conducted. With respect to dia-
lectical behaviour therapy, two randomisedlectical behaviour therapy, two randomised
clinical trials of small to moderate size haveclinical trials of small to moderate size have
been conducted (Linehanbeen conducted (Linehan et alet al, 1991,, 1991,
19991999aa). In addition, several other unpub-). In addition, several other unpub-
lished or uncontrolled studies have beenlished or uncontrolled studies have been
summarised by Koerner & Linehan (2000).summarised by Koerner & Linehan (2000).
In a randomised controlled trial, weIn a randomised controlled trial, we
compared the effectiveness of dialecticalcompared the effectiveness of dialectical
behaviour therapy with treatment as usualbehaviour therapy with treatment as usual
in terms of the therapy’s primary targetsin terms of the therapy’s primary targets
(Linehan(Linehan et alet al, 1999, 1999bb): first, treatment reten-): first, treatment reten-
tion and second, high-risk behaviours,tion and second, high-risk behaviours,
including suicidal, self-mutilating and self-including suicidal, self-mutilating and self-
damaging impulsive behaviours. A furtherdamaging impulsive behaviours. A further
aim was to examine whether the efficacy ofaim was to examine whether the efficacy of
dialectical behaviour therapy is modified bydialectical behaviour therapy is modified by
baseline severity of parasuicide. This reportbaseline severity of parasuicide. This report
describes the first 12 months of the trial.describes the first 12 months of the trial.
METHODMETHOD
Sample recruitmentSample recruitment
Women with borderline personality dis-Women with borderline personality dis-
order aged 18–70 years residing within aorder aged 18–70 years residing within a
40-km circle centred on Amsterdam, who40-km circle centred on Amsterdam, who
were referred by a psychologist or psy-were referred by a psychologist or psy-
chiatrist willing to sign an agreementchiatrist willing to sign an agreement
expressing the commitment to deliver 12expressing the commitment to deliver 12
months of treatment as usual, were consid-months of treatment as usual, were consid-
ered for recruitment. No restriction wasered for recruitment. No restriction was
made in terms of the referral source. Refer-made in terms of the referral source. Refer-
rals originated from addiction treatmentrals originated from addiction treatment
services, psychiatric hospitals, centres forservices, psychiatric hospitals, centres for
mental health care, independently workingmental health care, independently working
psychologists and psychiatrists, and evenpsychologists and psychiatrists, and even
from general practitioners and self-referral.from general practitioners and self-referral.
Women in the latter two categories wereWomen in the latter two categories were
allowed to participate in the study onlyallowed to participate in the study only
when they were able to locate a psycho-when they were able to locate a psycho-
logist or psychiatrist willing to providelogist or psychiatrist willing to provide
treatment as usual. The exclusion criteriatreatment as usual. The exclusion criteria
were a DSM–IV diagnosis of bipolarwere a DSM–IV diagnosis of bipolar
disorder or (chronic) psychotic disorderdisorder or (chronic) psychotic disorder
(American Psychiatric Association, 1994),(American Psychiatric Association, 1994),
insufficient command of the Dutch lan-insufficient command of the Dutch lan-
guage, and severe cognitive impairments.guage, and severe cognitive impairments.
The diagnosis of borderline personalityThe diagnosis of borderline personality
disorder was established using both the Per-disorder was established using both the Per-
sonality Diagnostic Questionnaire, DSM–sonality Diagnostic Questionnaire, DSM–
IV version (Hyler, 1994) and the StructuredIV version (Hyler, 1994) and the Structured
Clinical Interview for DSM–IV Axis IIClinical Interview for DSM–IV Axis II
personality disorders (SCID–II; Firstpersonality disorders (SCID–II; First et alet al,,
1994). Positive endorsement of DSM–IV1994). Positive endorsement of DSM–IV
diagnostic criteria for borderline person-diagnostic criteria for borderline person-
ality disorder was required on bothality disorder was required on both
instruments. In contrast to Linehan’s trialinstruments. In contrast to Linehan’s trial
(Linehan(Linehan et alet al, 1991), the sample consisted, 1991), the sample consisted
primarily of clinical referrals from both ad-primarily of clinical referrals from both ad-
diction treatment and psychiatric services,diction treatment and psychiatric services,
and participants were not required to haveand participants were not required to have
shown recent parasuicidal behaviour.shown recent parasuicidal behaviour.
Randomisation procedureRandomisation procedure
Following the completion of the intake as-Following the completion of the intake as-
sessments, patients were randomly assignedsessments, patients were randomly assigned
to treatment conditions. A minimisationto treatment conditions. A minimisation
method was used to ensure comparabilitymethod was used to ensure comparability
of the two treatment conditions on age,of the two treatment conditions on age,
alcohol problems, drug problems and socialalcohol problems, drug problems and social
problems (as measured by the Europeanproblems (as measured by the European
version of the Addiction Severity Indexversion of the Addiction Severity Index
(Kokkevi & Hartgers, 1995)).(Kokkevi & Hartgers, 1995)).
TreatmentsTreatments
Patients assigned to dialectical behaviourPatients assigned to dialectical behaviour
therapy received 12 months of treatmenttherapy received 12 months of treatment
as specified in the manual (Linehan,as specified in the manual (Linehan,
1993). The treatment combines weekly1993). The treatment combines weekly
individual cognitive–behavioural psy-individual cognitive–behavioural psy-
chotherapy sessions with the primarychotherapy sessions with the primary
therapist, weekly skills-training groupstherapist, weekly skills-training groups
lasting 2–2.5 h per session, and weeklylasting 2–2.5 h per session, and weekly
supervision and consultation meetings forsupervision and consultation meetings for
the therapists (Linehan, 1993). Individualthe therapists (Linehan, 1993). Individual
therapy focuses primarily on motivationaltherapy focuses primarily on motivational
issues, including the motivation to stay aliveissues, including the motivation to stay alive
and to stay in treatment. Group therapyand to stay in treatment. Group therapy
teaches self-regulation and change skills,teaches self-regulation and change skills,
and skills for self-acceptance andand skills for self-acceptance and
135135
BRITISH JOURNAL OF P SYCHIATRYBRITISH JOURNAL OF PSYCHIATRY (2003), 182, 135^140(200 3), 182, 135^140
Dialectical behaviour therapy for womenDialectical behaviour therapy for women
with borderline personality disorderwith borderline personality disorder
12-month, randomised clinical trial inThe Netherlands12-month, randomised clinical trial inThe Netherlands
ROELVERHEUL, LOUISE M. C. VAN DEN BOSCH, MAARTEN W. J. KOETER,ROEL VERHEUL, LOUISE M. C. VAN DEN BOSCH, M AARTEN W. J. KOETER,
MARIA A. J. DE RIDDER, THEO STIJNEN and W IM VAN DEN BRINKMARIA A. J. DE RIDDER, THEO ST IJNEN and W IM VAN DEN BRINK
VERHEUL ET ALVERHEUL ET AL
acceptance of others. Among its centralacceptance of others. Among its central
principles is dialectical behaviour therapy’sprinciples is dialectical behaviour therapy’s
simultaneous focus on both acceptancesimultaneous focus on both acceptance
and validation strategies and change strate-and validation strategies and change strate-
gies to achieve a synthetic (dialectical)gies to achieve a synthetic (dialectical)
balance in client functioning. The medianbalance in client functioning. The median
adherence score on a 5-point Likert scaleadherence score on a 5-point Likert scale
was 3.8 (range 2.5–4.5), indicating ‘almostwas 3.8 (range 2.5–4.5), indicating ‘almost
good dialectical behaviour therapy’ in termsgood dialectical behaviour therapy’ in terms
of conformity to the treatment manual.of conformity to the treatment manual.
‘Treatment as usual’ consisted of clini-‘Treatment as usual’ consisted of clini-
cal management from the original referralcal management from the original referral
source (addiction treatment centressource (addiction treatment centres nn¼11,11,
psychiatric servicespsychiatric services nn¼20). Patients in this20). Patients in this
group attended generally no more thangroup attended generally no more than
two sessions per month with a psychologist,two sessions per month with a psychologist,
a psychiatrist or a social worker.a psychiatrist or a social worker.
