A pilot study of Manual-Assisted Cognitive Therapy with a Therapeutic Assessment augmentation for Borderline Personality Disorder

Psychiatry Research 178 (2010) 531–535

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Psychiatry Research j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / p s yc h r e s

A pilot study of Manual-Assisted Cognitive Therapy with a Therapeutic Assessment augmentation for Borderline Personality Disorder Leslie C. Morey a,⁎, Sara E. Lowmaster a, Christopher J. Hopwood b a b

Department of Psychology, Texas A&M University, College Station, Texas, USA Department of Psychology, Michigan State University, East Lansing, Michigan, USA

a r t i c l e

i n f o

Article history: Received 24 June 2009 Received in revised form 20 April 2010 Accepted 29 April 2010 Keywords: Borderline Personality Disorder Suicide Manual-Assisted Cognitive Therapy Therapeutic Assessment

a b s t r a c t This study examined the efficacy of Manual Assisted Cognitive Therapy (MACT) as a stand-alone treatment for Borderline Personality Disorder (BPD) with suicidal ideation, and piloted a Therapeutic Assessment (TA) intervention among 16 patients randomly assigned to MACT or MACT + TA. Although MACT was associated with significant reductions in BPD features and suicidal ideation, less than half of the sample completed the treatment. The TA augmentation did not improve treatment retention but it was associated with somewhat greater clinical improvement. Although findings associate MACT with symptom reduction among persisting patients, attrition rate was problematically high in the overall sample. © 2010 Elsevier Ireland Ltd. All rights reserved.

1. Introduction Although much has been learned in recent years about treatment of Borderline Personality Disorder (BPD; de Groot et al., 2008), there are still few well-validated treatments for the disorder. Developing effective interventions is particularly salient because of the relative prevalence of BPD–estimated at 19% of psychiatric inpatients and 11% of outpatients by Widiger and Frances (1989)–and the severity of the consequences of this disorder, including markedly elevated risks for suicide (Martin et al., 1985), increased mortality (Paris, 2002), and treatment utilization (Bender et al., 2001; Frankenburg and Zanarini, 2004). Particularly problematic is the consistently high rate of treatment dropout among BPD patients (e.g., N50%; Skodol et al., 1983; Gunderson et al., 1989). The difficulty retaining patients in treatment is pervasive and evident even in those treatments that have demonstrated clinical efficacy (Koons et al., 2001; Verheul et al., 2003; Gregory et al., 2008). Specific treatments developed as treatment augmentations report similar problems with treatment retention (Davidson et al., 2006a, 2006b; Blum et al., 2008). High rates of premature discontinuation in combination with the generally modest yield of longer term treatments raise the possibility that briefer treatments may represent a cost-efficient method for treating BPD. However, the empirical support for brief treatments for BPD is limited (Hopwood, 2006). One brief treatment that has received empirical scrutiny is Manual-Assisted Cognitive behavior Therapy (MACT; Tyrer et al., 2004). MACT is a 6-session, manualized ⁎ Corresponding author. Department of Psychology, Texas A&M University, College Station, TX 77843-4235, USA. E-mail address: [email protected] (L.C. Morey). 0165-1781/$ – see front matter © 2010 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.psychres.2010.04.055

therapy that targets deliberate self-harm, incorporating elements of other cognitive-based interventions for BPD (e.g., Linehan, 1993; Beck et al., 2004). The MACT treatment centers on a treatment manual and accompanying patient workbook, with six chapters serving as a focus for each session. Evans et al. (1999) reported the results of a randomized controlled trial comparing MACT (n = 18) and treatment as usual (TAU; n = 16) in the reduction of parasuicidal acts (e.g., suicide attempts and non-suicidal acts of self-harm) in a group of psychiatric patients, all of whom were diagnosed with Cluster B personality disorders and many of whom met diagnostic criteria for BPD. Patients in the TAU group received standard psychiatric care, but it was unclear whether the MACT group received additional psychiatric treatment. Effect size estimates of change between pre- and posttherapy assessments of other variables indicated that MACT is a promising brief treatment for this relatively severe clinical population (anxiety: d = 0.65; depression: d = 0.90; social functioning: d = 0.73), and MACT patients had a significant decrease in their depression, time in the hospital, and future oriented thinking at six month follow-up (MacLeod et al., 1998). Impressively, these results were obtained even though participants in MACT only attended an average of 2.7 of the prescribed 6 sessions. In a follow-up study (Tyrer et al., 2003), 38% of patients randomly assigned to MACT did not attend treatment sessions, so their treatment constituted the manual alone. Overall, the treatment groups did not significantly differ on primary outcome variables in this study. However, BPD diagnosis was not required for study inclusion, limiting the generalizability to this disorder. In particular, the strategy of targeting DSH may have selected a sample composed of individuals representing a particularly severe (i.e., recently self-harming) subgroup of the borderline population as well as non-BPD individuals.

