Vous êtes sur la page 1sur 6

ARTICLE IN PRESS

Behaviour Research and Therapy xxx (2009) 16

Contents lists available at ScienceDirect

Behaviour Research and Therapy


journal homepage: www.elsevier.com/locate/brat

Dialectical behaviour therapy skills training compared to standard group therapy


in borderline personality disorder: A 3-month randomised controlled clinical trial
Joaquim Soler a, c, *, Juan Carlos Pascual a, c, Thas Tiana a, c, Anabel Cebria` a, c, Judith Barrachina a, c, M.
Josefa Campins a, c, Ignasi Gich b, c, Enrique Alvarez a, c, Vctor Perez a, c
a
b
c

n Biomedica en Red de Salud Mental, CIBERSAM, St. Antoni M. Claret, 167, 08025 Barcelona, Spain
Department of Psychiatry, Santa Creu i Sant Pau Hospital, Centro de Investigacio
Department of Epidemiology, Santa Creu i Sant Pau Hospital, St. Antoni M. Claret, 167, 08025 Barcelona, Spain
`noma de Barcelona, Barcelona 08025, Spain
Universitat Auto

a r t i c l e i n f o

a b s t r a c t

Article history:
Received 14 July 2008
Received in revised form
4 December 2008
Accepted 20 January 2009

Dialectical behaviour therapy (DBT) has proven to be an effective treatment in borderline personality
disorder (BPD). However, the effectiveness in BPD of DBT skills training (DBT-ST) alone is not known. This
study aimed at comparing the efcacy of DBT-ST and standard group therapy (SGT) for outpatients with
BPD. Sixty patients meeting the DSM-IV diagnostic criteria for BPD, as assessed by two semi-structured
diagnostic interviews, were included in a 3-month, single-blind randomised controlled trial. A total of 13
weekly group psychotherapy sessions of 120 min of either SGT or DBT-ST were conducted. Assessments
were carried out every 2 weeks by two blinded evaluators. Observer-rater, self-report scales and behavioural reports were used as outcome measures. DBT-ST was associated with lower dropout rates, 34.5%
compared to 63.4% with SGT. It was superior to SGT in improving several mood and emotion areas, such as:
depression, anxiety, irritability, anger and affect instability. A reduction in general psychiatric symptoms
was also observed. Three-months weekly DBT-ST proved useful. This therapy was associated with greater
clinical improvements and lower dropout rates than SGT. DBT-ST seems to play a role in the overall
improvement of BPD seen with standard DBT intervention. It allows straightforward implementation in
a wide range of mental health settings and provides the additional advantage that it is cost effective.
2009 Elsevier Ltd. All rights reserved.

Keywords:
Dialectical behaviour therapy
Borderline personality disorder
Controlled trial

Introduction
People with borderline personality disorder (BPD) are regular
users of emergency services and may often require admission to
hospital. They will likely need long psychotherapies and require
more medications than other personality disorder or major
depression patients (Bender et al., 2006; Lieb, Zanarini, Schmahl,
Linehan, & Bohus, 2004). Moreover, BPD is associated with a high
prevalence of self-injurious behaviour and an incidence of
completed suicide of up to 10%, a rate over 50 times higher than
that in the general population. This results in a high consumption of
healthcare resources (American Psychiatric Association, 2001; Lieb
et al., 2004; Paris, 2002; Stone, 1998) and non-health care costs are
even higher (Van Asselt, Dirksen, Arntz, & Severens, 2007).

* Corresponding author. Department of Psychiatry, Santa Creu i Sant Pau


Hospital, Centro de Investigacion Biomedica en Red de Salud Mental, CIBERSAM, St.
Antoni M. Claret, 167, 08025 Barcelona, Spain. Tel.: 34 932919185; fax: 34
2919399.
E-mail address: jsolerri@santpau.cat (J. Soler).

Various psychosocial interventions have been used in the


treatment of BPD and have proved to be effective in randomised
clinical trials. Two of these psychological interventions are
psychodynamic-oriented treatments, mentalization-based treatment (Bateman & Fonagy, 1999, 2001) and transference focused
therapy (Clarkin, Kenneth, Lenzenweger, & Kernberg, 2007). The
others are variations of cognitive behavioural therapy, such as
schema-focused therapy (Giesen-Bloo et al., 2006), cognitive
behavioural therapy (Blum et al., 2008; Davidson et al., 2006) and
DBT (Koons et al., 2001; Linehan, Amstrong, Suarez, Allmon, &
Heard 1991; Linehan et al., 1999, 2006; Verheul et al., 2003).
The standard DBT procedure (Linehan, 1993a, 1993b) includes
four modes of intervention: group therapy, individual psychotherapy, phone calls, and consultation team meetings. The group
component consists of approximately 2 h a week of skills coaching,
and it aims to increase behavioural capabilities. Individual
psychotherapy consists of approximately one-hour weekly session
whose objective is to improve motivation to change and reduce
target problem behaviours. The phone call mode focuses on
generalizing skills to daily life, preserving the therapeutic relationship, and learning how to ask for help. The consultation team