TherapistsTherapists
Extensive attention was paid to the selec-Extensive attention was paid to the selec-
tion, training and supervision of the dialec-tion, training and supervision of the dialec-
tical behaviour therapists, who includedtical behaviour therapists, who included
four psychiatrists and 12 clinical psy-four psychiatrists and 12 clinical psy-
chologists. Group training was conductedchologists. Group training was conducted
in three separate groups led jointly by socialin three separate groups led jointly by social
workers and clinical psychologists. Train-workers and clinical psychologists. Train-
ing, regular monitoring (using videotapes)ing, regular monitoring (using videotapes)
and weekly individual and group super-and weekly individual and group super-
vision were performed by the second authorvision were performed by the second author
(L.M.C.B.), who received intensive training(L.M.C.B.), who received intensive training
from Professor Linehan in Seattle and is afrom Professor Linehan in Seattle and is a
member of the international dialecticalmember of the international dialectical
behaviour therapy training group.behaviour therapy training group.
Outcome assessmentsOutcome assessments
Baseline assessments took place 1–16 weeksBaseline assessments took place 1–16 weeks
(median 6 weeks) before randomisation.(median 6 weeks) before randomisation.
Therapy began 4 weeks after randomis-Therapy began 4 weeks after randomis-
ation. Three clinical psychologists (twoation. Three clinical psychologists (two
with master’s degrees and one a Doctor ofwith master’s degrees and one a Doctor of
Philosophy) conducted all assessments.Philosophy) conducted all assessments.
They were experienced diagnosticians whoThey were experienced diagnosticians who
received additional specific training in thereceived additional specific training in the
administration of the instruments.administration of the instruments.
Recurrent parasuicidal and self-Recurrent parasuicidal and self-
damaging impulsive behaviours weredamaging impulsive behaviours were
measured at baseline and at 11, 22, 33,measured at baseline and at 11, 22, 33,
44 and 52 weeks after randomisation using44 and 52 weeks after randomisation using
the appropriate sections of the Borderlinethe appropriate sections of the Borderline
Personality Disorder Severity IndexPersonality Disorder Severity Index (BPDSI;(BPDSI;
ArntzArntz et alet al, 2003), a, 2003), a semi-structuredsemi-structured
interview assessing the frequency of border-interview assessing the frequency of border-
line symptoms in the previous 3-monthline symptoms in the previous 3-month
period. The BPDSI consists of nine sections,period. The BPDSI consists of nine sections,
one for each of the DSM–IV criteria forone for each of the DSM–IV criteria for
borderline personality disorder. The para-borderline personality disorder. The para-
suicide section includes three items reflect-suicide section includes three items reflect-
ing distinct suicidal behaviours (suicideing distinct suicidal behaviours (suicide
threats, preparations for suicide attempts,threats, preparations for suicide attempts,
and actual suicide attempts). The impulsiv-and actual suicide attempts). The impulsiv-
ity section includes 11 items reflecting theity section includes 11 items reflecting the
manifestations of self-damaging impulsivitymanifestations of self-damaging impulsivity
(e.g. gambling, binge eating, substance(e.g. gambling, binge eating, substance
misuse, reckless driving). The parasuicidemisuse, reckless driving). The parasuicide
and impulsivity sections have shownand impulsivity sections have shown
reasonable internal consistencies (0.69 andreasonable internal consistencies (0.69 and
0.67, respectively), excellent interrater0.67, respectively), excellent interrater
reliability (0.95 and 0.97, respectively)reliability (0.95 and 0.97, respectively)
and good concurrent validity (Arntzand good concurrent validity (Arntz et alet al,,
2003). Three month test–retest reliability2003). Three month test–retest reliability
for the total BPDSI score was 0.77.for the total BPDSI score was 0.77.
Self-mutilating behaviours were mea-Self-mutilating behaviours were mea-
sured using the Lifetime Parasuicide Countsured using the Lifetime Parasuicide Count
(LPC; Comtois & Linehan, 1999) at base-(LPC; Comtois & Linehan, 1999) at base-
line and the adapted (3-month) version wasline and the adapted (3-month) version was
administered 22 weeks and 52 weeksadministered 22 weeks and 52 weeks
after randomisation. The LPC obtains in-after randomisation. The LPC obtains in-
formation about the frequency and subse-formation about the frequency and subse-
quent medical treatment of self-mutilatingquent medical treatment of self-mutilating
behaviours (e.g. cutting, burning andbehaviours (e.g. cutting, burning and
pricking).pricking).
Completeness of dataCompleteness of data
Of the five follow-up assessments, partici-Of the five follow-up assessments, partici-
pants completed a mean of 3.7 assessments,pants completed a mean of 3.7 assessments,
with no significant difference between treat-with no significant difference between treat-
ment conditions(Cochran–Mantel–Haenszelment conditions (Cochran–Mantel–Haenszel
testtest ww2233¼1.51;1.51; PP¼0.14). Forty-seven (81%)0.14). Forty-seven (81%)
completed the assessment at week 52.completed the assessment at week 52.
Statistical analysisStatistical analysis
For the analysis of treatment retention, chi-For the analysis of treatment retention, chi-
squared analysis was used. The course ofsquared analysis was used. The course of
high-risk behaviours as measured with thehigh-risk behaviours as measured with the
LPC and BPDSI was analysed using a gen-LPC and BPDSI was analysed using a gen-
eral linear mixed model (GLMM) approacheral linear mixed model (GLMM) approach
(‘Mixed’ procedure from SAS version 6.12;(‘Mixed’ procedure from SAS version 6.12;
SAS Institute, Cary, NC). Preliminary toSAS Institute, Cary, NC). Preliminary to
the GLMM analyses, examination of thethe GLMM analyses, examination of the
variable characteristics revealed highlyvariable characteristics revealed highly
skewed distributions of the BPDSI para-skewed distributions of the BPDSI para-
suicide and impulsivity and the LPC totalsuicide and impulsivity and the LPC total
score. A shifted log transformation wasscore. A shifted log transformation was
performed on each of these variables. Aperformed on each of these variables. A
Bonferroni correction to the level of signif-Bonferroni correction to the level of signif-
icance was applied, resulting in anicance was applied, resulting in an aa ofof
0.013 (0.05/4).0.013 (0.05/4).
Within the GLMM approach, we usedWithin the GLMM approach, we used
a two-step procedure: first, the covariancea two-step procedure: first, the covariance
structure was fitted using restricted likeli-structure was fitted using restricted likeli-
hood and a saturated fixed model, andhood and a saturated fixed model, and
second the fixed model was refined usingsecond the fixed model was refined using
maximum likelihood (Verbeke & Molen-maximum likelihood (Verbeke & Molen-
berghs, 1997). The main advantage of theberghs, 1997). The main advantage of the
GLMM approach over standard repeated-GLMM approach over standard repeated-
measurement multivariate analysis ofmeasurement multivariate analysis of
variance is that it allows for inclusion ofvariance is that it allows for inclusion of
cases with missing values, thereby provid-cases with missing values, thereby provid-
ing a better estimate of the true (unbiased)ing a better estimate of the true (unbiased)
effect within the intention-to-treat sample.effect within the intention-to-treat sample.
To examine the effect of dialectical behav-To examine the effect of dialectical behav-
iour therapy on the course of high-riskiour therapy on the course of high-risk
behaviours, we used a model with time,behaviours, we used a model with time,
treatment, and timetreatment, and time66treatment inter-treatment inter-
action. To correct for possible initial differ-action. To correct for possible initial differ-
ences, baseline severity was added as aences, baseline severity was added as a
covariate. To examine the impact of initialcovariate. To examine the impact of initial
severity on outcome, we implemented aseverity on outcome, we implemented a
model with time, baseline severity, treat-model with time, baseline severity, treat-
ment condition and the two-way andment condition and the two-way and
three-way interactions between thesethree-way interactions between these
variables.variables.