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A more recent study by Weinberg et al. (2006) extended these previous studies by investigating interview-diagnosed BPD participants. In their study, thirty subjects meeting DSM-IV criteria for BPD were randomized to either MACT plus TAU (N = 15) or TAU (N = 15). Atypically, all MACT participants completed 6 sessions of MACT and only 2 TAU participants were not available for post-treatment and 6-month follow-up assessments. Overall, the addition of MACT to TAU was associated with a significant decrease in the frequency and severity of deliberate self-harm (DSH), although there were no significant between group differences for suicidal ideation. In summary, some evidence suggests that MACT may be a viable brief treatment alternative for DSH among individuals with BPD, although no studies have examined MACT as a stand-alone treatment, some studies have comprised individuals with mixed diagnoses, and most studies have shown that treatment retention is problematic. The current research sought to extend previous evidence regarding MACT in a number of ways. First, the study sought to explore the utility of MACT as a stand-alone outpatient treatment for BPD and BPD-related suicidality, in contrast to previous studies where MACT was often part of an inpatient treatment or a more extensive outpatient treatment regimen (e.g., Weinberg et al., 2006), or in which multiple diagnoses were sampled (e.g., Tyrer et al., 2003). Although this is not a controlled clinical trial in that we do not compare MACT to a control condition here, we are able to compare the effects of MACT without concurrent treatments in this study to the effects of MACT with concurrent treatments from previous research. Second, given limited retention/compliance rates in previous studies of BPD treatment in general and MACT in particular, we sought to test the possible utility of a Therapeutic Assessment (TA; Fischer, 1994; Finn and Tonsager, 1997; Finn, 2007) augmentation of MACT treatment that was hypothesized to facilitate more rapid engagement in treatment and hence enhance treatment participation and retention (e.g., Hilsenroth and Cromer, 2007). We thus randomized BPD patients to either a stand-alone MACT condition or a condition in which MACT was augmented with TA. 2. Methods 2.1. Participants Participants were 16 individuals (13 of whom were women) between the ages of 20 and 53 years (M = 31.1; S.D.= 8.9) pursuing services at the Texas A&M University Psychology Clinic. Demographic variables were similar across study conditions (Table 1).

2.2. Assessments 2.2.1. Borderline Personality Disorder The Diagnostic Interview for DSM-IV Personality Disorders DIPD-IV (Zanarini et al., 1996) is a semi-structured interview that assesses PD criteria, which must be present over at least the previous two years to count toward the diagnosis. In this study, only the module addressing the nine DSM-IV criteria for BPD was used. The kappa interrater reliability for the BPD diagnosis in another, larger sample was 0.68 (Zanarini et al., 2000). The Personality Assessment Inventory (PAI) Borderline Features scale (BOR; Morey, 1991) was constructed to target the core elements of BPD as identified in previous research, with four subscales (Affective Instability, Identity Disturbance, Negative Relationships, and Self-Harm) targeting different theoretical/factorial elements. The BOR scale in isolation has been found to distinguish borderline patients from unscreened controls with an 80% hit rate, and successfully identified 91% of these subjects as part of a discriminant function (Bell-Pringle et al., 1997). The Personality Diagnostic Questionnaire (PDQ-4) — Borderline scale (Hyler, 1994) is a widely used self-administered, true/false questionnaire on which each item corresponds to a DSM-IV criterion. Although specificity has typically been lower than optimal when structured interviews are used as a criterion (Davison et al., 2001), the PDQ-4 Borderline scale demonstrates similar external validity relative to a structured interview for BPD (Hopwood et al., 2008b). 2.2.2. Suicidal ideation The Personality Assessment Inventory Suicidal Ideation (SUI; Morey, 1991) scale captures elements of suicide and parasuicide that are common among BPD patients. SUI has been found to be significantly predictive of suicidal behavior (Hopwood et al., 2008a). The Suicide Probability Scale (SPS; Cull and Gill, 1988) is a 36 item self-report measure of current suicide ideation and related risk variables. It uses almost all nonsuicidal content items and produces a summary score and four subscale scores: Hopelessness, Suicidal Ideation, Negative Self-Evaluation, and Hostility. All scores on the SPS and PAI are standardized using T-scores, such that the mean of the community normative sample is 50 T with a standard deviation of 10 T in that sample. 2.3. Procedure The study targeted individuals with BPD and suicidal ideation. Participants were referred from local mental health agencies and were informed of the opportunity to participate in a psychotherapy research project. This method generated 50 referrals. A researcher then contacted interested individuals for an initial telephone screening composed of questions from the PAI BOR and SUI scales. Twenty individuals that met study criteria were invited to the clinic for an intake assessment, underwent a consent process, and were evaluated for study inclusion. Inclusion criteria were scores a) N 70 on PAI BOR and SUI, b) z 5 on the PDQ-4 BPD, c) N70 on the SPS total and d) N 5 BPD symptoms on the DIPD-IV. Participants were excluded if they exhibited an active psychosis, a history of schizophrenia, or substance intoxication or withdrawal. This resulted in a final sample of 16 who were randomly assigned to one of two intervention groups. Fifty-six percent of these individuals were currently taking psychotropic medication but no individuals were receiving other psychosocial interventions. Consenting clients in both conditions were assigned to a project therapist, who worked under the supervision of the primary investigator. The MACT manual from

