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Naturalistic evaluation of dialectical behavior therapy-oriented treatment for borderline personality disorder
Borderline Personality Disorder
for measuring clinical anxiety: Psychometric properties. Journal of Consulting and Clinical Psychology, 56, 893-897. Beck, A. T., Ward, C. H., Mendelson, M., Mock, J., & Erbaugh, J. (1961). An inventory for measuring depression. Archives of General Psychiatry, 4, 561-571. Cartwright-Hatton, S., & Wells, A. (1997). Beliefs about worry and intrusions: The Meta-Cognitions Questionnaire and its correlates. Journal of Anxiety Disorders, 3, 279-296. Fenigstein, A., Scheier, M. E, & Buss, A. H. (1975). Public and private self-consciousness: Assessment and theory. Journal of Consulting and ClinicalPsychology, 43, 522-527. Fennell, M.J.V., Teasdale,J. D.,Jones, S., & Daml6, A. (1987). Distraction in neurotic and endogenous depression: An investigation of negative thinking in major depressive disorder. PsychologicalMedicine, 17, 441-452. First, M. B., Spitzer, R. L., Gibbon, M., & Williams,J. B. W. (1997). Structured Clinical Interview for DSM-1V Axis I Disorders-Patient Edition (SCID-I/P, Version 2.0, 4/97 revision). New York: Biometrics Research Department, New York State Psychiatric Institute. Hollon, S., & Kendall, E (1980). Cognitive self-statements in depression: Development of the Automatic Thoughts Questionnaire. Cognitive Therapy and Research, 4, 383-395. Nolen-Hoeksema, S. (1991). Responses to depression and their effects on the duration of depressive episodes. Journal ofAbnormaIPsychology, 100, 569-582. Nolen-Hoeksema, S., & Morrow, J. (1991). A prospective study of depression and posttraumatic stress symptoms after a natural disaster: The 1989 Loma Prieta earthquake.Journal of Personality and Social Psychology, 61, 115-121. Papageorgiou, C., & Wells, A. (1998). Effects of attention training on hypochondriasis: A brief case series. Psychological Medicine, 28, 193-200.
Papageorgiou, C., & Wells, A. (1999a). Process and meta-cognitive dimensions of depressive and anxious thoughts and relationships with emotional intensity. Clinical Psychology and Psychotherapy, 6, 156-162. Papageorgiou, C., & Wells, A. (1999b, November). Dimensions of depressive rumination and anxious worry: A comparative study. Paper presented at the 33rd Annual Convention of the Association for Advancement of Behavior Therapy, Toronto, Canada. Teasdale, J. D., Segal, Z., & Williams, J. M. G. (1995). How does cognitive therapy prevent depressive relapse and why should attentionai control (mindfulness) training help? Behaviour Research and Therapy, 33, 25-39. Wells, A. (1990). Panic disorder in association with relaxation induced anxiety: An attentional training approach to treatment. Behavior Therapy, 21, 273-280. Wells, A. (2000). Emotional disorders and metacognition: b~novative cognitive therapy. Chichester, UK: Wiley. Wells, A., & Matthews, G. (1994). Attention and emotien: A elinicalperspective. Hove, UK: Lawrence Erlbanm Associates. Wells, A., White, J., & Carter, K. (1997). Attention training: Effects on anxiety and beliefs in panic and social phobia. Clinical Psychology and Psychotherapy, 4, 226-232. Address correspondence to Adrian Wells, Division of Clinical Psychology, University of Manchester, Rawnsley Building, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK; e-mail: [email protected]. Received: December29, 1999 Accepted: July 5, 2000
Naturalistic Evaluation o f Dialectical Behavior T h e r a p y - O r i e n t e d Treatment for Borderline Personality Disorder R a l p h M. T u r n e r , University o f the Sciences This article reports the results of a naturalistic investigation comparing the effectiveness of a dialectical behavior therapy-oriented treatment (DBT) with a client-centered therapy control condition ( CCT) for borderline personality disorder patients (BPD). Twentyfour patients diagnosed with BPD were randomly assigned to either D B T or CCT. Blinded, independent rater evaluations and a battery of patient self-report measures were completed at baseline, 6 months, and 1 year during the course of treatment. Measures of suicide attempts and self-harm episodes were collected on a weekly basis. The number of psychiatric hospitalization days per 6-month period was also measured. Outcomes showed the D B T group improved more than the CCT group on most measures. The quality of the therapeutic alliance accounted for significant variance in patients' outcomes across both treatments.
NEHAN (1993) d e v e l o p e d dialectical b e h a v i o r t h e r a p y (DBT) specifically for t h e t r e a t m e n t o f w o m e n w h o m a k e m u l t i p l e a n d r e p e a t e d suicide a t t e m p t s a n d w h o m o s t o f t e n m e e t criteria f o r b o r d e r l i n e p e r s o n a l i t y disord e r (BPD). Five e x p e r i m e n t a l a n d q u a s i - e x p e r i m e n t a l studies have s u p p o r t e d t h e efficacy o f D B T versus treat-
Cognitive and Behavioral Practice 7, 4 1 3 - 4 1 9 , 2000 107%7229/00/413-41951.00/0 Copyright © 2000 by Association for Advancement of Behavior Therapy. All rights of reproduction in any form reserved.
m e n t as usual (TAU) in t h e c o m m u n i t y for p a r a s u i c i d a l adults a n d a d o l e s c e n t s (Koons et al., 1998; L i n e h a n , A r m strong, Suarez, A l l m o n , & H e a r d , 1991; L i n e h a n et al., in press; R a t h u s & Miller, 1999; Stanley, Ivanoff, Brodsky, & O p p e n h e i m , 1998). T h e p r e s e n t study takes t h e r e s e a r c h o n D B T treatm e n t f o r BPD o n e step f u r t h e r by c o n t r a s t i n g a DBTo r i e n t e d therapy m o d e l to an alternative psychosocial treatm e n t r a t h e r t h a n c o m p a r i n g it to TAU. In a d d i t i o n , t h e p r e s e n t study focuses o n assessing t h e effectiveness, in c o n t r a s t to efficacy, o f D B T - o r i e n t e d therapy. To a c h i e v e
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the first goal, DBT-oriented t r e a t m e n t is c o m p a r e d to a client-centered therapy (CCT) t r e a t m e n t protocol. To achieve the s e c o n d goal, regular m e n t a l health staff in a The present study community mental health clinic setting c o n d u c t e d the takes the research treatments, in the c o n t e x t of on DBT treatment the real-world comorbidity and for BPD o n e step complexities associated with this diagnosis. In addition, further by b o t h m e n a n d w o m e n are repcontrasting a DBTr e s e n t e d in this study. T h e CCT treatment m o d e l was chooriented therapy sen as the contrasting treatmodel to an m e n t c o n d i t i o n because m a n y alternative clinicians view supportive psyc h o t h e r a p y m o d e l s of treatpsychosocial m e n t as a p p r o p r i a t e for BPD treatment rather patients (Adler, 1979, 1985; than comparing it Buie & Adler, 1982). Furtherto TAU. more, all psychotherapy m o d els b u i l d on a f o u n d a t i o n o f supportive c o m p o n e n t s to establish a t r e a t m e n t relationship (Luborsky, 1984; Luborsky, Barber, & Beutler, 1993).