RESULTSRESULTS
Recruitment and patientRecruitment and patient
characteristicscharacteristics
Of the 92 patients referred to and consid-Of the 92 patients referred to and consid-
ered for this study, 64 were eligible andered for this study, 64 were eligible and
gave written informed consent. Thirty-onegave written informed consent. Thirty-one
were assigned to dialectical behaviourwere assigned to dialectical behaviour
therapy and 33 to treatment as usual.therapy and 33 to treatment as usual.
Two patients assigned to the treatment-as-Two patients assigned to the treatment-as-
usual condition were dropped from theusual condition were dropped from the
intention-to-treat analyses because theyintention-to-treat analyses because they
did not accept the randomisation outcomedid not accept the randomisation outcome
and therefore refused to cooperate furtherand therefore refused to cooperate further
with the study protocol, and four patientswith the study protocol, and four patients
assigned to dialectical behaviour therapyassigned to dialectical behaviour therapy
were dropped because they refused to startwere dropped because they refused to start
treatment. Flow through the study and thetreatment. Flow through the study and the
main reasons for exclusion are shown inmain reasons for exclusion are shown in
Fig. 1. Severity of borderline personalityFig. 1. Severity of borderline personality
disorder, addiction severity and age weredisorder, addiction severity and age were
not significantly associated with attritionnot significantly associated with attrition
between the intake phase and inclusion inbetween the intake phase and inclusion in
the intention-to-treat sample. There wasthe intention-to-treat sample. There was
no significant differenceno significant difference between treatmentbetween treatment
conditions on socio-conditions on socio- demographic vari-demographic vari-
ables, number of DSM–IV criteria forables, number of DSM–IV criteria for
borderline personality disorder met, historyborderline personality disorder met, history
of suicide attempts, number of self-of suicide attempts, number of self-
mutilating acts, or prevalence of clinicallymutilating acts, or prevalence of clinically
significant alcohol and/or drug use problemssignificant alcohol and/or drug use problems
(Table 1).(Table 1).
Treatment retentionTreatment retention
Significantly more patients who wereSignificantly more patients who were
receiving dialectical behaviour therapyreceiving dialectical behaviour therapy
((nn¼17; 63%) than patients in the control17; 63%) than patients in the control
group (group (nn¼7; 23%) continued in therapy7; 23%) continued in therapy
with the same therapist for the entire yearwith the same therapist for the entire year
((ww2211¼9.70;9.70; PP¼0.002). This difference was0.002). This difference was
maintained when two members of the con-maintained when two members of the con-
trol group who were assigned to othertrol group who were assigned to other
therapists within the same institutes weretherapists within the same institutes were
13 6136
DIALECTICAL BEHAVIOUR THERAPY IN BORDERLINE PERSONALITY DISORDERDIALECTICAL BEHAVIOUR THER APY IN BORDERLINE PERSONALITY DISORDER
included in the calculation (included in the calculation (ww2211¼6.72;6.72;
PP¼0.010).0.010).
High-risk behavioursHigh-risk behaviours
The frequency and course of suicidal beha-The frequency and course of suicidal beha-
viours were not significantly differentviours were not significantly different
across treatment conditions: neither treat-across treatment conditions: neither treat-
ment condition (ment condition (tt1,1371,137¼0.03;0.03; PP¼0.866) nor0.866) nor
the interaction between time and treatmentthe interaction between time and treatment
condition (condition (tt1,1661,166¼0.22;0.22; PP¼0.639) reached0.639) reached
statistical significance. An additional analy-statistical significance. An additional analy-
sis revealed that, although fewer patients insis revealed that, although fewer patients in
the dialectical behaviour therapy groupthe dialectical behaviour therapy group
((nn¼2; 7%) than in the control group2; 7%) than in the control group
((nn¼8; 26%) attempted suicide during the8; 26%) attempted suicide during the
year, this difference was not statisticallyyear, this difference was not statistically
significant (significant (ww2211¼3.24;3.24; PP¼0.064).0.064).
Self-mutilating behaviours of patientsSelf-mutilating behaviours of patients
assigned to dialectical behaviour therapyassigned to dialectical behaviour therapy
gradually diminished over the treatmentgradually diminished over the treatment
year, whereas patients assigned to treat-year, whereas patients assigned to treat-
ment as usual gradually deteriorated in thisment as usual gradually deteriorated in this
respect: a significantrespect: a significant effect was observedeffect was observed
for the interaction term timefor the interaction term time66treatmenttreatment
condition (condition (tt1,44.41,44.4¼10.24;10.24; PP¼0.003) but0.003) but
not fornot for treatment condition alonetreatment condition alone
((tt1,69.11,69.1¼3.80;3.80; PP¼0.055)0.055) (Fig. 2). The most(Fig. 2). The most
frequently reported self-mutilating actsfrequently reported self-mutilating acts
were cutting, burning, pricking and head-were cutting, burning, pricking and head-
banging. At the week 52 assessment,banging. At the week 52 assessment,
57% (57% (nn¼13) of the treatment-as-usual13) of the treatment-as-usual
patients reported engaging in any self-patients reported engaging in any self-
mutilating behaviour at least once in themutilating behaviour at least once in the
previous 6-month period (median 13previous 6-month period (median 13
times), against 35% (times), against 35% (nn¼8) of the dialecti-8) of the dialecti-
cal behaviour therapy group (median 1.5cal behaviour therapy group (median 1.5
times); median testtimes); median test ww2211¼4.02;4.02; PP¼0.045.0.045.
In terms of self-damaging impulsiveIn terms of self-damaging impulsive
behaviour, patients assigned to dialecticalbehaviour, patients assigned to dialectical
behaviour therapy showed more improve-behaviour therapy showed more improve-
ment over time than patients in the controlment over time than patients in the control
group: a significant effect was evidentgroup: a significant effect was evident
for the interaction term timefor the interaction term time66treatmenttreatment
condition (condition (tt1,1641,164¼2.60;2.60; PP¼0.010) but not0.010) but not
for treatment condition alone (for treatment condition alone (tt1,1221,122¼1.02;1.02;
PP¼0.315) (Fig. 3).0.315) (Fig. 3).
Confounding by medication useConfounding by medication use
Medication use was monitored by adminis-Medication use was monitored by adminis-
tration of the Treatment History Interviewtration of the Treatment History Interview
(Linehan & Heard, 1987) at weeks 22 and(Linehan & Heard, 1987) at weeks 22 and
52. The greater improvement in the dialecti-52. The greater improvement in the dialecti-
cal behaviour therapy group could not becal behaviour therapy group could not be
explained by greater or other use of psycho-explained by greater or other use of psycho-
tropic medications by these patients. In bothtropic medications by these patients. In both
conditions, three-quarters of the patientsconditions, three-quarters of the patients
reported use of medication from one orreported use of medication from one or
more of the following categories: benzo-more of the following categories: benzo-
diazepines, selective serotonin reuptakediazepines, selective serotonin reuptake
inhibitors (SSRIs), tricyclic antidepressants,inhibitors (SSRIs), tricyclic antidepressants,
mood stabilisers and neuroleptics. Usemood stabilisers and neuroleptics. Use
of SSRIs was reported by 14 (52%) ofof SSRIs was reported by 14 (52%) of
the dialectical behaviour therapy patientsthe dialectical behaviour therapy patients
137137
Fig. 1Fig. 1 Recruitment and attrition of study participants.BPD, borderline personality disorder; DBT, dialecticalRecruitment and attrition of study participants. BPD, borderline personality disorder; DBT, dialectical
behaviour therapy; TAU, treatment as usual.behaviour therapy; TAU, treatment a s usual.