Table 1 Demographic and treatment process characteristics of treatment groups. Variable Demographics Age Gender Marital status

Education

Race Occupation

Treatment process Treatment retention

Male Female Single Married Separated/divorced High school diploma or equiv. Some college College degree White Non-White Unemployed Student Employed

Completed treatment Did not complete treatment

# of sessions attended Note. None of the comparisons were found to be statistically significant.

MACT

TA + MACT

Significance

29.63 ± 8.72 2 6 5 1 2 2 5 1 7 1 2 4 2

32.5 ± 9.41 1 7 5 1 2 3 5 0 4 4 4 2 2

t(14) = − 0.63 2 χ(1) = 0.41

4 4 3.88 ± 2.36

3 5 3.5 ± 2.27

2 = 0.25 χ(1)

2 = 0.00 χ(2)

2 = 1.20 χ(2)

2 = 2.62 χ(1) 2 = 1.33 χ(2)

t(14) = 0.324

L.C. Morey et al. / Psychiatry Research 178 (2010) 531–535 Tyrer et al. (2004) was utilized in the current study, with slight wording modifications to ensure applicability to an outpatient population from the south-central United States. In addition, the original manual exclusively focused on a recent self-harm episode, while the current manual broadened the definition to make it more applicable to an outpatient sample, extending focus beyond parasuicidal behavior to include prominent historical or current suicidal ideations and self-damaging behaviors (e.g., impulsive sexual behavior or substance use). Clients in both conditions completed the SPS, PDQ-4 BPD scale, DIPD-IV BPD scale, and PAI BOR and SUI scales at study enrollment, and the complete PAI after session 1. Further assessments were administered by the independent evaluator following sessions 3 and 6 including the SPS, the PAI BOR and SUI scales, and a critical incidents interview. Administration of assessments was parallel for the experimental and control conditions. Baseline and follow-up assessments after sessions three and six were conducted by an independent evaluator, while the administration of the MACT treatment was performed by masters level therapists masked to study hypotheses. The evaluator and all therapists had obtained a master's degree and had at least two years of clinical experience in an APA-accredited clinical psychology program at the time of the study. Clients were randomly assigned to study condition. Because treatment retention was a critical outcome variable in the current study, procedures regarding missed appointments were standardized in a manner designed to mirror those typically implemented in an outpatient practice. Specifically, if a client missed an appointment without notification, efforts were made to contact and reschedule with the client. These efforts were made over a continuous three-week period. If the client did not respond to these attempts, a letter was then sent notifying the client that they had one week to contact the clinic or their services would be terminated. 2.3.1. MACT condition Immediately following the first session of the MACT treatment, clients met with a research assistant to complete a standard administration of the full PAI. Therapists received the PAI test results and were free to use them in the manner which they typically used test data during the early sessions of psychotherapy; however, they were not given any special supervision in the use of the results. The initial session and PAI administration was followed by 5 additional sessions of Manual-Assisted Cognitive behavior Therapy (MACT; Tyrer et al., 2004), supervised by the primary investigator. 2.3.2. Therapeutic Assessment + MACT condition (TA + MACT) Adaptations were made to the first two-sessions of the TA + MACT condition manual to incorporate the intervention according to Finn's (2007) Therapeutic Assessment model. More specifically, in addition to the standard MACT orientation material, the first session also included an individualized collaborative assessment. This procedure included developing questions that the client would like to “ask the test data” about themselves and the articulation of specific, individualized treatment goals. Between the first and second sessions, therapists met with the primary investigator for one supervision session to discuss the case and strategies for addressing the assessment questions and enhancing client motivation. During the second session, the therapist and client discussed the assessment results and motivational feedback was provided, in addition to implementing the second MACT session. Aside from these augmentations to the first two sessions, the manual for the remainder of the treatment was identical for both conditions. 2.4. Analyses Changes in borderline features and suicidal ideation were analyzed using repeated measures ANOVA at baseline and post-treatment. This method of analysis controlled for baseline levels of the outcome variables and allowed for between group comparisons. In addition, these analyses examined a group-by-time interaction for the outcome variables at post-treatment. These analyses were conducted using two different but commonly used strategies for considering missing data due to treatment attrition (Hollis and Campbell, 1999), the first using complete case analysis (focusing solely on those completing treatment) and the second using a more conservative approach of missing value imputation by carrying forward the last observed score for attriting clients.