Method Research Participants Potential participants were initially treated in local hospital e m e r g e n c y services for suicide attempts. T h e y were t h e n r e f e r r e d to the c o m m u n i t y m e n t a l health outp a t i e n t clinic for follow-up services. Sixty-two patients were r e f e r r e d a n d evaluated. To be eligible for participation in the study, patients h a d to m e e t diagnostic criteria for BPD, n o t m e e t criteria for an exclusionary diagnosis, give written i n f o r m e d c o n s e n t to participate in the study, a n d h a d to accept r a n d o m assignment to treatment. T h e exclusionary diagnoses i n c l u d e d schizophrenia, schizoaffective disorder, b i p o l a r disorder, organic m e n t a l disorders, a n d m e n t a l retardation. Thirty-three patients m e t criteria for a BPD diagnosis a n d gave i n f o r m e d c o n s e n t to participate in the p r o g r a m for a r e d u c e d fee. D u r i n g the screening a n d intake process, 9 patients withdrew o r h a d to be r e m o v e d from the study. F o u r patients d r o p p e d o u t a n d refused to participate in pretest evaluations; 3 others r e q u i r e d i n p a t i e n t d r u g a n d alcohol t r e a t m e n t a n d were r e f e r r e d for those sin-rices; a n d 2 participants withdrew from the study after t r e a t m e n t assignment. This left a total o f 24 participants to be r a n d o m l y assigned to either DBT o r CCT. D u r i n g the year-long treatment, 4 DBT a n d 6 CCT patients withdrew f r o m treatment. O f these patients, 1 person in the DBT c o n d i t i o n r e t u r n e d to DBT t r e a t m e n t af-
ter a 5-week break. Nine DBT a n d 6 CCT patients were still in t r e a t m e n t at 12 months. All 24 patients particip a t e d in the 6-month a n d 12-month assessments a n d c o m p o s e d the intent-to-treat sample for the analyses. N i n e t e e n females a n d 5 males were i n c l u d e d in the sample. T h e ethnic c o m p o s i t i o n i n c l u d e d 19 Caucasians, 4 African Americans, a n d 1 Asian American. T h e average age was 22 a n d the range was from 18 to 27. Average level o f e d u c a t i o n in years was 13.3 with a range from 12 to 16 years. Twenty-three patients m e t criteria for a c o m o r b i d Axis I disorder. T h e majority was d i a g n o s e d with dysthymia plus c o m o r b i d generalized anxiety d i s o r d e r (n = 17). T h r e e patients m e t criteria for m a j o r depressive disorder, 3 m e t criteria for dysthymia, 18 m e t criteria for alcohol abuse, a n d 20 m e t criteria for substance abuse. Most patients (n = 18) m e t criteria for two additional personality disorders. T h e most f r e q u e n t c o m b i n a t i o n was 9 cases o f the b o r d e r l i n e plus d e p e n d e n t personality disorder. T h e absolute c o u n t o f c o m o r b i d Axis II disorders i n c l u d e d 2 antisocial, 1 compulsive, 9 d e p e n d e n t , 6 histrionic, 6 narcissistic, 2 p a r a n o i d , a n d 3 schizotypal. T h e types of self-harmful behaviors r e p o r t e d by the patients i n c l u d e d parasuicide; fights; wrist cutting o r scratching; bruising arms a n d legs; impulsive, u n p r o tected sexual episodes; impulsive abuse o f alcohol a n d drugs; a n d accidental overdosing. Eight patients h a d a history o f b r i e f psychotic, o r p a r a n o i d , episodes, which h a d previously resulted in psychiatric hospitalizations. T h e study p r o t o c o l d i d n o t include a p h a r m a c o t h e r apy c o m p o n e n t . However, 19 patients were taking prescribed psychotropic medications at the b e g i n n i n g o f the study. T h e r e was no consistent p a t t e r n o f m e d i c a t i o n types. T h e r a n d o m assignment p r o c e d u r e p l a c e d 8 m e d ication subjects in the DBT g r o u p a n d 11 in the CCT group. This difference was n o t statistically significant, X2(1) 2.27, p = .132. At the 12-month evaluation, 4 DBT patients a n d 10 CCT patients r e p o r t e d they were receiving phalwnacotherapy. This difference was statistically significant, X2(a) = 6.17, p = .01. =
Procedure Assessment Patients r e f e r r e d to the clinic were initially s c r e e n e d by the investigator to d e c i d e if they were a p p r o p r i a t e for the study. T h e screening interview consisted of a 90m i n u t e structured interview based on the Diagnostic Interview for Borderlines (DIB; G u n d e r s o n , Kolb, & Austin, 1981) a n d the Structured Clinical Interview for DSM-III Disorders (SCID-I; Spitzer, Williams, Gibbon, & First, 1990). Patients m e e t i n g DIB criteria for BPD a n d n o t m e e t i n g exclusionary criteria were invited to participate in a s e c o n d assessment session. At the s e c o n d assessm e n t session, an i n d e p e n d e n t assessor a d m i n i s t e r e d the
Borderline Personality Disorder Personality Disorders Examination (PDE; Loranger, 1988) to cross-validate the BPD diagnosis and determine the presence of additional Axis II disorders. Only patients meeting criteria for BPD by both diagnostic systems were invited to participate in the study. Outcome Measures
Independent assessor ratings. Outcome assessment was conducted at pretreatment, 6 months, and 12 months. The outcome evaluation consisted of independent assessor ratings and patient self-report. The independent assessor was unaware of the patients' treatment condition but was aware of the purpose of the study. The assessor rated patients on the Hamilton Rating Scale for Depression (HRSD; Hamilton, 1960, 1967), the Brief Psychiatric Rating Scale (BPRS; Overall & Gorman, 1962), and Target Behavior Ratings for the problems of anger, impulsive behavior, emotional instability, and frequency of parasuicide. Target Behavior Ratings were made on a 0-to-8 scale, with 0 indicating no symptoms and 8 indicating severe symptoms. The assessor also determined the number of days of psychiatric hospitalization patients had undergone during the previous 6 months. Before starting the study, the independent assessor received three 90-minute training sessions on using the scales and making the clinical ratings. As a check on the reliability of the independent assessor ratings during the study, the investigator also conducted evaluations at each assessment period. The Pearson correlations between the independent assessor and the investigator ranged from .75 for the ratings of anger to .84 for the ratings of selfharm. Only the independent assessor ratings were used in the outcome analyses. Self-report ratings. Patient self-reports consisted of the Beck Depression Inventory (BDI; Beck, Ward, Mendelson, Mock, & Erbaugh, 1961), the Beck Anxiety Inventory (BAI; Beck, Epstein, Brown, & Steer, 1988), and the Beck Scale for Suicidal Ideation (BSI; Beck, Steel, & Ranieri, 1988). Patients also maintained daily logs of suicidal urges and attempts. Assignment Following the initial assessments, patients were randomly assigned to either DBT or CCT. Next, patients were sequentially assigned to a mental health clinician. Four therapists conducted both treatments. They had an average of 22 years of experience, with theoretical backgrounds in family systems, client centered, and psychodynamic treatments. Training and Adherence Training in DBT lasted 3 months. There were 12 training sessions. Each training session lasted 90 minutes. Therapists were given five lectures on the model's theory
and intervention strategies. They watched videotapes of treatment sessions, and they engaged in role-play practice. As noted above, the therapists in this study were already trained and experienced in client-centered, psychodynamically oriented, and family systems-oriented treatFour therapists ment models; however, to ensure the consistency and adeconducted both quacy of the CCT treatment, treatments. They the therapists received 12 trainhad an average ing sessions over 3 months. Therapists read books and paof 22 years pers describing the supportive of experience, treatment of BPD patients. with theoretical They role-play practiced the basic elements of supportive backgrounds listening and reflecting. Fiin family nally, group discussions were systems, client used to clarify issues such as how to avoid interpreting and centered, and challenging defenses and how psychodynamic to maintain BPD patients in treatments. treatment. The investigator and the senior clinic therapist monitored adherence to the treatment protocols. Both supervisors met with the therapists weekly in two separate group supervision meetings. Therapists presented audiotapes of their previous sessions with patients during supervision. When therapists deviated from the assigned treatment plan, supervisors coached them on how to return to the protocol. Treatments Patients received a minimum of 49 sessions and a maximum of 84 sessions of treatment during the study period. There were no significant differences between groups regarding the average number of treatment sessions during either the first or last 6-month periods. DBT. The DBT-oriented therapy delivered in this study was based upon the Linehan approach (Linehan, 1993). There were two modifications made to the DBT approach. First, psychodynamic techniques were incorporated to conceptualize patients' behavioral, emotional, and cognitive relationship schema. Second, in order to keep the treatment conditions equal with regard to clinical contact hours, we decided not to run a separate DBT skills training group, but to provide skills during the course of individual therapy. Six group sessions were provided to patients in both treatment conditions. In these six group sessions, the format for skills training groups was modified to focus on significant persons in patients' natural environment, such as partners, family
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m e m b e r s , friends, a n d o t h e r c o m m u n i t y s u p p o r t persons. CCT. T h e m o d e l o f supportive t r e a t m e n t used in this study was based on Carkhuff's (Carkhuff, 1969; Carkhuff, Pierce, & C a n n o n , 1976) m o d e l s o f client-centered therapy. F r o m this perspective, t r e a t m e n t emphasizes empathic u n d e r s t a n d i n g o f the patient's sense o f aloneness a n d providing a supportive a t m o s p h e r e for individuation. Carkhuff's t r e a t m e n t manuals provide directions for increasing the t h e r a p e u t i c relationship's e m p a t h i c a n d supportive elements. T h e CCT t r e a t m e n t p r o v i d e d patients with a safe therapeutic e n v i r o n m e n t a n d accurate e m p a t h i c reflection only. CCT a c c e n t u a t e d the therapist's role as a s u p p o r t e r a n d advocate. Therapists a i d e d patients in using selfc o n t r o l a n d reflection to r e d u c e stress. Clinicians d i d n o t i n t e r p r e t o r c o n f r o n t conflicts a n d defenses. T h e i r singular focus was to provide s u p p o r t to e n a b l e patients to deal with everyday stress a n d p r e v e n t relapse. T h e CCT t r e a t m e n t plan was s c h e d u l e d for 12 months. Sessions were s c h e d u l e d two times p e r week when possible. A t r e a t m e n t contract was d e v e l o p e d a n d signed by the p a r t i c i p a n t a n d therapist. T h e contract stipulated that patients would n o t m a k e a suicide a t t e m p t or e n g a g e in a self-harming act d u r i n g the course o f treatment. CCT t r e a t m e n t d i d n o t use a structured agenda. Instead, therapists instructed patients to express what was
o n their m i n d s at each session. F o u r phases characterized the CCT t r e a t m e n t p r o g r a m : (1) increased s u p p o r t during periods o f crisis, (2) p r o b l e m assessment, (3) supportive treatment, a n d (4) termination. D u r i n g the crisism a n a g e m e n t phase, therapists m e t with patients as often as 3 times p e r week.