Ta b l e 1Ta b l e 1 Demographic and clinical characteristics of the study par ticipantsDemographic and clinical characteristics of the study participants
CharacteristicCharacteristic Treatment groupTr ea tment gr oup
DBT (DBT (nn¼27)27) TAU (TAU (nn¼31)31) TotalTot al
Dutch nationality,Dutch nationality, nn (%)(%) 26 (96)26 (96) 30 (97)30 (97) 56 (97)56 (97)
Never married,Never married, nn (%)(%) 15 (56)15 (56) 21 (68)21 (68) 36 (62)36 (62)
Living alone,Living alone, nn (%)(%) 9 (33)9(33) 12(39)12 (39) 21 (36)21 (36)
Unemployed,Unemployed, nn (%)(%) 7 (26)7 (26) 5 (16)5(16) 12(21)12 (21)
Disability pension,Disability pension, nn (%)(%) 15 (56)15 (56) 19 (61)19 (61) 34 (59)34 (59)
Age (years), mean (s.d.)Age(years),mean(s.d.) 35.1(8.2)35.1 (8.2) 34.7 (7.4)34.7 ( 7.4) 34.9 (7.7)34.9 (7.7)
Education (years), mean (s.d.)Education (years), mean (s.d.) 12.6 (3.3)12.6 (3.3) 13.6 (3.8)13.6 (3.8) 13.1 (3.6)13.1 (3.6)
Number of BPD criteria, mean (s.d.)Number of BPD criteria, mean (s.d.)11 7.3 ( 1.3 )7.3 (1. 3) 7.3 ( 1.3 )7.3 (1. 3) 7.3 ( 1.3 )7.3 (1. 3)
History of suicide attempts,History of suicide a ttempts, nn (%)(%)22 19 (70)19 (70) 22 (71)22 ( 71) 41 ( 71)41 (71)
History of self-mutilation,History of self-mutilation, nn (%)(%)33 25 (93)25 (93) 29 (94)29 (94) 54 (93)54 (93)
Lifetime self-mutilating acts, medianLifetime self-mutilating acts, median33 13.113.1 14.414.4 14.214.2
Addictive problems,Addictive problems, nn (%)(%)22 16 (59)16 (59) 16 (52)16 (52) 32 (55)32 (55)
BPD, borderline personality disorder; DBT, dialectical behaviour therapy;TAU, treatment as usual.BPD, borderline personalitydisorder; DBT, dialec tical behaviour therapy;TAU, treatment as usual.
1. According to Structured Clinical Interview for DSM^IV personality disorders (SCID^II).1. According to Structured Clinical Interview for DSM^IV personality disorders (SCID^II).
2. According to Europ ean version of Addic tion Severity Index.2. According to Europe an version o f Addiction Severity Index.
3. According to Lifetime Para suicide Count.3. According to Lifetime Parasuicide Count.
Fig. 2Fig. 2 Frequencyof self-mutilating behaviours inFrequency of self-mutilating behaviours in
the previous 3 months at week 22 and week 52 fromthe previous 3 months at week 22 and week 52 from
the star t of treatment with dialec tical behaviourthe start of treatment with dialec tical behaviour
therapy (th erapy (^^)()(nn¼27 ) or treatment as usual (27) or treatment as usual (~~))
((nn¼31).LPC,Lifetime Parasuicide Count.31). LPC, Lifetime Parasuicide Count.
VERHEUL ET ALVERHEUL ET AL
and 19 (61%) of treatment-as-usual pa-and 19 (61%) of treatment-as-usual pa-
tients (tients (ww2211¼0.44;0.44; PP¼0.509). These findings0.509). These findings
eliminate the possibility of confounding byeliminate the possibility of confounding by
medication use.medication use.
Impact of baseline severityImpact of baseline severity
on effectivenesson effectiveness
The sample was divided according to aThe sample was divided according to a
median split on the lifetime number ofmedian split on the lifetime number of
self-mutilating acts. The number in theself-mutilating acts. The number in the
lower-severity group ranged from 0 to 14lower-severity group ranged from 0 to 14
(median 4.0) and in the higher-severity(median 4.0) and in the higher-severity
group from 14 to more than 1000 (mediangroup from 14 to more than 1000 (median
60.5). The two groups did not differ with60.5). The two groups did not differ with
respect to the total score on the BPDSIrespect to the total score on the BPDSI
and the Addiction Severity Index. Forand the Addiction Severity Index. For
suicidal behaviour an almost significantsuicidal behaviour an almost significant
effect was evident for the three-wayeffect was evident for the three-way
interaction term timeinteraction term time66severityseverity66treatmenttreatment
condition (condition (tt1,1701,170¼4.81;4.81; PP¼0.029), indicating0.029), indicating
a trend towards greater effectiveness ofa trend towards greater effectiveness of
dialectical behaviour therapy in severelydialectical behaviour therapy in severely
affected individuals. For self-mutilatingaffected individuals. For self-mutilating
behaviours a significant effect was evidentbehaviours a significant effect was evident
for the three-way interaction term timefor the three-way interaction term time66
severityseverity66treatment condition (treatment condition (tt1,4041,404¼16.82;16.82;
PP¼0.000) and the interaction term severity0.000) and the interaction term severity
66treatment condition (treatment condition (tt1,67.61,67.6¼9.63;9.63;
PP¼0.003), indicating that dialectical behav-0.003), indicating that dialectical behav-
iour therapy was superior to treatment asiour therapy was superior to treatment as
usual for patients in the high-severity groupusual for patients in the high-severity group
but not for their low-severity counterpartsbut not for their low-severity counterparts
(Fig. 4). No differential effectiveness was(Fig. 4). No differential effectiveness was
found for self-damaging impulsivity.found for self-damaging impulsivity.
DISCUSSIONDISCUSSION
Summary of findingsSummary of findings
This randomised controlled trial of dia-This randomised controlled trial of dia-
lectical behaviour therapy yielded threelectical behaviour therapy yielded three
major results. First, dialectical behaviourmajor results. First, dialectical behaviour
therapy had a substantially lower 12-monththerapy had a substantially lower 12-month
attrition rate (37%) compared with treat-attrition rate (37%) compared with treat-
ment as usual (77%). Second, it resultedment as usual (77%). Second, it resulted
in greater reductionsin greater reductions in self-mutilating be-in self-mutilating be-
haviours and self-haviours and self-damaging impulsivedamaging impulsive
acts than treatment as usual. Importantly,acts than treatment as usual. Importantly,
the greater impact of dialectical behaviourthe greater impact of dialectical behaviour
therapy could not be explained by differ-therapy could not be explained by differ-
ences between the treatment groups in theences between the treatment groups in the
use of psychotropic medications. Finally,use of psychotropic medications. Finally,
the beneficial impact on the frequency ofthe beneficial impact on the frequency of
self-mutilating behaviours was far moreself-mutilating behaviours was far more
pronounced in participants who reportedpronounced in participants who reported
higher baseline frequencies than in thosehigher baseline frequencies than in those
reporting lower baseline frequencies.reporting lower baseline frequencies.
Significance of findingsSignificance of findings
The current study results being highlyThe current study results being highly
concordant with previously publishedconcordant with previously published
studies – are significant for several reasons.studies – are significant for several reasons.
First, this is the first clinical trial of dia-First, this is the first clinical trial of dia-
lectical behaviour therapy that was notlectical behaviour therapy that was not
conducted by its developer and that wasconducted by its developer and that was
conducted outside the USA. This studyconducted outside the USA. This study
supports the accumulating evidence thatsupports the accumulating evidence that
mental health professionals outside aca-mental health professionals outside aca-
demic research centres can effectively learndemic research centres can effectively learn
and apply dialectical behaviour therapyand apply dialectical behaviour therapy
(Hawkins & Sinha, 1998), and that the(Hawkins & Sinha, 1998), and that the
therapy can be successfully disseminatedtherapy can be successfully disseminated
in other settings (Barleyin other settings (Barley et alet al, 1993; Spring-, 1993; Spring-
erer et alet al, 1996) and in other countries., 1996) and in other countries.