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3. Results 3.1. Clinical characteristics and treatment completion Clients in the two study conditions were similar in terms of pretreatment scores on indicators of BPD symptoms and suicidal ideation (Table 2). Only 7 of 16 clients (44%) completed all six sessions of treatment across the two conditions. Contrary to hypotheses, no significant retention rate differences between conditions were observed, with four MACT condition (50%) and five TA + MACT condition (63%) participants failing to complete all six sessions of treatment. There were also no significant differences between study conditions in terms of number of sessions attended (d = − 0.16, Table 1). However, 6 of 7 completers were concurrently being treated with medications whereas only 3 of 9 non-completers were being treated with medications (χ 2(1) = 4.39, P b 0.05), suggesting that concurrent psychiatric care may promote retention in MACT. 3.2. Treatment effects for those completing treatment Among those who did complete treatment, significant improvements were observed in both conditions with respect to reducing both borderline symptomatology and suicidal ideation. Repeated measures ANOVA investigating changes in borderline features from baseline to posttreatment for those who completed treatment indicated a substantial and significant main effect for change in PAI-BOR from baseline to posttreatment (F(1, 5) =13.33, Pb 0.05), representing an effect size of d=1.07. Analyses of BOR subscales suggest a significant change in affective instability (BOR-A; F(1, 5) =16.84, Pb 0.01, d=1.78) and a moderately significant change in self-harm (BOR-S; F(1, 5) =5.71, Pb 0.07, d=0.48). No significant differences in treatment response across study groups were found for borderline features, although large differential changes in BOR-A were observed that approached significance (F(1, 5) =5.67, P b 0.07, d=4.35), suggesting superior treatment response in the TA+MACT group. With regard to suicidal ideation, participants reported substantial and significant decreases on both the PAI-SUI (F(1, 5) =16.59, Pb 0.01, d=2.01) and SPS-SI (F(1, 5) =23.44, Pb 0.01, d=1.07) scales. Again, a trend for a group-by-time interaction was found for SPS-SI (F(1, 5) = 4.84, P b 0.08, d = 1.75), also suggesting a larger improvement over time in the TA+ MACT group. 3.2.1. Reliable change To examine client improvement at the individual level, reliable change indices (RC; Jacobson and Truax, 1991) were computed to determine whether the MACT treatment significantly improved borderline symptomatology and suicidal ideation. Of the 7 participants who completed treatment, 5 (71%) showed significant reductions on PAI-BOR. With regard to suicidal symptoms, 3 of the 7 participants (43%) demonstrated significant improvement on the SPS and 6 out of 7 (86%) had significant decrement in suicidal ideation as measured by the PAI-SUI.