Results
Table 1 presents the means a n d s t a n d a r d deviations o f the d e p e n d e n t variables for b o t h t r e a t m e n t groups at p r e t r e a t m e n t , 6 months, a n d 1 year. F o r the m a i n o u t c o m e analyses, the d e p e n d e n t variables were g r o u p e d in three categories. Measures evaluating self-harm/suicide severity i n c l u d e d the rating o f parasuicide, the BSI, and the patients' logs o f suicide/serf-harm attempts. Measures assessing affective disturbance included the rating o f anger, the BDI, the HRSD, the BAI, a n d the rating o f impulsiveness. T h e indicators o f global m e n t a l health f u n c t i o n i n g i n c l u d e d the BPRS a n d the n u m b e r of hospitalization days d u r i n g each 6-month period. Pret r e a t m e n t n u m b e r o f hospitalization days was based o n the 6 m o n t h s before the p r e t r e a t m e n t assessment. To d e t e r m i n e if the r a n d o m assignment p r o c e d u r e worked, we e x a m i n e d the p r e t r e a t m e n t values o f the dep e n d e n t variables for each o f the t h r e e categories o f outc o m e using a Hotelling's T 2 on the T r e a t m e n t factor. F o r
Table 1
Means and Standard Deviations of Dependent Measures for Client-Centered Therapy and Dialectical Behavior-Oriented Therapy DBT-Oriented Therapy (n = 12)
Client-Centered Therapy Control (n = 12) Measure Rating of Parasuicide Beck Suicide Ideation Scale Number of Suicide/Self-Harm Attempts Rating of Impulsiveness Rating of Anger Beck Depression Inventory Hamilton Depression Rating Beck Anxiety Inventory Brief Psychiatric Rating Scale Hospitalization Days
Pretreatment
6 Months
12 Months
Pretreatment
6 Months
12 Months
7.25 (.75) 23.53 (3.34) 13.58 (3.34) 7.58 (.51) 7.08 (.90) 27.75 (6.11) 17.42 (4.46) 20.42 (3.45) 30.83 (6.00) 10.00 (8.11)
4.33 (1.92) 13.33 (9.79) 6.75 (5.97) 6.67 (.78) 5.92 (.79) 24.75 (4.94) 13.67 (2.93) 17.08 (5.82) 25.83 (8.40) 10.75 (16.27)
4.25 (2.18) 11.58 (9.21) 5.58 (5.28) 6.08 (1.08) 5.67 (1.15) 24.08 (5.55) 12.58 (3.90) 14.83 (6.34) 25.33 (3.94) 13.00 (15.34)
7.17 (.83) 24.08 (3.73) 14.08 (3.73) 7.42 (.51) 7.33 (.65) 27.58 (5.30) 20.75 (4.33) 19.25 (3.55) 30.33 (6.56) 10.20 (3.37)
2.08 (2.02) 2.83 (3.49) 2.17 (1.95) 5.83 (.83) 5.00 (1.21) 18.08 (7.91) 8.58 (6.58) 12.58 (4.89) 18.42 (7.33) 2.67 (6.58)
1.50 (1.98) 3.83 (8.03) .75 (1.23) 4.58 (1.62) 4.67 (1.30) 14.92 (8.26) 7.50 (5.96) 10.17 (6.53) 18.17 (7.90) .75 (1.96)
Borderline Personality Disorder all t h r e e construct-clusters, t h e r e were n o significant initial differences between the groups. O u t c o m e Assessment To assess the comparative effectiveness o f the two treatments, a three-factor repeated-measures Multivariate Analysis o f Variance (RMMANOVA) analysis was c o n d u c t e d on each construct-cluster o f d e p e n d e n t measures. T r e a t m e n t c o n d i t i o n was the between-subjects factor. Time of assessment was the repeated-measures factor. Post hoc analyses were d o n e using the Roy-Bose 95% Multivariate Simultaneous J o i n t Confidence Bounds procedure. R e g a r d i n g suicide/self-harm behavior, the analysis showed that significant i m p r o v e m e n t s in patients' behavior were o b t a i n e d for b o t h treatments over time, F(6' 84) 26.8, p = .001, R 2 = .657; however, the DBT-oriented therapy patients' gains were g r e a t e r t h a n those receiving CCT at b o t h 6 m o n t h s a n d 12 months, F(6 ' s4) = 5.1, p = .001, R 2 = .268. T h e measures involved in the significant effects were the rating o f parasuicide [95% CI (.559, 2.83)], the BSI [95% CI (3.1, 11.3)], a n d n u m b e r of suicide a n d self-harm attempts [95% CI (.24, 5.7)] favoring DBT at 6 m o n t h s a n d 12 months. T h e results showed b o t h treatments i m p r o v e d patients' functioning in the e m o t i o n a l d o m a i n measures over time, F(10, so) = 13.2, p = .0001, R 2 = .62. However, again there was a significant T r e a t m e n t × T i m e interaction, F(10,so) = 2.6, p = .008, R 2 = .25. DBT-oriented therapy p r o d u c e d significantly lower scores t h a n CCT o n Impulsiveness at 12 m o n t h s [95% CI (.21, 1.4)], b u t n o t at 6 months. A n g e r ratings were significantly lower at 12 m o n t h s for the DBT-oriented t r e a t e d g r o u p [95% CI (.27, 1.3)]. Depression, as m e a s u r e d by the BDI a n d HRSD, was significantly lower in the DBT-oriented therapy at 12 months, b u t n o t at 6 m o n t h s [95% CI (1.3, 9.3) a n d 95% CI (.90, 5.5)]. T h e r e were no statistically significant differences between the two treatments o n anxiety as m e a s u r e d by the BAI at 6 m o n t h s or 12 months. R e g a r d i n g global m e n t a l h e a l t h functioning, there was a significant Time effect, F(4' 19) = 5.3, p = .005, R z = .53, a n d a significant T r e a t m e n t × T i m e interaction, F(4, s6) = 2.4, p = .05, R 2 = .27. A l t h o u g h b o t h treatments p r o d u c e d significant reductions in BPRS scores, DBTo r i e n t e d t h e r a p y p r o d u c e d significantly greater reductions at 12 m o n t h s [95% CI (1.3, 8.8)]. DBT-oriented t h e r a p y r e d u c e d hospitalization days significantly m o r e at b o t h 6 m o n t h s a n d 12 m o n t h s [95% CI (.43, 13.9)]. =
Assessment o f Clinical Significance and Effectiveness To assess the clinical significance o f the statistical findings, cutoff scores signifying an absence of clinically significant symptoms for each o u t c o m e measure were e i t h e r drawn from the literature for an i n d i c a t o r o r clinically det e r m i n e d when there was n o guiding normative data.
T h e two treatments were then c o m p a r e d on how m a n y patients m o v e d below the cutoff score on each o u t c o m e indicator by the 12-month assessment. Suicide~self-harm behavior. A rating o f 2 o r lower on the I n d e p e n d e n t Rater Parasuicide Rating Scale was j u d g e d to indicate a n e a r absence of symptoms. T h r e e CCT patients a n d 11 DBT-oriented t h e r a p y patients o b t a i n e d ratings below 2, which was statistically different, Xe(1) = 10.9, p = .001. T h e BSI has a suggested cutoff score o f 3; 11 DBT-oriented therapy patients a n d 4 CCT patients o b t a i n e d scores o f 3 o r below by m o n t h I2; this was also statistically significant, X2(1) = 8.7, p = .003. F o r the selfr e p o r t e d suicide attempts a n d self-harm behavioral incidents, it was d e c i d e d that only a score o f zero reliably ind i c a t e d a clinically significant r e d u c t i o n in symptoms. Again, as with the BSI, 11 DBT-oriented t h e r a p y patients a n d 4 CCT patients achieved this goal. Across all t h r e e measures o f the s u i c i d e / s e l f - h a r m d o m a i n , DBT-oriented therapy m o v e d 11 o f 12 patients into the clinically improved zone. Emotional disregulation. A rating o f 2 o r lower on the I n d e p e n d e n t Rater Impulsiveness Rating Scale a n d the A n g e r Rating Scale was j u d g e d to indicate a n e a r absence o f symptoms. Only 2 DBT-oriented therapy patients a n d n o n e o f the CCT patients achieved this goal o n the impulsiveness rating; this was n o t a significant difference, X2(1) 2.2, p = .140. N o n e o f the patients in either g r o u p achieved this goal for the a n g e r rating. Scores below 10 on b o t h the BDI a n d the BAI are c o n s i d e r e d m i l d a n d n o t clinically significant. Therefore, for these two measures, patients receiving scores o f less t h a n 10 were cons i d e r e d clinically improved. Six patients receiving DBTo r i e n t e d t r e a t m e n t a n d no CCT patients achieved scores of less than 10 on the BDI. This was a statistically significant finding, X20) = 8.0, p --- .005. O n the BAI, 6 DBT-orie n t e d t r e a t m e n t patients a n d 2 CCT patients achieved this clinical goal. However, this was n o t a statistically significant difference, X2(a) = 2.7, p --- .1. O n the HDRS, we also used a cut score o f 10 to d e m a r c a t e the clinically imp r o v e d category. Five CCT patients a n d 9 DBT-oriented therapy patients achieved this goal on the HDRS; however, this was n o t a significant difference, X2(1) = 2.7, p -.1. O n n o n e o f o u r e m o t i o n regulation measures d i d CCT o b t a i n b e t t e r clinical results; however, t h e r e was m u c h less success overall for moving patients into the n o n s y m p t o m a t i c range. For n e i t h e r impulsiveness n o r a n g e r was there any evidence o f clinically significant imp r o v e m e n t with e i t h e r treatment. While the n u m b e r s favored DBT-oriented therapy o n the BDI a n d the BAI, only 6 DBT-oriented t h e r a p y patients m o v e d into the clinically i m p r o v e d range o n e i t h e r measure. T h e HDRS showed a b e t t e r o u t c o m e with r e g a r d to depression than the BDI d i d for b o t h groups, b u t t h e r e was n o t a reliable difference between the treatments. =
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Impact of treatment indicators. For the n u m b e r o f days o f psychiatric hospitalization, zero was set as the clinically relevant cutoff point. Ten DBT-oriented t h e r a p y patients a n d 6 CCT patients achieved this goal d u r i n g the last 6 m o n t h s o f the study. This finding was n o t significant at traditional c o n f i d e n c e levels, ×2(a) = 3.0, p = .08. F o r the BPRS, the cutoff score was set at 15. Five DBT-oriented therapy patients a n d n o CCT treated patients achieved this The results goal; this was statistically significant, X2(1~ = 6.3, p - .01, suggest that DBTdespite the low n u m b e r o f paoriented therapy tients c h a n g i n g their global can be more psychopathology status. Taken together, it does a p p e a r that effective than DBT-oriented therapy m a d e providing only the clinically significant improvesupportive ments in these impact-oftreatment-level indicators. At components of least 5 DBT-oriented therapy psychotherapy. patients r e a c h e d clinical imp r o v e m e n t on b o t h measures, a n d a n o t h e r 5 were able to stay o u t o f the hospital. In contrast, n o CCT patients were able to simultaneously achieve clinical i m p r o v e m e n t o n b o t h indicators. Assessment of Treatment Credibility At the 6-month evaluation, patients r a t e d their confid e n c e that their t r e a t m e n t was credible o n a 7-point Likeft scale. This strategy was used to test the hypothesis that significant differences between the treatments were because o f differential credibility o f the treatments. T h e analysis f o u n d no significant difference between treatments r e g a r d i n g credibility, t(22) : 1.63, p = .116. Assessment of Helping Alliance Differences At the 6-month evaluation, patients were asked to c o m p l e t e the l 1-item H e l p i n g Relationship Questionnaire ( H R Q ; Luborsky, 1984). Patients' scores o n the H R Q were first analyzed to d e t e r m i n e if differences between treatments d e t e c t e d in the m a i n o u t c o m e analyses were plausibly d u e to differences in the quality o f the h e l p i n g alliance. T h e r e was n o significant difference between treatments o n the H R Q , F(1' ~6) = 1.10, p =. 31. Second, an analysis was c o n d u c t e d to d e t e r m i n e if patients' h e l p i n g alliance e x p e r i e n c e was related to their outcome. A canonical correlation analysis was used to regress t r e a t m e n t a n d H R Q scores simultaneously o n the whole set o f d e p e n d e n t variables. T h e H R Q scores were t r e a t e d as a c o n t i n u o u s variable. T h e t r e a t m e n t factor was c o d e d as a d u m m y variable. O n e significant canonical function was o b t a i n e d (R 2 = .79, ~ = .182, X2(18) : 28.954, p = .049). T h e s t a n d a r d i z e d canonical coefficients for the i n d e p e n d e n t variables were G r o u p = .631
a n d H R Q = .628. Thus, the h e l p i n g alliance a c c o u n t e d for as m u c h variance in the patients' i m p r o v e m e n t as the differences in the t r e a t m e n t conditions. T h e d e p e n d e n t variables with s t a n d a r d i z e d canonical coefficients above .4 were BSI = .84, suicide a t t e m p t s / s e l f h a r m behavior = .80, HRSD = .70, BPRS = .58, rating o f self-harmful behavior = .56, a n d the BDI = .40.