Second, a relatively large sample sizeSecond, a relatively large sample size
allowed more rigorous statistical testing ofallowed more rigorous statistical testing of
the therapy’s efficacy than former trials,the therapy’s efficacy than former trials,
thereby countering some of the recentlythereby countering some of the recently
expressed concerns about the status ofexpressed concerns about the status of
dialectical behaviour therapy as the treat-dialectical behaviour therapy as the treat-
ment of choice for borderline personalityment of choice for borderline personality
disorder (Scheel, 2000; Tyrer, 2002). Third,disorder (Scheel, 2000; Tyrer, 2002). Third,
our findings indicated that patients receiv-our findings indicated that patients receiv-
ing treatment as usual deteriorated overing treatment as usual deteriorated over
time, suggesting that non-specialised treat-time, suggesting that non-specialised treat-
ment facilities might actually cause harmment facilities might actually cause harm
rather than improvement. Finally, in con-rather than improvement. Finally, in con-
trast to the original trial (Linehantrast to the original trial (Linehan et alet al,,
1991), the sample was drawn from clinical1991), the sample was drawn from clinical
referrals from both addiction treatment andreferrals from both addiction treatment and
psychiatric services, and people with sub-psychiatric services, and people with sub-
stance use disorders were not excluded.stance use disorders were not excluded.
Our study provides evidence that standardOur study provides evidence that standard
dialectical behaviour therapy is suitabledialectical behaviour therapy is suitable
for patients with borderline personalityfor patients with borderline personality
disorder regardless of the presence of sub-disorder regardless of the presence of sub-
stance use disorders (cf. Boschstance use disorders (cf. Bosch et alet al,,
2002). This is consistent with a previous re-2002). This is consistent with a previous re-
port showing that, in borderline personalityport showing that, in borderline personality
disorder, patients with substance use disor-disorder, patients with substance use disor-
ders are largely similar to those withoutders are largely similar to those without
such disorders in terms of type and severitysuch disorders in terms of type and severity
of symptoms, treatment history, family his-of symptoms, treatment history, family his-
tory of substance use disorders and adversetory of substance use disorders and adverse
childhood experiences (Boschchildhood experiences (Bosch et alet al, 2001)., 2001).
Together these findings imply that addictiveTogether these findings imply that addictive
behaviours in patients with borderline per-behaviours in patients with borderline per-
sonality disorder can best be considered assonality disorder can best be considered as
a manifestation of the borderline disordera manifestation of the borderline disorder
rather than as a condition that constitutesrather than as a condition that constitutes
significant clinical heterogeneity and justi-significant clinical heterogeneity and justi-
fies the exclusion of these patients fromfies the exclusion of these patients from
efficacy studies.efficacy studies.
Clinical implicationsClinical implications
Based upon multiple effectiveness studies, itBased upon multiple effectiveness studies, it
is now well established that dialecticalis now well established that dialectical
behaviour therapy is an efficacious treat-behaviour therapy is an efficacious treat-
ment of high-risk behaviours in patientsment of high-risk behaviours in patients
with borderline personality disorder. Thiswith borderline personality disorder. This
is probably due to some of this treatment’sis probably due to some of this treatment’s
distinguishing features:distinguishing features:
(a)(a) routine monitoring of the risk of theseroutine monitoring of the risk of these
behaviours throughout the treatmentbehaviours throughout the treatment
programme;programme;
(b)(b) an explicit focus on the modification ofan explicit focus on the modification of
these behaviours in the first stage ofthese behaviours in the first stage of
treatment;treatment;
(c)(c) encouragement of patients to consultencouragement of patients to consult
therapists by telephone before carryingtherapists by telephone before carrying
out these behaviours;out these behaviours;
(d)(d) prevention of therapist burnoutprevention of therapist burnout
through frequent supervision andthrough frequent supervision and
13 813 8
Fig. 4Fig. 4 Frequency of self-mutilating behaviour inFrequencyof self-mutilating behaviour in
the previous 3 months at week 22 and week 52 fromthe previous 3 months at week 22 and week 52 from
the start of treatment, analysed according to treat-the start of treatment, analysed according to treat-
ment condition and baseline severity. Membershipmentcondition and baseline severity. Membership
of severitygroup is determined by the median splitof severitygroup is determined by the median split
on the lifetime number of self-mu tilating actson the lifetime number of self-mutilating acts
((551414 vv.. 5514 ) . DBT, dia le c t ic al b eh avi o ur t he ra py ;14). DBT, dialecticalbehaviour therapy;
LPC, Lifetime Parasuicide Count;TAU, treatment a sLPC, Lifetime Parasuicide Count;TAU, treatment a s
usual.usual.
Fig. 3Fig. 3 Frequency of self-damaging impulsive actsFrequency of self-damaging impulsive acts
in the previous 3 months at weeks 11, 22, 33, 44 andin the previous 3 months at weeks11, 22, 33, 4 4 and
52 from the start of treatment with dialectical52 from the start of treatment with dialectical
behaviour therapy (behaviour therapy (^^ )()(nn¼2 7) or treatment as usual27) or treatmenta s usual
((~~)()(nn¼31). BPDSI, Borderline Per sonality Disorder31). BPDSI, Bor derline Pers onality Disorder
Severity Index.Severity Index.
DIALECTICAL BEHAVIOUR THERAPY IN BORDERLINE PERSONALITY DISORDERDIALECTICAL BEHAVIOUR THER APY IN BORDERLINE PERSONALITY DISORDER
consultation group meetings (Linehan,consultation group meetings (Linehan,
1993).1993).
Across studies, however, dialecticalAcross studies, however, dialectical
behaviour therapy has not been effectivebehaviour therapy has not been effective
in reducing depression and hopelessness,in reducing depression and hopelessness,
or in improving survival and coping beliefsor in improving survival and coping beliefs
or overall life satisfaction (Scheel, 2000). Inor overall life satisfaction (Scheel, 2000). In
addition, our study showed that, althoughaddition, our study showed that, although
dialectical behaviour therapy was effectivedialectical behaviour therapy was effective
in reducing self-harm in chronically para-in reducing self-harm in chronically para-
suicidal patients, its impact on patients insuicidal patients, its impact on patients in
the low-severity group was similar to thatthe low-severity group was similar to that
of treatment as usual. Together, these find-of treatment as usual. Together, these find-
ings suggest that dialectical behaviourings suggest that dialectical behaviour
therapy should consistent with itstherapy should consistent with its
original aims (Linehan, 1987) – be theoriginal aims (Linehan, 1987) – be the
treatment of choice only for patients withtreatment of choice only for patients with
borderline personality disorder who areborderline personality disorder who are
chronically parasuicidal and should per-chronically parasuicidal and should per-
haps be extended or followed by anotherhaps be extended or followed by another
treatment, focusing on other componentstreatment, focusing on other components
of the borderline personality disorder, asof the borderline personality disorder, as
soon as the level of high-risk behaviour issoon as the level of high-risk behaviour is
sufficiently reduced. Alternatively, it couldsufficiently reduced. Alternatively, it could
be argued that dialectical behaviourbe argued that dialectical behaviour
therapy is the treatment of choice fortherapy is the treatment of choice for
patients with severe, life-threateningpatients with severe, life-threatening
impulse-control disorders rather thanimpulse-control disorders rather than
borderline personality disorderborderline personality disorder per seper se,,
implying that patients with other severeimplying that patients with other severe
impulse-regulation disorders (e.g. substanceimpulse-regulation disorders (e.g. substance
use disorders or eating disorders) mightuse disorders or eating disorders) might
benefit from the therapy. The latterbenefit from the therapy. The latter
interpretation is consistent with the devel-interpretation is consistent with the devel-
opment of modified versions of dialecticalopment of modified versions of dialectical
behaviour therapy for the treatment ofbehaviour therapy for the treatment of
patients with borderline personalitypatients with borderline personality
disorder and a comorbid diagnosis of drugdisorder and a comorbid diagnosis of drug
dependence (Linehandependence (Linehan et alet al, 1999, 1999aa), or), or
patients with a binge eating disorder (Wiserpatients with a binge eating disorder (Wiser
& Telch, 1999).& Telch, 1999).