Table 2 Borderline features and suicidal ideation at baseline, post-treatment for completers only. Pre

Post

MACT PAI-BOR BOR-A BOR-I BOR-N BOR-S PAI-SUI SPS SPS-SI

86.50 81.50 76.25 77.25 83.75 96.00 77.75 73.75

(4.36) (6.03) (1.50) (5.12) (11.44) (12.25) (4.99) (5.06)

TA + MACT

Total

83.33 88.00 76.00 81.33 67.00 88.67 91.33 70.67

85.14 84.29 76.14 79.00 76.57 92.86 83.57 72.43

Note. †P b 0.08, *P b 0.05, **P b 0.01.

(5.13) (0.00) (12.12) (9.50) (9.54) (20.82) (21.82) (5.03)

Effect size (d)

MACT (4.60) (5.50) (7.08) (6.93) (13.26) (15.32) (14.97) (4.89)

79.50 77.25 71.75 74.50 75.75 72.25 74.00 69.75

(6.81) (3.77) (6.65) (11.24) (16.50) (8.26) (7.96) (5.38)

TA + MACT

Total

73.67 72.00 68.00 71.67 61.67 62.67 67.67 60.00

77.00 75.00 70.14 73.29 69.71 68.14 71.29 65.57

(13.50) (5.20) (15.87) (13.65) (10.97) (5.03) (10.97) (7.00)

(9.68) (4.90) (10.49) (11.29) (15.26) (8.30) (9.12) (7.61)

MACT

TA + MACT

Total

1.22 0.85 0.93 0.31 0.56 2.27 0.56 0.77

0.95 4.35 0.57 0.82 0.52 1.72 1.37 1.75

1.07 1.78 0.67 0.61 0.48 2.01 0.99 1.07

Time

Group × Time

13.33* 16.84** 4.17 3.94 5.71† 16.59** 6.00† 23.44**

0.34 5.67† 0.33 1.22 0.23 0.03 3.17 4.84†

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Table 3 Borderline features and suicidal ideation at baseline, post-treatment using carry-forward methodology. Pre

Post

MACT PAI-BOR BOR-A BOR-I BOR-N BOR-S PAI-SUI SPS SPS-SI

84.63 80.13 75.13 77.50 79.00 95.5 76.13 71.13

(5.60) (4.61) (3.18) (8.04) (17.41) (10.11) (3.87) (4.79)

TA + MACT

Total

85.00 83.63 77.75 80.00 72.13 91.13 82.13 72.00

84.81 81.88 76.44 78.75 75.56 93.31 79.13 71.56

(6.99) (7.42) (9.98) (6.63) (14.83) (15.12) (13.98) (4.50)

Effect size (d)

MACT (6.12) (6.24) (7.28) (7.23) (16.02) (12.63) (10.39) (4.52)

79.00 74.63 73.25 73.88 73.38 80.25 73.63 68.5

(8.96) (5.66) (5.95) (12.10) (22.41) (15.78) (5.78) (4.50)

TA + MACT

Total

82.75 79.88 78.13 74.38 71.63 80.88 73.00 67.88

80.88 77.25 75.69 74.13 72.50 80.56 73.31 68.19

(12.07) (8.11) (13.31) (9.68) (19.23) (18.93) (7.56) (8.36)

(10.45) (7.28) (10.27) (10.59) (19.23) (16.84) (6.51) (6.49)

MACT

TA + MACT

Total

0.75 1.07 0.39 0.35 0.28 1.15 0.51 0.57

0.23 0.48 − 0.03 0.68 0.03 0.60 0.81 0.61

0.46 0.68 0.08 0.51 0.17 0.86 0.67 0.60

Time

Group × Time

4.72* 4.29† 0.15 9.78** 0.75 10.10** 3.57† 8.01*

0.87 0.15 0.33 0.46 0.52 0.39 1.16 0.40

Note. †P b 0.08, *P b 0.05, **P b 0.01.