Discussion T h e p r e s e n t study's results s u p p o r t a growing literature that suggests that BPD patients can o b t a i n b e t t e r o u t c o m e s from psychosocial t r e a t m e n t than previously t h o u g h t ( L i n e h a n et al., 1991; Stone, 1990). Specifically, the results suggest that DBT-oriented therapy can be m o r e effective than providing only the supportive comp o n e n t s o f psychotherapy. Patients receiving DBTo r i e n t e d therapy showed greater i m p r o v e m e n t than patients receiving CCT on measures o f suicide a n d selfh a r m behavior, suicidal ideation, depression, impulsiveness, anger, global psychological functioning, a n d a r e d u c t i o n in days s p e n t in psychiatric hospitals. Furthermore, DBT-oriented t r e a t m e n t led to clinically significant i m p r o v e m e n t for the most i m p o r t a n t p r o b l e m facing BPD patients: suicide a n d self-harm behavior. DBTo r i e n t e d therapy also led to clinically significant improvem e n t in some areas o f e m o t i o n a l regulation a n d o n the i m p a c t o f treatment, albeit, m o r e modestly. In addition, DBT-oriented t r e a t m e n t m a i n t a i n e d patients in therapy slightly l o n g e r than CCT. These results c a n n o t be attribu t e d to differences between the treatments in terms o f credibility o r t h e r a p e u t i c alliance. T h e results o f this study cross-validate the findings o f Koons et al. (1998), L i n e h a n et al. (1991), L i n e h a n et al. (in press), a n d Stanley et al. (1998) that show DBT-oriented t h e r a p y to be efficacious for BPD problems. Importantly, to the best o f o u r knowledge, this study is the first e x p e r i m e n t a l test o f DBT-oriented t r e a t m e n t using a comparative psychotherapy c o n t r o l c o n d i t i o n for BPD problems. In addition, the p r e s e n t study contrasted DBT-oriented therapy with CCT using an intent-to-treat design in a c o m m u n i t y m e n t a l health setting. All patients were evaluated at every assessment p o i n t regardless o f w h e t h e r they r e m a i n e d in treatment. However, in this study, the quality o f the t h e r a p e u t i c alliance was shown to a c c o u n t for as m u c h variance in i m p r o v e m e n t as the treatments across all o u t c o m e indicators taken together. These results p r o m p t e d an additional set o f post hoc analyses that focused on d e t e r m i n i n g if there were any differential therapists results in the outcomes. It t u r n e d out that o n e clinician was m o r e effective using CCT while three were m o r e effective using DBT. Surprisingly, one clinician was m o r e effective than the others regardless o f the t r e a t m e n t model. T h r e e plausi-
Borderline Personality Disorder line personality. InternationalJournal of Psychoanalytic Psychotherapy, 9, 51-87. Carkhuff, R. R. (1969). Helping and human relations. New York: Holt, Rinehart, & Winston. Carkhuff, R. R., Pierce, R., & Cannon, J. (1976). The art of helping. Amherst, MA: Human Resources Press. Gunderson,J. G., Kolb,J. E., & Austin, V. (1981). The diagnostic interview for borderlines. American Jou.mal of Psychiatry, 138, 896-903. Hamilton, M. (1960). A rating scale for depression. Journal of Nenrology, Neu~vsurgery, and Psychiatry, 23, 56-62. Hamilton, M. (1967). Development of a rating scale for primary depressive illness. B'ritish Journal of Social and Clinical Psychology, 6, 278-296. Koons, C. R., Robbins, C.J., Bishop, G. K., Morse, J. Q., Tweed, J. L., Lynch, T. R., Gonzales, A. M., Butterfield, M. L, & Bastian, L. A. (1998, November). Efficacy of dialectical behavior therapy with borderline women veterans: A randomized controlled trial Paper presented at the meeting of the Association for Advancement of Behavior Therapy, Washington, DC. Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder. New York: Guilford Press. Linehan, M. M., Armstrong, H. E, Suarez, A., Allmon, D., & Heard, H. L. (1991). Cognitive-behavioral treatment of chronically parasuicidal borderline patients. Archives of General Psychiatry, 48, 1060-1064. Linehan, M. L., Schmidt, H. I., Dimeff, L. A., Craft, J. C., Kanter, J., & Comtois, K.A. (in press). Dialectical behavior therapy for patients with borderline personality disorder and drug-dependence. American Journal of Addictions. Loranger, A. (1988). Personality disorder examination manual Yonkers, NY: D.V. Communications. Luborsky, L. (1984). Principles of psychoanalytic psychotherapy. New York: Basic Books. Luborsky, L., Barber, J. E, & Beutler, L. E. (1993). Introduction to special section: A briefing on curative factors in dynamic psychotherapy.Journal of Consulting and Clinical Psychology, 61, 539-541. Overall, J. E., & Gorman, G. R. (1962). The brief psychiatric rating scale. Psychological Reports, 1 O, 799-812. Rathus, J. H., & Miller, A. L. (2000). DBT for adolescents: Dialectical dilemmas and secondary treatment targets. Cognitive and Behavioral Practice, 7, 425-434. Spitzer, R. L., Williams, J. B., Gibbon, M., & First, M. B. (1990). User's gaide for the structured clinical interview for DSM-III-R (SC1D). Washington, DC: American Psychiatric Press. Stanley, B., Ivanoff, A., Brodsky, B., & Oppenheim, S. (1998, November). Compa,4son of DBT and "treatment as usual" in suicidal and self-mutilating behavior. Paper presented at the meeting of the Association for Advancement of Behavior Therap)~ Washington, DC. Stone, M. H. (1990). The fate of borderline patients. New York: Guilford Press.
ble e x p l a n a t i o n s c o m e to m i n d f o r t h e t h e r a p i s t differe n c e s o b s e r v e d in t h e s e analyses. First, t h e therapists m a y n o t have b e e n equally p r o f i c i e n t u s i n g D B T a n d CCT. T h i s m i g h t b e d u e to an insufficiently specified D B T m o d e l o r flaws in t h e t r a i n i n g p r o g r a m . S e c o n d , differe n c e s in therapists' beliefs a n d e x p e c t a n c i e s a b o u t t h e t r e a t m e n t s m i g h t h a v e c o n t r i b u t e d to differential p a t i e n t o u t c o m e s . However, since all f o u r therapists p r a c t i c e d c l i e n t - c e n t e r e d , p s y c h o d y n a m i c a l l y o r i e n t e d a n d family systems a p p r o a c h e s , it is s u r p r i s i n g t h a t t h e y p e r f o r m e d so well with the i n t e g r a t e d c o g n i t i v e b e h a v i o r a l m o d e l . T h i s is possibly d u e to t h e c o n t i n u o u s t r a i n i n g a n d supervision t h e y r e c e i v e d t h r o u g h o u t t h e study; this v i e w p o i n t agrees with L i n e h a n ' s (1993) assertion t h a t c o n t i n u o u s s u p e r v i s i o n p r i m a r i l y d e t e r m i n e s positive p s y c h o t h e r a p y o u t c o m e with BPD patients. A n o t h e r possibility is t h a t t h e therapists h a d d i f f e r e n t attitudes a n d e x p e c t a n c i e s specifically a b o u t t r e a t i n g BPD patients. Finally, p e r h a p s t h e r e are j u s t s o m e very e x c e l l e n t therapists a n d s o m e o f m o r e m o d e s t abilities. T h e results o f this study s h o u l d n o t b e i n t e r p r e t e d as d e m o n s t r a t i n g t h a t c l i e n t - c e n t e r e d a n d s u p p o r t i v e psyc h o t h e r a p i e s in g e n e r a l are ineffective with BPD patients. T h e r e was n o c o n t r o l c o n d i t i o n to w a r r a n t this appraisal. T h e p r o v i s i o n o f C C T with t h e r i g h t t h e r a p i s t w o r k e d well f o r s o m e BPD patients. T h e s e f i n d i n g s s u p p o r t t h e opinion that the alliance-building supportive and emp a t h i c e l e m e n t s o f t r e a t m e n t are i m p o r t a n t for p a t i e n t i m p r o v e m e n t . W h a t we c o n c l u d e h e r e is t h a t the provision o f a strategic a n d i n t e g r a t e d set o f t h e r a p e u t i c strategies adds to t h e p r o v i s i o n o f s u p p o r t i v e e l e m e n t s for m a n y b o r d e r l i n e patients. Specifically, it a p p e a r s that t h e p r o v i s i o n o f D B T strategies a n d i n t e r v e n t i o n s in t h e cont e x t o f a s o u n d t h e r a p e u t i c r e l a t i o n s h i p leads to a clinically significant r e d u c t i o n o f s o m e o f t h e m o s t d a n g e r o u s p r o b l e m s associated with BPD.