LimitationsLimitations
One limitation of our study is that dialecti-One limitation of our study is that dialecti-
cal behaviour therapy was compared withcal behaviour therapy was compared with
treatment as usual or unstructured clinicaltreatment as usual or unstructured clinical
management. This has been recommendedmanagement. This has been recommended
as a first step in establishing the efficacyas a first step in establishing the efficacy
of a treatment (Teasdaleof a treatment (Teasdale et alet al, 1984;, 1984;
LinehanLinehan et alet al, 1991), but it allows no, 1991), but it allows no
conclusion about the effect of the experi-conclusion about the effect of the experi-
mental treatment compared with othermental treatment compared with other
manual-based treatment programmes.manual-based treatment programmes.
The observed effect size of dialecticalThe observed effect size of dialectical
behaviour therapy might be different frombehaviour therapy might be different from
the true effect size because of a number ofthe true effect size because of a number of
factors. First, although the research asses-factors. First, although the research asses-
sors were not informed about the treatmentsors were not informed about the treatment
condition of their interviewees, it is unlikelycondition of their interviewees, it is unlikely
that they remained ‘masked’ throughoutthat they remained ‘masked’ throughout
the project. Patients might have given themthe project. Patients might have given them
this information, or it could easily havethis information, or it could easily have
been derived from some of the interviews.been derived from some of the interviews.
This concern is somewhat mitigated byThis concern is somewhat mitigated by
the fact that the research focused on objec-the fact that the research focused on objec-
tive behaviours rather than subjectivetive behaviours rather than subjective
perceptions and experiences. Second, it isperceptions and experiences. Second, it is
important to note that an effect of dialecti-important to note that an effect of dialecti-
cal behaviour therapy was observed in spitecal behaviour therapy was observed in spite
of the potentially equalising impact of theof the potentially equalising impact of the
attention paid to patients by the researchattention paid to patients by the research
assessors during multiple repeated measure-assessors during multiple repeated measure-
ments, including the substantial effortsments, including the substantial efforts
made to contact patients for appointments.made to contact patients for appointments.
Third, because we selected patients inThird, because we selected patients in
ongoing therapy who were willing toongoing therapy who were willing to
terminate the treatment, some of theterminate the treatment, some of the
patients might have perceived assignmentpatients might have perceived assignment
to treatment as usual to be a less desirableto treatment as usual to be a less desirable
randomisation outcome than assignmentrandomisation outcome than assignment
to dialectical behaviour therapy. Finally,to dialectical behaviour therapy. Finally,
the observed effect might be biased by athe observed effect might be biased by a
possible Hawthorne effect in terms ofpossible Hawthorne effect in terms of
greater enthusiasm among the dialecticalgreater enthusiasm among the dialectical
behaviour therapists compared with thosebehaviour therapists compared with those
providing conventional therapy.providing conventional therapy.
Although the latter two factors couldAlthough the latter two factors could
have favoured dialectical behaviour therapyhave favoured dialectical behaviour therapy
in terms of patient satisfaction or thein terms of patient satisfaction or the
139139
CLINICAL IMPLICATIONSCLINICAL IMPLIC AT IONS
&& Dialectic al behaviour therapy (DBT) is an efficacious treatment of high-riskDialec tical behaviour therapy (DBT ) is an efficacious treatment of high-risk
behaviours in patients with borderline personality disorder (BPD).Evidence suggestsbehaviours in patients with borderline personality disorder (BPD ).Evidence suggests
that DBT should be followed by another treatment focusing on other comp onents ofthat DBT should be followed by another treatment focusing on o ther components of
BPD, a s soon as the high-risk behaviours are sufficiently reduced.BPD, a s soon as the high-risk behaviours are sufficiently reduced.
&& Mentalhealthprofessionals outside academic researchcentres can effectively learnMental health professionals outside academic research centres can ef fectively learn
and apply DBT, and it can be successfully disseminated in other settings and otherand apply DBT, and it can be successfully disseminated in other settings and other
countries.countries.
&& Dialectic al behaviour therapy may be a treatment of choice for patients withDialectic al behaviour therapy may be a treatment of choice for patients with
severe, life-threateningimpulse control disorders rather than for BPDsevere, life-threateningimpulse control disorders rather than for BPD per seperse.Thereis.There is
a lack of evidence that DBT is ef ficacious for o ther core features o f BPD, such asa lack of evidence that DBT is ef ficacious for o ther core features of BPD, such as
interpersonal instability, chronic feelings of emp tiness and boredom, and identityinterper sonal instability, chronic feelings of emptiness and boredom, and identity
disturbance.disturbance.
LIMITATIONSLIMITATIONS
&& Although the research assessors were not informed about the treatmentAlthough the research assessors were not informed about the treatment
condition of their interviewees, it is unlikely that they remained ‘masked’ throughoutcondition of their interviewees, it is unlikely that they remained ‘masked’ throughout
the project.the proje ct.
&& Comparing DBTwith treatment as usual allows no conclusion about the efficacy ofComparing DBTwith treatment as usual allows no conclusion about the efficacy of
DBTrelative to other manual-bas ed treatment programmes.DBTrelative to other manual-based treatment programmes.
&& The observed effect might be biased by greater enthusiasm among the dialecticalThe observed effect might be biased by greater enthusiasm among the dialectical
behaviour therapists, although DBT was not superior in terms of patient-reportedbehaviour therapists, although DBT was not superior in terms of patient-reported
working alliance.working alliance.
ROELVERHEUL, Ph D, D eVier sprong Center of Psychoth erapy, University of Amsterdam, Halsteren;ROELVERHEUL, PhD, D eViersprong Center of Psychotherapy, University of Amsterdam, Halsteren;
LOUISE M. C.VAN DEN BOSCH, MA, MA ARTEN W. J. KOETER, Ph D, Amsterdam Institute for AddictionLOUISE M.C.VAN DEN BOSCH, MA,MAARTEN W. J. KOETER, PhD, Amsterdam Institute for Addiction
Rese arch; MARIA A. J. DE RIDDER, PhD, THEO STIJNEN, PhD, Erasmus University Medical Centre, Rotterdam;Research; MARIA A. J.DE RIDDER,PhD,THEO STIJNEN, PhD, Erasmus University Medical Centre, Rotterdam;
WIM VAN DENBRINK, PhD, Amsterdam Institute for Addiction Research, Amsterdam,The NetherlandsWIM VAN DEN BRINK, PhD, Amsterdam Institute for Addiction Research, Amsterdam,The Netherlands
Correspondence:Dr Roel Verheul, Psychotherapeutisch Centrum De Viersprong,Post B ox 7, 466 0 A ACorrespondence:Dr Roel Verheul, Psychotherapeutisch Centrum De Viersprong, Post B ox 7, 466 0 A A
Halsteren,T he Netherlands. Tel: +31 0 164 632 20 0; f ax: + 31 0 164 632 22 0; e -mail:Halsteren, The Netherla nds.Tel: +31 0 164 632 20 0; fa x: + 31 0 16 4 6 3222 0; e -mail:
roel.verheulroel.verheul@@deviersprong.netdeviersprong.net
(First received 28 March 2002, final revision 5 August 2002, accepted15 October 2002)(First received 28 March 2002, f inal revision 5 August 2002, accepted15 October 2002)
VERHEUL ET ALVERHEUL ET AL
quality of the working alliance, additionalquality of the working alliance, additional
analyses revealed that the two patientanalyses revealed that the two patient
groups were highly similar in terms ofgroups were highly similar in terms of
scores on the three sub-scales of the Work-scores on the three sub-scales of the Work-
ing Alliance Inventory (Horvath & Green-ing Alliance Inventory (Horvath & Green-
berg, 1989): development of bond,berg, 1989): development of bond,
agreement on goals and agreement onagreement on goals and agreement on
tasks. This observed similarity is strikingtasks. This observed similarity is striking
since the quality of the working alliance issince the quality of the working alliance is
often considered to be a prerequisite ofoften considered to be a prerequisite of
efficacy in psychotherapy (e.g. Lambert &efficacy in psychotherapy (e.g. Lambert &
Bergin, 1994) and because a substantial fea-Bergin, 1994) and because a substantial fea-
ture of dialectical behaviour therapy is theture of dialectical behaviour therapy is the
establishment of a working alliance (Line-establishment of a working alliance (Line-
han, 1993). Perhaps the efficacy of dialecti-han, 1993). Perhaps the efficacy of dialecti-
cal behaviour therapy results from thecal behaviour therapy results from the
persistent and enduring focus on certainpersistent and enduring focus on certain
target behaviours rather than an ‘optimal’target behaviours rather than an ‘optimal’
working alliance.working alliance.