3.3. Estimation of change for all participants Given the significant rate of attrition, a carry-forward methodology was utilized to provide a more conservative estimate of the changes observed during MACT treatment, independent of treatment attrition. This methodology entailed reporting the last known value for each participant as the post-test datum. A repeated measures ANOVA investigating changes in borderline features from baseline to posttreatment for all participants using the carry-forward imputation (Table 3) indicated a significant main effect for change in PAI-BOR from baseline to post-treatment (F(1, 14) = 4.72, P b 0.05, d = 0.46). With respect to suicidal ideation, significant decreases were observed on the PAI-SUI (F(1, 14) = 10.10, P b 0.01, d = 0.86) and SPS-SI (F(1, 14) = 8.01, P b 0.05, d = 0.60). No significant differences in treatment response across groups were found for borderline features or suicidal ideation using this more conservative carry-forward approach. 4. Discussion The purpose of this study was to examine the impact of a brief, manualized intervention for BPD as a stand-alone outpatient treatment, as well as to pilot a Therapeutic Assessment intervention designed to augment retention and early treatment efficacy. Because patients with BPD tend to present for treatment in acute crisis but are at very high risk for dropping out of treatment, it is particularly important to rapidly reduce suicidality in these patients. The results from this study highlight the promise as well as the potential limitations of brief, structured treatments for Borderline Personality Disorder. Our results suggest that if patients can be retained in this six week treatment, noteworthy reductions in suicidal ideation and borderline symptomatology are likely. However, as is often found in previous research, these patients are at high risk to discontinue treatment and retention rates for this manualized intervention appear no better than those reported in the literature for treatment as usual in this population. Although we had hypothesized that augmenting the manualized treatment with a Therapeutic Assessment intervention would improve retention, this did not appear to be the case; those patients who received MACT plus the Therapeutic Assessment augmentation and those who only received MACT did not differ in completion status or the number of sessions attended. To the extent that any differences in condition were observed, it involved symptomatic change rather than retention; among those completing treatment, these limited data suggested that the TA + MACT group showed greater reduction in affective instability and suicidal ideation. As a pilot study, the present study was limited in scope with respect to the sample size, the lack of a control condition, and the lack of available follow-up information on study clients. It should be noted that large effects were observed in the present study that in some cases failed to reach statistical significance because of limited statistical power. Thus, in many instances, particularly those where large effect sizes were observed (i.e., d N 0.80; Cohen, 1988), certain

non-significant study findings should not be interpreted as null or uninformative, but as promising pilot data for subsequent investigations of hypotheses drawn from these results. Previous research investigating the utility of MACT in BPD suggests that patients sustain treatment gains, such as decreased frequency of deliberate self-harm and significant reductions in depressive symptoms at follow-up (Evans et al., 1999; Weinberg et al., 2006). Even more interesting is that some changes not evident at treatment completion become significant six months after treatment has ended (e.g. decreases in DSH severity), suggesting a possible lag effect (Weinberg et al., 2006). Future research should continue to examine the possibility that improvement with MACT and similar interventions will continue to be observed post-treatment, particularly given the lack of follow-up data in the current study. Retention results were similar to most other studies using MACT or other standardized treatments for BPD, with the exception of the recent Weinberg et al. study in which there was no attrition. One potentially influential difference between these studies is that in the current approach, MACT represented a stand-alone treatment, whereas in the Weinberg et al. procedure, patients were often enrolled in other psychosocial treatments. This suggests that adjunct therapeutic support and structure facilitates treatment retention. Indeed, the finding that individuals in this study who were managed with medication had better retention rates supports the potential utility of concurrent treatment for MACT adherence. Another potential difference involves the expanded focus in this study on multiple forms of self-harm which was embedded in the manual. This could have the effect of making the treatment diffuse for patients, given its brevity. Future research should focus on the effects of broadening the therapeutic goals of highly focused interventions such as MACT. One consequence of the small sample size is that we were unable to examine potentially important influences on outcome such as therapist effects. Future studies with larger studies should examine these issues. Overall, MACT research underscores the need for a careful delineation of mechanisms that lead to retention in treatment for patients with BPD, and the recognition that these mechanisms may differ from those that lead most directly to symptomatic change. Perhaps future efforts in the development and study of treatment process for BPD can draw successfully from parallel efforts in substance abuse treatment, where treatment retention is also of considerable concern. For example, Simpson (2004) describes a conceptual model for the substance abuse treatment process that underscores the sequential phases of the treatment, and how therapeutic interventions link together over time to help sustain engagement and retention. We continue to believe that efforts to augment existing treatments with interventions tied to sequentially varying goals constitute a promising direction for research in the treatment of BPD. Results presented here and elsewhere suggest that there is room for optimism that time-limited intervention can be useful for producing meaningful changes in such individuals, but that

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retention even in these more brief treatments still poses a considerable challenge. Acknowledgement This study was funded by a research grant from the American Foundation for Suicide Prevention awarded to Dr. Morey.

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