References
I am extremely grateful to my clinician colleagues for their generous time and help in conducting this study. I especially want to thank Lynne Becker and Crystal DeLoach for their diligent work and collaboration. I am indebted to Marsha Linehan and Tracie Shea for their critical reading and feedback on earlier versions of this manuscript. Address correspondence to Ralph M. Turner, Ph.D., Health Psychology Section, Department of Social Sciences, 600 South 43rd Street, Philadelphia, PA 19104-4495; e-mail: MACTURNER@AOL. COM.
Adler, G. (1979). Aloneness and borderline psychopathology: The possible relevance of child development issues. InternationalJournal of Psychoanalysis, 60, 83-96. Adler, G. (1985). Borderlinepsych~athology and its treatment. New York: Aronson. Beck, A. T., Epstein, N., Brown, G., & Steer, R. A. (1988). An inventory for measuring clinical anxiety: Psychometric properties. Jowrnal of Consulting and Clinical Psydwlogy, 56, 893-897. Beck, A. T., Steer, R. A., & Ranieri, W. E (1988). Scale for suicidal ideation.Journal of Consulting and Clinical Psychology, 44, 499-505. Beck, A. T., Ward, C. H., Mendelson, M., Mock, J., & Erbaugh, J. ( 1961 ). An inventory for measuring depression. Archives of General Psychiatry, 4, 561-571. Buie, D., & Adler, G. (1982). The definitive treatment of the border-
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Naturalistic Evaluation o f Dialectical Behavior T h e r a p y - O r i e n t e d Treatment for Borderline Personality Disorder R a l p h M. T u r n e r , University o f the Sciences This article reports the results of a naturalistic investigation comparing the effectiveness of a dialectical behavior therapy-oriented treatment (DBT) with a client-centered therapy control condition ( CCT) for borderline personality disorder patients (BPD). Twentyfour patients diagnosed with BPD were randomly assigned to either D B T or CCT. Blinded, independent rater evaluations and a battery of patient self-report measures were completed at baseline, 6 months, and 1 year during the course of treatment. Measures of suicide attempts and self-harm episodes were collected on a weekly basis. The number of psychiatric hospitalization days per 6-month period was also measured. Outcomes showed the D B T group improved more than the CCT group on most measures. The quality of the therapeutic alliance accounted for significant variance in patients' outcomes across both treatments.
NEHAN (1993) d e v e l o p e d dialectical b e h a v i o r t h e r a p y (DBT) specifically for t h e t r e a t m e n t o f w o m e n w h o m a k e m u l t i p l e a n d r e p e a t e d suicide a t t e m p t s a n d w h o m o s t o f t e n m e e t criteria f o r b o r d e r l i n e p e r s o n a l i t y disord e r (BPD). Five e x p e r i m e n t a l a n d q u a s i - e x p e r i m e n t a l studies have s u p p o r t e d t h e efficacy o f D B T versus treat-
Cognitive and Behavioral Practice 7, 4 1 3 - 4 1 9 , 2000 107%7229/00/413-41951.00/0 Copyright © 2000 by Association for Advancement of Behavior Therapy. All rights of reproduction in any form reserved.
m e n t as usual (TAU) in t h e c o m m u n i t y for p a r a s u i c i d a l adults a n d a d o l e s c e n t s (Koons et al., 1998; L i n e h a n , A r m strong, Suarez, A l l m o n , & H e a r d , 1991; L i n e h a n et al., in press; R a t h u s & Miller, 1999; Stanley, Ivanoff, Brodsky, & O p p e n h e i m , 1998). T h e p r e s e n t study takes t h e r e s e a r c h o n D B T treatm e n t f o r BPD o n e step f u r t h e r by c o n t r a s t i n g a DBTo r i e n t e d therapy m o d e l to an alternative psychosocial treatm e n t r a t h e r t h a n c o m p a r i n g it to TAU. In a d d i t i o n , t h e p r e s e n t study focuses o n assessing t h e effectiveness, in c o n t r a s t to efficacy, o f D B T - o r i e n t e d therapy. To a c h i e v e
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the first goal, DBT-oriented t r e a t m e n t is c o m p a r e d to a client-centered therapy (CCT) t r e a t m e n t protocol. To achieve the s e c o n d goal, regular m e n t a l health staff in a The present study community mental health clinic setting c o n d u c t e d the takes the research treatments, in the c o n t e x t of on DBT treatment the real-world comorbidity and for BPD o n e step complexities associated with this diagnosis. In addition, further by b o t h m e n a n d w o m e n are repcontrasting a DBTr e s e n t e d in this study. T h e CCT treatment m o d e l was chooriented therapy sen as the contrasting treatmodel to an m e n t c o n d i t i o n because m a n y alternative clinicians view supportive psyc h o t h e r a p y m o d e l s of treatpsychosocial m e n t as a p p r o p r i a t e for BPD treatment rather patients (Adler, 1979, 1985; than comparing it Buie & Adler, 1982). Furtherto TAU. more, all psychotherapy m o d els b u i l d on a f o u n d a t i o n o f supportive c o m p o n e n t s to establish a t r e a t m e n t relationship (Luborsky, 1984; Luborsky, Barber, & Beutler, 1993).
Method Research Participants Potential participants were initially treated in local hospital e m e r g e n c y services for suicide attempts. T h e y were t h e n r e f e r r e d to the c o m m u n i t y m e n t a l health outp a t i e n t clinic for follow-up services. Sixty-two patients were r e f e r r e d a n d evaluated. To be eligible for participation in the study, patients h a d to m e e t diagnostic criteria for BPD, n o t m e e t criteria for an exclusionary diagnosis, give written i n f o r m e d c o n s e n t to participate in the study, a n d h a d to accept r a n d o m assignment to treatment. T h e exclusionary diagnoses i n c l u d e d schizophrenia, schizoaffective disorder, b i p o l a r disorder, organic m e n t a l disorders, a n d m e n t a l retardation. Thirty-three patients m e t criteria for a BPD diagnosis a n d gave i n f o r m e d c o n s e n t to participate in the p r o g r a m for a r e d u c e d fee. D u r i n g the screening a n d intake process, 9 patients withdrew o r h a d to be r e m o v e d from the study. F o u r patients d r o p p e d o u t a n d refused to participate in pretest evaluations; 3 others r e q u i r e d i n p a t i e n t d r u g a n d alcohol t r e a t m e n t a n d were r e f e r r e d for those sin-rices; a n d 2 participants withdrew from the study after t r e a t m e n t assignment. This left a total o f 24 participants to be r a n d o m l y assigned to either DBT o r CCT. D u r i n g the year-long treatment, 4 DBT a n d 6 CCT patients withdrew f r o m treatment. O f these patients, 1 person in the DBT c o n d i t i o n r e t u r n e d to DBT t r e a t m e n t af-
ter a 5-week break. Nine DBT a n d 6 CCT patients were still in t r e a t m e n t at 12 months. All 24 patients particip a t e d in the 6-month a n d 12-month assessments a n d c o m p o s e d the intent-to-treat sample for the analyses. N i n e t e e n females a n d 5 males were i n c l u d e d in the sample. T h e ethnic c o m p o s i t i o n i n c l u d e d 19 Caucasians, 4 African Americans, a n d 1 Asian American. T h e average age was 22 a n d the range was from 18 to 27. Average level o f e d u c a t i o n in years was 13.3 with a range from 12 to 16 years. Twenty-three patients m e t criteria for a c o m o r b i d Axis I disorder. T h e majority was d i a g n o s e d with dysthymia plus c o m o r b i d generalized anxiety d i s o r d e r (n = 17). T h r e e patients m e t criteria for m a j o r depressive disorder, 3 m e t criteria for dysthymia, 18 m e t criteria for alcohol abuse, a n d 20 m e t criteria for substance abuse. Most patients (n = 18) m e t criteria for two additional personality disorders. T h e most f r e q u e n t c o m b i n a t i o n was 9 cases o f the b o r d e r l i n e plus d e p e n d e n t personality disorder. T h e absolute c o u n t o f c o m o r b i d Axis II disorders i n c l u d e d 2 antisocial, 1 compulsive, 9 d e p e n d e n t , 6 histrionic, 6 narcissistic, 2 p a r a n o i d , a n d 3 schizotypal. T h e types of self-harmful behaviors r e p o r t e d by the patients i n c l u d e d parasuicide; fights; wrist cutting o r scratching; bruising arms a n d legs; impulsive, u n p r o tected sexual episodes; impulsive abuse o f alcohol a n d drugs; a n d accidental overdosing. Eight patients h a d a history o f b r i e f psychotic, o r p a r a n o i d , episodes, which h a d previously resulted in psychiatric hospitalizations. T h e study p r o t o c o l d i d n o t include a p h a r m a c o t h e r apy c o m p o n e n t . However, 19 patients were taking prescribed psychotropic medications at the b e g i n n i n g o f the study. T h e r e was no consistent p a t t e r n o f m e d i c a t i o n types. T h e r a n d o m assignment p r o c e d u r e p l a c e d 8 m e d ication subjects in the DBT g r o u p a n d 11 in the CCT group. This difference was n o t statistically significant, X2(1) 2.27, p = .132. At the 12-month evaluation, 4 DBT patients a n d 10 CCT patients r e p o r t e d they were receiving phalwnacotherapy. This difference was statistically significant, X2(a) = 6.17, p = .01. =