Further directionsFurther directions
The participants in this study were followedThe participants in this study were followed
up after 18 months to examine whether theup after 18 months to examine whether the
treatment results were maintained after dis-treatment results were maintained after dis-
charge. The results will be publishedcharge. The results will be published
elsewhere. Future research should focus onelsewhere. Future research should focus on
comparison with concurrent therapies suchcomparison with concurrent therapies such
as schema-focused cognitive therapyas schema-focused cognitive therapy
(Young, 1990) and psychoanalytically(Young, 1990) and psychoanalytically
oriented partial hospitalisation (Batemanoriented partial hospitalisation (Bateman
& Fonagy, 2001), as well as on the effective& Fonagy, 2001), as well as on the effective
mechanisms at work. Potential mediators ofmechanisms at work. Potential mediators of
favourable outcomes are, for example,favourable outcomes are, for example,
reduced catastrophising, enhanced skillsreduced catastrophising, enhanced skills
for regulating affect and coping with lifefor regulating affect and coping with life
events, or an increase in reasons for livingevents, or an increase in reasons for living
(Rietdijk(Rietdijk et alet al, 2001). Knowledge about, 2001). Knowledge about
the specific mechanisms that make dialec-the specific mechanisms that make dialec-
tical behavior therapy work might enabletical behavior therapy work might enable
therapists to better direct the focus in treat-therapists to better direct the focus in treat-
ment, and possibly stimulate dismantlingment, and possibly stimulate dismantling
studies to investigate the efficacy of thestudies to investigate the efficacy of the
individual components of the therapy.individual components of the therapy.
ACKNOWLED GE MENTSACKNOWLED GEMENTS
We gratefully acknowledge the a ssistance of EvelineWe gratefully acknowledge the assistance of Eveline
Rietdijk and Wijnand van der Vlist in collecting theRietdijk and Wijnand van der Vlist in collecting the
data.data.
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... Few studies have reported research recruitment rates in BPD population in the past. A RCT of dialectical behavioral therapy in women with BPD in Netherlands reported a recruitment rate of 70% [16]. Our retention rate was consistent with a meta-analysis of psychotherapy trials for BPD, which reported an overall retention rate of 71-75% [13]. ...
... There are several potential reasons behind the differences in recruitment rates between our study (45%) and the past RCT in BPD (70%) [16]. One potential reason is that our sample consisted of general psychiatric inpatients, whereas the aforementioned studies examined individuals with BPD. ...
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Background Previous studies have shown that stigma is a major barrier to participation in psychiatric research and that individuals who participate in psychiatric research may differ clinically and demographically from non-participants. However, few studies have explored research recruitment and retention challenges in the context of personality disorders. Aim To provide an analysis of the factors affecting participant recruitment and retention in a study of borderline personality disorder among general psychiatric inpatients. Methods Adult inpatients in a tertiary psychiatric hospital were approached about participating in a cross-sectional study of borderline personality disorder. Recruitment rates, retention rates, and reasons for declining participation or withdrawing from the study were collected. Demographic characteristics were compared between participants and non-participants and between patients who remained in the study and those who withdrew. Results A total of 71 participants were recruited into the study between January 2018 and March 2020. Recruitment and retention rates were 45% and 70%, respectively. Lack of interest was the most commonly cited reason for non-participation, followed by scheduling conflicts and concerns regarding mental/physical well-being. Age and sex were not predictors of study participation or retention. Conclusions More research is needed to explore patients’ perspectives and attitudes towards borderline personality disorder diagnosis and research, determine effects of different recruitment strategies, and identify clinical predictors of recruitment and retention in personality disorder research.
... Over the past three decades, there have been a number of randomised controlled trials across different sites which have demonstrated the efficacy of DBT in treating individuals with this diagnosis (e.g. [1][2][3]). Results have demonstrated reductions in a number of outcomes associated with BPD including self-harm, suicidal behaviours, and hospital admissions. ...
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Background Qualitative research in the area of DBT is limited, particularly at follow-up. The current study explored the follow-up experiences of individuals who previously received a diagnosis of borderline personality disorder and self-report having benefitted from DBT at the time of treatment. Methods Individuals who completed 12 months of standard DBT and were a minimum of two years post-completion were recruited. Individual semi-structured interviews were completed with a total of twelve participants. Results A thematic analysis generated three main themes which indicated that participants found DBT had a positive impact on their lives in the years after the programme and enabled further development; gave them control over their lives and the ability to manage setbacks and difficult situations; and contributed to healthier and more meaningful relationships with others. Conclusions The findings of this study indicated that DBT contributed positively to the participants’ lives and helped advance their recovery in the years after the programme. Despite the positive impact of DBT, participants required further support in the years following the intervention. Clinical and research implications of these findings are discussed.
... The authors failed to find prescriptive factors, but it should be noted that the sample size was inadequate to detect subtle differences between treatments. In addition, Verheul et al. [40] found that patients with a high frequency of selfmutilating behavior before treatment were more likely to benefit from DBT compared to treatment as usual, whereas for patients with a low frequency of self-mutilating behavior effectiveness did not differ. ...
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Background Specialized evidence-based treatments have been developed and evaluated for borderline personality disorder (BPD), including Dialectical Behavior Therapy (DBT) and Schema Therapy (ST). Individual differences in treatment response to both ST and DBT have been observed across studies, but the factors driving these differences are largely unknown. Understanding which treatment works best for whom and why remain central issues in psychotherapy research. The aim of the present study is to improve treatment response of DBT and ST for BPD patients by a) identifying patient characteristics that predict (differential) treatment response (i.e., treatment selection) and b) understanding how both treatments lead to change (i.e., mechanisms of change). Moreover, the clinical effectiveness and cost-effectiveness of DBT and ST will be evaluated. Methods The BOOTS trial is a multicenter randomized clinical trial conducted in a routine clinical setting in several outpatient clinics in the Netherlands. We aim to recruit 200 participants, to be randomized to DBT or ST. Patients receive a combined program of individual and group sessions for a maximum duration of 25 months. Data are collected at baseline until three-year follow-up. Candidate predictors of (differential) treatment response have been selected based on the literature, a patient representative of the Borderline Foundation of the Netherlands, and semi-structured interviews among 18 expert clinicians. In addition, BPD-treatment-specific (ST: beliefs and schema modes; DBT: emotion regulation and skills use), BPD-treatment-generic (therapeutic environment characterized by genuineness, safety, and equality), and non-specific (attachment and therapeutic alliance) mechanisms of change are assessed. The primary outcome measure is change in BPD manifestations. Secondary outcome measures include functioning, additional self-reported symptoms, and well-being. Discussion The current study contributes to the optimization of treatments for BPD patients by extending our knowledge on “Which treatment – DBT or ST – works the best for which BPD patient, and why?”, which is likely to yield important benefits for both BPD patients (e.g., prevention of overtreatment and potential harm of treatments) and society (e.g., increased economic productivity of patients and efficient use of treatments). Trial registration Netherlands Trial Register, NL7699 , registered 25/04/2019 - retrospectively registered.
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Introduction: Evidence-based psychotherapies for borderline personality disorder (BPD) are lengthy, posing a barrier to their access. Brief psychotherapy may achieve comparable outcomes to long-term psychotherapy for BPD. Evidence is needed regarding the comparative effectiveness of short- versus long-term psychotherapy for BPD. Objective: The aim was to determine if 6 months of Dialectical Behavior Therapy (DBT) is noninferior to 12 months of DBT in terms of clinical effectiveness. Methods: This two-arm, single-blinded, randomized controlled noninferiority trial with suicidal or self-harming patients with BPD was conducted at two sites in Canada. Participants (N = 240, M (SD)age = 28.27 (8.62), 79% females) were randomized to receive either 6 (DBT-6) or 12 months (DBT-12) of comprehensive DBT. Masked assessors obtained measures of clinical effectiveness at baseline and every 3 months, ending at month 24. DBT-6 and DBT-12 were outpatient treatments consisting of weekly individual therapy sessions, weekly DBT skills training group sessions, telephone consultation as needed, and weekly therapist consultation team meetings. Results: The noninferiority hypothesis was supported for the primary outcome, total self-harm (6 months: margin = -1.94, Mdiff [95% CI] = 0.16 [-0.14, 0.46]; 12 months: margin = -1.47, Mdiff [95% CI] = 0.04 [-0.17, 0.23]; 24 months: margin = -1.25, Mdiff [95% CI] = 0.12 [-0.02, 0.36]). Results also supported noninferiority of DBT-6 for general psychopathology and coping skills at 24 months. Furthermore, DBT-6 participants showed more rapid reductions in BPD symptoms and general psychopathology. There were no between-group differences in dropout rates. Conclusions: The noninferiority of a briefer yet comprehensive treatment for BPD has potential to reduce barriers to treatment access.
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Background The cost-effectiveness of using a mobile diary app as an adjunct in dialectical behavior therapy (DBT) in patients with borderline personality disorder is unknown. Objective This study aims to perform an economic evaluation of a mobile diary app compared with paper-based diary cards in DBT treatment for patients with borderline personality disorder in a psychiatric outpatient facility. Methods This study was conducted alongside a pragmatic, multicenter, randomized controlled trial. The participants were recruited at 5 Danish psychiatric outpatient facilities and were randomized to register the emotions, urges, and skills used in a mobile diary app or on paper-based diary cards. The participants in both groups received DBT delivered by the therapists. A cost-consequence analysis with a time horizon of 12 months was performed. Consequences included quality-adjusted life years (QALYs), depression severity, borderline severity, suicidal behavior, health care use, treatment compliance, and system usability. All relevant costs were included. Focus group interviews were conducted with patients, therapists, researchers, and industry representatives to discuss the potential advantages and disadvantages of using a mobile diary app. Results A total of 78 participants were included in the analysis. An insignificantly higher number of participants in the paper group dropped out before the start of treatment (P=.07). Of those starting treatment, participants in the app group had an average of 37.1 (SE 27.55) more days of treatment and recorded an average of 3.16 (SE 5.10) more skills per week than participants in the paper group. Participants in both groups had a QALY gain and a decrease in depression severity, borderline severity, and suicidal behavior. Significant differences were found in favor of the paper group for both QALY gain (adjusted difference −0.054; SE 0.03) and reduction in depression severity (adjusted difference −1.11; SE 1.57). The between-group difference in total costs ranged from US $107.37 to US $322.10 per participant during the 12 months. The use of services in the health care sector was similar across both time points and groups (difference: psychiatric hospitalization <5 and <5; general practice −1.32; SE 3.68 and 2.02; SE 3.19). Overall, the patients showed high acceptability and considered the app as being easy to use. Therapists worried about potential negative influences on the therapist-patient interaction from new work tasks accompanying the introduction of the new technology but pointed at innovation potential from digital database registrations. Conclusions This study suggests both positive and negative consequences of mobile diary apps as adjuncts to DBT compared with paper diary cards. More research is needed to draw conclusions regarding its cost-effectiveness. Trial Registration ClinicalTrials.gov NCT03191565; http://clinicaltrials.gov/ct2/show/NCT03191565 International Registered Report Identifier (IRRID) RR2-10.2196/17737
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A randomized, controlled study evaluated the effectiveness of a cognitive-behavioral therapy group, based on Linehan's dialectical behavior therapy, for inpatients with personality disorders. The treatment, a problem-solving skills group focused on parasuicidality, was compared with a discussion control group. Change was assessed by self-report measures and behavioral observations on the unit. Subjects in both groups improved significantly on most change measures, although no significant between-group differences were found. However, the treatment group patients viewed the intervention as more beneficial to them in their lives outside the hospital. The usefulness of this type of group on a short-term unit is discussed.
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The empirical literature offered in support and validation of Linehan's dialectical behavior therapy (DBT) is critically examined in this article. Although results to date are promising, there remain methodological difficulties in the limited research base that supports this eagerly received clinical approach to borderline personality disorder. Implications for clinical decision making are discussed and suggestions offered as to how future investigations can begin to better substantiate DBT as a thoroughly established clinical approach to treating this challenging disorder.
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Parasuicide, is particularly prevalent among individuals meeting criteria for borderline personality disorder (Clarkin, Widiger, Frances. Hurt, & Gil-more, 1983). To date almost all published treatments for these individuals have been psychoanalytic (Adler, 1985; Kernberg, 1984; Masterson, 1976). Behavior therapy methods are also useful. Over the past several years, we have developed and evaluated a comprehensive, behavioral treatment Dialectical Behavior Therapy (DBT) for chronically parasuicidal individuals. DBT is based on a biosocial theory that views parasuicide as problem-solving behavior emitted to cope with or ameliorate psychic distress brought on by negative environmental events, self-generated dysfunctional behaviors, and individual temperamental characteristics. Three factors keep parasuicide high in the individual's hierarchy of problem-solving responses: (1) low distress tolerance, (2) inadequate functional coping resources, and (3) parasuicidogenic expectancies. Low distress tolerance provi...
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This article describes an inpatient treatment program for borderline personality disorder. The program has evolved from a purely psychodynamic to a more cognitive-behavioral treatment approach. It emphasizes dialectical behavior therapy, which we believe more effectively operationalizes treatment interventions. DBT is the only treatment approach shown in a randomized clinical trial to decrease parasuicidal behavior in patients with borderline personality disorder, and the use of DBT in an inpatient setting has not been previously described. Inpatient DBT immerses borderline patients in a culture of support for their attempts to skillfully solve problems with emotion regulation and related dysfunctions. Data are presented that suggest that this approach is associated with decreased rates of parasuicide on the inpatient unit.
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Present stages of development and preliminary validation of a self-report instrument for measuring the quality of alliance, the Working Alliance Inventory (WAI). The measure is based on Bordin's (1980) pantheoretical, tripartite (bonds, goals, and tasks) conceptualizaton of the alliance. Results from 3 studies were used to investigate the instrument's reliability and validity and the relations among the WAI scales. Data suggest that the WAI has adequate reliability. The instrument is reliably correlated with a variety of counselor and client self-reported outcome measures. Nontrivial relations were also observed between the WAI and other relationship indicators. Results are interpreted as preliminary support for the validity of the instrument. Although the results obtained in the reviewed studies are encouraging, the high correlations between the 3 subscales of the inventory bring into question the distinctness of the alliance components. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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A randomized clinical trial was conducted to evaluate whether Dialectical Behavior Therapy (DBT), an effective cognitive-behavioral treatment for suicidal individuals with borderline personality disorder (BPD), would also be effective for drug-dependent women with BPD when compared with treatment-as-usual (TAU) in the community. Subjects were randomly assigned to either DBT or TAU for a year of treatment. Subjects were assessed at 4, 8, and 12 months, and at a 16-month follow-up. Subjects assigned to DBT had significantly greater reductions in drug abuse measured both by structured interviews and urinalyses throughout the treatment year and at follow-up than did subjects assigned to TAU. DBT also maintained subjects in treatment better than did TAU, and subjects assigned to DBT had significantly greater gains in global and social adjustment at follow-up than did those assigned to TAU. DBT has been shown to be more effective than treatment-as-usual in treating drug abuse in this study, providing more support for DBT as an effective treatment for severely dysfunctional BPD patients across a range of presenting problems.