Procedure Assessment Patients r e f e r r e d to the clinic were initially s c r e e n e d by the investigator to d e c i d e if they were a p p r o p r i a t e for the study. T h e screening interview consisted of a 90m i n u t e structured interview based on the Diagnostic Interview for Borderlines (DIB; G u n d e r s o n , Kolb, & Austin, 1981) a n d the Structured Clinical Interview for DSM-III Disorders (SCID-I; Spitzer, Williams, Gibbon, & First, 1990). Patients m e e t i n g DIB criteria for BPD a n d n o t m e e t i n g exclusionary criteria were invited to participate in a s e c o n d assessment session. At the s e c o n d assessm e n t session, an i n d e p e n d e n t assessor a d m i n i s t e r e d the
Borderline Personality Disorder Personality Disorders Examination (PDE; Loranger, 1988) to cross-validate the BPD diagnosis and determine the presence of additional Axis II disorders. Only patients meeting criteria for BPD by both diagnostic systems were invited to participate in the study. Outcome Measures
Independent assessor ratings. Outcome assessment was conducted at pretreatment, 6 months, and 12 months. The outcome evaluation consisted of independent assessor ratings and patient self-report. The independent assessor was unaware of the patients' treatment condition but was aware of the purpose of the study. The assessor rated patients on the Hamilton Rating Scale for Depression (HRSD; Hamilton, 1960, 1967), the Brief Psychiatric Rating Scale (BPRS; Overall & Gorman, 1962), and Target Behavior Ratings for the problems of anger, impulsive behavior, emotional instability, and frequency of parasuicide. Target Behavior Ratings were made on a 0-to-8 scale, with 0 indicating no symptoms and 8 indicating severe symptoms. The assessor also determined the number of days of psychiatric hospitalization patients had undergone during the previous 6 months. Before starting the study, the independent assessor received three 90-minute training sessions on using the scales and making the clinical ratings. As a check on the reliability of the independent assessor ratings during the study, the investigator also conducted evaluations at each assessment period. The Pearson correlations between the independent assessor and the investigator ranged from .75 for the ratings of anger to .84 for the ratings of selfharm. Only the independent assessor ratings were used in the outcome analyses. Self-report ratings. Patient self-reports consisted of the Beck Depression Inventory (BDI; Beck, Ward, Mendelson, Mock, & Erbaugh, 1961), the Beck Anxiety Inventory (BAI; Beck, Epstein, Brown, & Steer, 1988), and the Beck Scale for Suicidal Ideation (BSI; Beck, Steel, & Ranieri, 1988). Patients also maintained daily logs of suicidal urges and attempts. Assignment Following the initial assessments, patients were randomly assigned to either DBT or CCT. Next, patients were sequentially assigned to a mental health clinician. Four therapists conducted both treatments. They had an average of 22 years of experience, with theoretical backgrounds in family systems, client centered, and psychodynamic treatments. Training and Adherence Training in DBT lasted 3 months. There were 12 training sessions. Each training session lasted 90 minutes. Therapists were given five lectures on the model's theory
and intervention strategies. They watched videotapes of treatment sessions, and they engaged in role-play practice. As noted above, the therapists in this study were already trained and experienced in client-centered, psychodynamically oriented, and family systems-oriented treatFour therapists ment models; however, to ensure the consistency and adeconducted both quacy of the CCT treatment, treatments. They the therapists received 12 trainhad an average ing sessions over 3 months. Therapists read books and paof 22 years pers describing the supportive of experience, treatment of BPD patients. with theoretical They role-play practiced the basic elements of supportive backgrounds listening and reflecting. Fiin family nally, group discussions were systems, client used to clarify issues such as how to avoid interpreting and centered, and challenging defenses and how psychodynamic to maintain BPD patients in treatments. treatment. The investigator and the senior clinic therapist monitored adherence to the treatment protocols. Both supervisors met with the therapists weekly in two separate group supervision meetings. Therapists presented audiotapes of their previous sessions with patients during supervision. When therapists deviated from the assigned treatment plan, supervisors coached them on how to return to the protocol. Treatments Patients received a minimum of 49 sessions and a maximum of 84 sessions of treatment during the study period. There were no significant differences between groups regarding the average number of treatment sessions during either the first or last 6-month periods. DBT. The DBT-oriented therapy delivered in this study was based upon the Linehan approach (Linehan, 1993). There were two modifications made to the DBT approach. First, psychodynamic techniques were incorporated to conceptualize patients' behavioral, emotional, and cognitive relationship schema. Second, in order to keep the treatment conditions equal with regard to clinical contact hours, we decided not to run a separate DBT skills training group, but to provide skills during the course of individual therapy. Six group sessions were provided to patients in both treatment conditions. In these six group sessions, the format for skills training groups was modified to focus on significant persons in patients' natural environment, such as partners, family
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m e m b e r s , friends, a n d o t h e r c o m m u n i t y s u p p o r t persons. CCT. T h e m o d e l o f supportive t r e a t m e n t used in this study was based on Carkhuff's (Carkhuff, 1969; Carkhuff, Pierce, & C a n n o n , 1976) m o d e l s o f client-centered therapy. F r o m this perspective, t r e a t m e n t emphasizes empathic u n d e r s t a n d i n g o f the patient's sense o f aloneness a n d providing a supportive a t m o s p h e r e for individuation. Carkhuff's t r e a t m e n t manuals provide directions for increasing the t h e r a p e u t i c relationship's e m p a t h i c a n d supportive elements. T h e CCT t r e a t m e n t p r o v i d e d patients with a safe therapeutic e n v i r o n m e n t a n d accurate e m p a t h i c reflection only. CCT a c c e n t u a t e d the therapist's role as a s u p p o r t e r a n d advocate. Therapists a i d e d patients in using selfc o n t r o l a n d reflection to r e d u c e stress. Clinicians d i d n o t i n t e r p r e t o r c o n f r o n t conflicts a n d defenses. T h e i r singular focus was to provide s u p p o r t to e n a b l e patients to deal with everyday stress a n d p r e v e n t relapse. T h e CCT t r e a t m e n t plan was s c h e d u l e d for 12 months. Sessions were s c h e d u l e d two times p e r week when possible. A t r e a t m e n t contract was d e v e l o p e d a n d signed by the p a r t i c i p a n t a n d therapist. T h e contract stipulated that patients would n o t m a k e a suicide a t t e m p t or e n g a g e in a self-harming act d u r i n g the course o f treatment. CCT t r e a t m e n t d i d n o t use a structured agenda. Instead, therapists instructed patients to express what was
o n their m i n d s at each session. F o u r phases characterized the CCT t r e a t m e n t p r o g r a m : (1) increased s u p p o r t during periods o f crisis, (2) p r o b l e m assessment, (3) supportive treatment, a n d (4) termination. D u r i n g the crisism a n a g e m e n t phase, therapists m e t with patients as often as 3 times p e r week.
Results
Table 1 presents the means a n d s t a n d a r d deviations o f the d e p e n d e n t variables for b o t h t r e a t m e n t groups at p r e t r e a t m e n t , 6 months, a n d 1 year. F o r the m a i n o u t c o m e analyses, the d e p e n d e n t variables were g r o u p e d in three categories. Measures evaluating self-harm/suicide severity i n c l u d e d the rating o f parasuicide, the BSI, and the patients' logs o f suicide/serf-harm attempts. Measures assessing affective disturbance included the rating o f anger, the BDI, the HRSD, the BAI, a n d the rating o f impulsiveness. T h e indicators o f global m e n t a l health f u n c t i o n i n g i n c l u d e d the BPRS a n d the n u m b e r of hospitalization days d u r i n g each 6-month period. Pret r e a t m e n t n u m b e r o f hospitalization days was based o n the 6 m o n t h s before the p r e t r e a t m e n t assessment. To d e t e r m i n e if the r a n d o m assignment p r o c e d u r e worked, we e x a m i n e d the p r e t r e a t m e n t values o f the dep e n d e n t variables for each o f the t h r e e categories o f outc o m e using a Hotelling's T 2 on the T r e a t m e n t factor. F o r
Table 1
Means and Standard Deviations of Dependent Measures for Client-Centered Therapy and Dialectical Behavior-Oriented Therapy DBT-Oriented Therapy (n = 12)
Client-Centered Therapy Control (n = 12) Measure Rating of Parasuicide Beck Suicide Ideation Scale Number of Suicide/Self-Harm Attempts Rating of Impulsiveness Rating of Anger Beck Depression Inventory Hamilton Depression Rating Beck Anxiety Inventory Brief Psychiatric Rating Scale Hospitalization Days
Pretreatment
6 Months
12 Months
Pretreatment
6 Months
12 Months
7.25 (.75) 23.53 (3.34) 13.58 (3.34) 7.58 (.51) 7.08 (.90) 27.75 (6.11) 17.42 (4.46) 20.42 (3.45) 30.83 (6.00) 10.00 (8.11)
4.33 (1.92) 13.33 (9.79) 6.75 (5.97) 6.67 (.78) 5.92 (.79) 24.75 (4.94) 13.67 (2.93) 17.08 (5.82) 25.83 (8.40) 10.75 (16.27)
4.25 (2.18) 11.58 (9.21) 5.58 (5.28) 6.08 (1.08) 5.67 (1.15) 24.08 (5.55) 12.58 (3.90) 14.83 (6.34) 25.33 (3.94) 13.00 (15.34)
7.17 (.83) 24.08 (3.73) 14.08 (3.73) 7.42 (.51) 7.33 (.65) 27.58 (5.30) 20.75 (4.33) 19.25 (3.55) 30.33 (6.56) 10.20 (3.37)
2.08 (2.02) 2.83 (3.49) 2.17 (1.95) 5.83 (.83) 5.00 (1.21) 18.08 (7.91) 8.58 (6.58) 12.58 (4.89) 18.42 (7.33) 2.67 (6.58)
1.50 (1.98) 3.83 (8.03) .75 (1.23) 4.58 (1.62) 4.67 (1.30) 14.92 (8.26) 7.50 (5.96) 10.17 (6.53) 18.17 (7.90) .75 (1.96)
Borderline Personality Disorder all t h r e e construct-clusters, t h e r e were n o significant initial differences between the groups. O u t c o m e Assessment To assess the comparative effectiveness o f the two treatments, a three-factor repeated-measures Multivariate Analysis o f Variance (RMMANOVA) analysis was c o n d u c t e d on each construct-cluster o f d e p e n d e n t measures. T r e a t m e n t c o n d i t i o n was the between-subjects factor. Time of assessment was the repeated-measures factor. Post hoc analyses were d o n e using the Roy-Bose 95% Multivariate Simultaneous J o i n t Confidence Bounds procedure. R e g a r d i n g suicide/self-harm behavior, the analysis showed that significant i m p r o v e m e n t s in patients' behavior were o b t a i n e d for b o t h treatments over time, F(6' 84) 26.8, p = .001, R 2 = .657; however, the DBT-oriented therapy patients' gains were g r e a t e r t h a n those receiving CCT at b o t h 6 m o n t h s a n d 12 months, F(6 ' s4) = 5.1, p = .001, R 2 = .268. T h e measures involved in the significant effects were the rating o f parasuicide [95% CI (.559, 2.83)], the BSI [95% CI (3.1, 11.3)], a n d n u m b e r of suicide a n d self-harm attempts [95% CI (.24, 5.7)] favoring DBT at 6 m o n t h s a n d 12 months. T h e results showed b o t h treatments i m p r o v e d patients' functioning in the e m o t i o n a l d o m a i n measures over time, F(10, so) = 13.2, p = .0001, R 2 = .62. However, again there was a significant T r e a t m e n t × T i m e interaction, F(10,so) = 2.6, p = .008, R 2 = .25. DBT-oriented therapy p r o d u c e d significantly lower scores t h a n CCT o n Impulsiveness at 12 m o n t h s [95% CI (.21, 1.4)], b u t n o t at 6 months. A n g e r ratings were significantly lower at 12 m o n t h s for the DBT-oriented t r e a t e d g r o u p [95% CI (.27, 1.3)]. Depression, as m e a s u r e d by the BDI a n d HRSD, was significantly lower in the DBT-oriented therapy at 12 months, b u t n o t at 6 m o n t h s [95% CI (1.3, 9.3) a n d 95% CI (.90, 5.5)]. T h e r e were no statistically significant differences between the two treatments o n anxiety as m e a s u r e d by the BAI at 6 m o n t h s or 12 months. R e g a r d i n g global m e n t a l h e a l t h functioning, there was a significant Time effect, F(4' 19) = 5.3, p = .005, R z = .53, a n d a significant T r e a t m e n t × T i m e interaction, F(4, s6) = 2.4, p = .05, R 2 = .27. A l t h o u g h b o t h treatments p r o d u c e d significant reductions in BPRS scores, DBTo r i e n t e d t h e r a p y p r o d u c e d significantly greater reductions at 12 m o n t h s [95% CI (1.3, 8.8)]. DBT-oriented t h e r a p y r e d u c e d hospitalization days significantly m o r e at b o t h 6 m o n t h s a n d 12 m o n t h s [95% CI (.43, 13.9)]. =
Assessment o f Clinical Significance and Effectiveness To assess the clinical significance o f the statistical findings, cutoff scores signifying an absence of clinically significant symptoms for each o u t c o m e measure were e i t h e r drawn from the literature for an i n d i c a t o r o r clinically det e r m i n e d when there was n o guiding normative data.
T h e two treatments were then c o m p a r e d on how m a n y patients m o v e d below the cutoff score on each o u t c o m e indicator by the 12-month assessment. Suicide~self-harm behavior. A rating o f 2 o r lower on the I n d e p e n d e n t Rater Parasuicide Rating Scale was j u d g e d to indicate a n e a r absence of symptoms. T h r e e CCT patients a n d 11 DBT-oriented t h e r a p y patients o b t a i n e d ratings below 2, which was statistically different, Xe(1) = 10.9, p = .001. T h e BSI has a suggested cutoff score o f 3; 11 DBT-oriented therapy patients a n d 4 CCT patients o b t a i n e d scores o f 3 o r below by m o n t h I2; this was also statistically significant, X2(1) = 8.7, p = .003. F o r the selfr e p o r t e d suicide attempts a n d self-harm behavioral incidents, it was d e c i d e d that only a score o f zero reliably ind i c a t e d a clinically significant r e d u c t i o n in symptoms. Again, as with the BSI, 11 DBT-oriented t h e r a p y patients a n d 4 CCT patients achieved this goal. Across all t h r e e measures o f the s u i c i d e / s e l f - h a r m d o m a i n , DBT-oriented therapy m o v e d 11 o f 12 patients into the clinically improved zone. Emotional disregulation. A rating o f 2 o r lower on the I n d e p e n d e n t Rater Impulsiveness Rating Scale a n d the A n g e r Rating Scale was j u d g e d to indicate a n e a r absence o f symptoms. Only 2 DBT-oriented therapy patients a n d n o n e o f the CCT patients achieved this goal o n the impulsiveness rating; this was n o t a significant difference, X2(1) 2.2, p = .140. N o n e o f the patients in either g r o u p achieved this goal for the a n g e r rating. Scores below 10 on b o t h the BDI a n d the BAI are c o n s i d e r e d m i l d a n d n o t clinically significant. Therefore, for these two measures, patients receiving scores o f less t h a n 10 were cons i d e r e d clinically improved. Six patients receiving DBTo r i e n t e d t r e a t m e n t a n d no CCT patients achieved scores of less than 10 on the BDI. This was a statistically significant finding, X20) = 8.0, p --- .005. O n the BAI, 6 DBT-orie n t e d t r e a t m e n t patients a n d 2 CCT patients achieved this clinical goal. However, this was n o t a statistically significant difference, X2(a) = 2.7, p --- .1. O n the HDRS, we also used a cut score o f 10 to d e m a r c a t e the clinically imp r o v e d category. Five CCT patients a n d 9 DBT-oriented therapy patients achieved this goal on the HDRS; however, this was n o t a significant difference, X2(1) = 2.7, p -.1. O n n o n e o f o u r e m o t i o n regulation measures d i d CCT o b t a i n b e t t e r clinical results; however, t h e r e was m u c h less success overall for moving patients into the n o n s y m p t o m a t i c range. For n e i t h e r impulsiveness n o r a n g e r was there any evidence o f clinically significant imp r o v e m e n t with e i t h e r treatment. While the n u m b e r s favored DBT-oriented therapy o n the BDI a n d the BAI, only 6 DBT-oriented t h e r a p y patients m o v e d into the clinically i m p r o v e d range o n e i t h e r measure. T h e HDRS showed a b e t t e r o u t c o m e with r e g a r d to depression than the BDI d i d for b o t h groups, b u t t h e r e was n o t a reliable difference between the treatments. =
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Impact of treatment indicators. For the n u m b e r o f days o f psychiatric hospitalization, zero was set as the clinically relevant cutoff point. Ten DBT-oriented t h e r a p y patients a n d 6 CCT patients achieved this goal d u r i n g the last 6 m o n t h s o f the study. This finding was n o t significant at traditional c o n f i d e n c e levels, ×2(a) = 3.0, p = .08. F o r the BPRS, the cutoff score was set at 15. Five DBT-oriented therapy patients a n d n o CCT treated patients achieved this The results goal; this was statistically significant, X2(1~ = 6.3, p - .01, suggest that DBTdespite the low n u m b e r o f paoriented therapy tients c h a n g i n g their global can be more psychopathology status. Taken together, it does a p p e a r that effective than DBT-oriented therapy m a d e providing only the clinically significant improvesupportive ments in these impact-oftreatment-level indicators. At components of least 5 DBT-oriented therapy psychotherapy. patients r e a c h e d clinical imp r o v e m e n t on b o t h measures, a n d a n o t h e r 5 were able to stay o u t o f the hospital. In contrast, n o CCT patients were able to simultaneously achieve clinical i m p r o v e m e n t o n b o t h indicators. Assessment of Treatment Credibility At the 6-month evaluation, patients r a t e d their confid e n c e that their t r e a t m e n t was credible o n a 7-point Likeft scale. This strategy was used to test the hypothesis that significant differences between the treatments were because o f differential credibility o f the treatments. T h e analysis f o u n d no significant difference between treatments r e g a r d i n g credibility, t(22) : 1.63, p = .116. Assessment of Helping Alliance Differences At the 6-month evaluation, patients were asked to c o m p l e t e the l 1-item H e l p i n g Relationship Questionnaire ( H R Q ; Luborsky, 1984). Patients' scores o n the H R Q were first analyzed to d e t e r m i n e if differences between treatments d e t e c t e d in the m a i n o u t c o m e analyses were plausibly d u e to differences in the quality o f the h e l p i n g alliance. T h e r e was n o significant difference between treatments o n the H R Q , F(1' ~6) = 1.10, p =. 31. Second, an analysis was c o n d u c t e d to d e t e r m i n e if patients' h e l p i n g alliance e x p e r i e n c e was related to their outcome. A canonical correlation analysis was used to regress t r e a t m e n t a n d H R Q scores simultaneously o n the whole set o f d e p e n d e n t variables. T h e H R Q scores were t r e a t e d as a c o n t i n u o u s variable. T h e t r e a t m e n t factor was c o d e d as a d u m m y variable. O n e significant canonical function was o b t a i n e d (R 2 = .79, ~ = .182, X2(18) : 28.954, p = .049). T h e s t a n d a r d i z e d canonical coefficients for the i n d e p e n d e n t variables were G r o u p = .631
a n d H R Q = .628. Thus, the h e l p i n g alliance a c c o u n t e d for as m u c h variance in the patients' i m p r o v e m e n t as the differences in the t r e a t m e n t conditions. T h e d e p e n d e n t variables with s t a n d a r d i z e d canonical coefficients above .4 were BSI = .84, suicide a t t e m p t s / s e l f h a r m behavior = .80, HRSD = .70, BPRS = .58, rating o f self-harmful behavior = .56, a n d the BDI = .40.
Discussion T h e p r e s e n t study's results s u p p o r t a growing literature that suggests that BPD patients can o b t a i n b e t t e r o u t c o m e s from psychosocial t r e a t m e n t than previously t h o u g h t ( L i n e h a n et al., 1991; Stone, 1990). Specifically, the results suggest that DBT-oriented therapy can be m o r e effective than providing only the supportive comp o n e n t s o f psychotherapy. Patients receiving DBTo r i e n t e d therapy showed greater i m p r o v e m e n t than patients receiving CCT on measures o f suicide a n d selfh a r m behavior, suicidal ideation, depression, impulsiveness, anger, global psychological functioning, a n d a r e d u c t i o n in days s p e n t in psychiatric hospitals. Furthermore, DBT-oriented t r e a t m e n t led to clinically significant i m p r o v e m e n t for the most i m p o r t a n t p r o b l e m facing BPD patients: suicide a n d self-harm behavior. DBTo r i e n t e d therapy also led to clinically significant improvem e n t in some areas o f e m o t i o n a l regulation a n d o n the i m p a c t o f treatment, albeit, m o r e modestly. In addition, DBT-oriented t r e a t m e n t m a i n t a i n e d patients in therapy slightly l o n g e r than CCT. These results c a n n o t be attribu t e d to differences between the treatments in terms o f credibility o r t h e r a p e u t i c alliance. T h e results o f this study cross-validate the findings o f Koons et al. (1998), L i n e h a n et al. (1991), L i n e h a n et al. (in press), a n d Stanley et al. (1998) that show DBT-oriented t h e r a p y to be efficacious for BPD problems. Importantly, to the best o f o u r knowledge, this study is the first e x p e r i m e n t a l test o f DBT-oriented t r e a t m e n t using a comparative psychotherapy c o n t r o l c o n d i t i o n for BPD problems. In addition, the p r e s e n t study contrasted DBT-oriented therapy with CCT using an intent-to-treat design in a c o m m u n i t y m e n t a l health setting. All patients were evaluated at every assessment p o i n t regardless o f w h e t h e r they r e m a i n e d in treatment. However, in this study, the quality o f the t h e r a p e u t i c alliance was shown to a c c o u n t for as m u c h variance in i m p r o v e m e n t as the treatments across all o u t c o m e indicators taken together. These results p r o m p t e d an additional set o f post hoc analyses that focused on d e t e r m i n i n g if there were any differential therapists results in the outcomes. It t u r n e d out that o n e clinician was m o r e effective using CCT while three were m o r e effective using DBT. Surprisingly, one clinician was m o r e effective than the others regardless o f the t r e a t m e n t model. T h r e e plausi-
Borderline Personality Disorder line personality. InternationalJournal of Psychoanalytic Psychotherapy, 9, 51-87. Carkhuff, R. R. (1969). Helping and human relations. New York: Holt, Rinehart, & Winston. Carkhuff, R. R., Pierce, R., & Cannon, J. (1976). The art of helping. Amherst, MA: Human Resources Press. Gunderson,J. G., Kolb,J. E., & Austin, V. (1981). The diagnostic interview for borderlines. American Jou.mal of Psychiatry, 138, 896-903. Hamilton, M. (1960). A rating scale for depression. Journal of Nenrology, Neu~vsurgery, and Psychiatry, 23, 56-62. Hamilton, M. (1967). Development of a rating scale for primary depressive illness. B'ritish Journal of Social and Clinical Psychology, 6, 278-296. Koons, C. R., Robbins, C.J., Bishop, G. K., Morse, J. Q., Tweed, J. L., Lynch, T. R., Gonzales, A. M., Butterfield, M. L, & Bastian, L. A. (1998, November). Efficacy of dialectical behavior therapy with borderline women veterans: A randomized controlled trial Paper presented at the meeting of the Association for Advancement of Behavior Therapy, Washington, DC. Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder. New York: Guilford Press. Linehan, M. M., Armstrong, H. E, Suarez, A., Allmon, D., & Heard, H. L. (1991). Cognitive-behavioral treatment of chronically parasuicidal borderline patients. Archives of General Psychiatry, 48, 1060-1064. Linehan, M. L., Schmidt, H. I., Dimeff, L. A., Craft, J. C., Kanter, J., & Comtois, K.A. (in press). Dialectical behavior therapy for patients with borderline personality disorder and drug-dependence. American Journal of Addictions. Loranger, A. (1988). Personality disorder examination manual Yonkers, NY: D.V. Communications. Luborsky, L. (1984). Principles of psychoanalytic psychotherapy. New York: Basic Books. Luborsky, L., Barber, J. E, & Beutler, L. E. (1993). Introduction to special section: A briefing on curative factors in dynamic psychotherapy.Journal of Consulting and Clinical Psychology, 61, 539-541. Overall, J. E., & Gorman, G. R. (1962). The brief psychiatric rating scale. Psychological Reports, 1 O, 799-812. Rathus, J. H., & Miller, A. L. (2000). DBT for adolescents: Dialectical dilemmas and secondary treatment targets. Cognitive and Behavioral Practice, 7, 425-434. Spitzer, R. L., Williams, J. B., Gibbon, M., & First, M. B. (1990). User's gaide for the structured clinical interview for DSM-III-R (SC1D). Washington, DC: American Psychiatric Press. Stanley, B., Ivanoff, A., Brodsky, B., & Oppenheim, S. (1998, November). Compa,4son of DBT and "treatment as usual" in suicidal and self-mutilating behavior. Paper presented at the meeting of the Association for Advancement of Behavior Therap)~ Washington, DC. Stone, M. H. (1990). The fate of borderline patients. New York: Guilford Press.
ble e x p l a n a t i o n s c o m e to m i n d f o r t h e t h e r a p i s t differe n c e s o b s e r v e d in t h e s e analyses. First, t h e therapists m a y n o t have b e e n equally p r o f i c i e n t u s i n g D B T a n d CCT. T h i s m i g h t b e d u e to an insufficiently specified D B T m o d e l o r flaws in t h e t r a i n i n g p r o g r a m . S e c o n d , differe n c e s in therapists' beliefs a n d e x p e c t a n c i e s a b o u t t h e t r e a t m e n t s m i g h t h a v e c o n t r i b u t e d to differential p a t i e n t o u t c o m e s . However, since all f o u r therapists p r a c t i c e d c l i e n t - c e n t e r e d , p s y c h o d y n a m i c a l l y o r i e n t e d a n d family systems a p p r o a c h e s , it is s u r p r i s i n g t h a t t h e y p e r f o r m e d so well with the i n t e g r a t e d c o g n i t i v e b e h a v i o r a l m o d e l . T h i s is possibly d u e to t h e c o n t i n u o u s t r a i n i n g a n d supervision t h e y r e c e i v e d t h r o u g h o u t t h e study; this v i e w p o i n t agrees with L i n e h a n ' s (1993) assertion t h a t c o n t i n u o u s s u p e r v i s i o n p r i m a r i l y d e t e r m i n e s positive p s y c h o t h e r a p y o u t c o m e with BPD patients. A n o t h e r possibility is t h a t t h e therapists h a d d i f f e r e n t attitudes a n d e x p e c t a n c i e s specifically a b o u t t r e a t i n g BPD patients. Finally, p e r h a p s t h e r e are j u s t s o m e very e x c e l l e n t therapists a n d s o m e o f m o r e m o d e s t abilities. T h e results o f this study s h o u l d n o t b e i n t e r p r e t e d as d e m o n s t r a t i n g t h a t c l i e n t - c e n t e r e d a n d s u p p o r t i v e psyc h o t h e r a p i e s in g e n e r a l are ineffective with BPD patients. T h e r e was n o c o n t r o l c o n d i t i o n to w a r r a n t this appraisal. T h e p r o v i s i o n o f C C T with t h e r i g h t t h e r a p i s t w o r k e d well f o r s o m e BPD patients. T h e s e f i n d i n g s s u p p o r t t h e opinion that the alliance-building supportive and emp a t h i c e l e m e n t s o f t r e a t m e n t are i m p o r t a n t for p a t i e n t i m p r o v e m e n t . W h a t we c o n c l u d e h e r e is t h a t the provision o f a strategic a n d i n t e g r a t e d set o f t h e r a p e u t i c strategies adds to t h e p r o v i s i o n o f s u p p o r t i v e e l e m e n t s for m a n y b o r d e r l i n e patients. Specifically, it a p p e a r s that t h e p r o v i s i o n o f D B T strategies a n d i n t e r v e n t i o n s in t h e cont e x t o f a s o u n d t h e r a p e u t i c r e l a t i o n s h i p leads to a clinically significant r e d u c t i o n o f s o m e o f t h e m o s t d a n g e r o u s p r o b l e m s associated with BPD.
References
I am extremely grateful to my clinician colleagues for their generous time and help in conducting this study. I especially want to thank Lynne Becker and Crystal DeLoach for their diligent work and collaboration. I am indebted to Marsha Linehan and Tracie Shea for their critical reading and feedback on earlier versions of this manuscript. Address correspondence to Ralph M. Turner, Ph.D., Health Psychology Section, Department of Social Sciences, 600 South 43rd Street, Philadelphia, PA 19104-4495; e-mail: MACTURNER@AOL. COM.
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Received: March 3, 2000 Accepted: September30, 2000
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