0005-7967/$ see front matter 2009 Elsevier Ltd. All rights reserved.
doi:10.1016/j.brat.2009.01.013

Please cite this article in press as: Soler, J., et al., Dialectical behaviour therapy skills training compared to standard group therapy in..., Behaviour
Research and Therapy (2009), doi:10.1016/j.brat.2009.01.013

ARTICLE IN PRESS
2

J. Soler et al. / Behaviour Research and Therapy xxx (2009) 16

meetings are attended by all the therapists using DBT and they are
held weekly. These meetings aim to provide support for therapists,
maintain motivation and adherence to the treatment model, and
help to prevent burn out.
Although several studies have introduced modications in the
application of the original design, these adaptations have adjusted
DBT to other settings, such as BPD inpatients (Bohus et al., 2004) or
to other disorders, such as binge eating disorder (Telch, Agras, &
Linehan, 2001).
One study using this standard DBT treatment for BPD (Lindenboim, Comtois, & Linehan, 2007) focused especially on the
group component. The authors examined the type and frequency
of skills practised by patients receiving one year of standard DBT as
a part of a clinical trial (Linehan et al., 2006). This study addressed
several questions regarding the skills in standard DBT treatment. In
contrast with what is traditionally expected concerning compliance in BPD patients, they reported using some skills regularly,
a minimum of at least one skill on most days. The average was
more than four skills per day during the one year of treatment. This
skills practice increased over the course of treatment, especially in
the rst months of the therapy. Another nding of interest was
that patients preferred to use skills aimed at acceptance rather
than change. Although it seems clear that the group mode of DBT
in BPD may be partially responsible for the positive outcomes
reported in this setting, there is no evidence that DBT-ST treatment
is an efcacious intervention without the individual DBT therapy
mode. In a nonpublished study, Linehan et al. (Linehan, 1993a)
assigned a subgroup of BPD patients receiving non-DBT individual
therapy to DBT-ST. The results suggested that adding DBT-ST to
non-DBT individual therapy was no more effective than non-DBT
individual therapy, and less effective than individual DBT plus
DBT-ST treatment. Only one controlled study has been published
(Springer, Lohr, Buchtel, & Silk, 1996) to date. It compares contentreduced DBT-ST to a non-psychotherapeutic discussion group.
Subjects in both groups signicantly improved in most change
measures although no signicant between-group differences were
found. The ndings from this study are limited because treatment
was short (13 weekdays), the sample characteristics were not
homogenous (inpatients with different personality disorders),
diagnosis was made by means of a self-reported questionnaire, and
considerable modications were introduced in the standard
content of DBT skills training (e.g. the Mindfulness module was not
taught).
Skills training is an essential element in DBT treatment in view of
the skills decit underlying BPD. It can be conceptualised as a set of
abilities to manage emotional instability and has been adapted to
and tested in other diagnoses. In a controlled study that compared
an adapted 20-session DBT-ST to waiting list condition in binge
eating disorder (Telch et al., 2001), the intervention was associated
with a decrease in binge eating behaviour immediately post treatment and at 6-months follow-up. Similarly, DBT-ST plus medication
and scheduled telephone coaching have been successfully adapted
to treat older depressed patients and have been associated with an
improvement in depressive symptoms compared with medication
(Lynch, Morse, Mendelson, & Robins, 2003).
Although skills training is thought to play an important role in
DBT treatment, is frequently used by BPD patients and have
proved to be useful in other disorders such as binge eating
disorder or depression, they are not adequately been tested in BPD
patients. The aim of this randomised controlled clinical trial was to
evaluate whether skills training, one of the four modes of DBT
intervention, was sufcient to induce an observable improvement
in people with BPD in comparison with standard group therapy
(SGT) administered over the same number of hours in a 3-month
period.

Method
Participants
A total of 63 patients were included (participants were recruited
from outpatient facilities and emergency service). Inclusion criteria
consisted of: 1) meeting the DSM-IV diagnostic criteria for BPD as
assessed by two semi-structured diagnostic interviews: the Structured Clinical Interview for DSM-IV Axis II Disorders (SCID-II;
Gomez-Beneyto et al., 1994) and the Revised Diagnostic Interview
for Borderlines (DIB-R; Barrachina et al., 2004); 2) age between 18
and 45 years; 3) no comorbidity with schizophrenia, drug-induced
psychosis, organic brain syndrome, alcohol or other psychoactive
substance dependence, bipolar disorder, mental retardation, or
major depressive episode in course; 4) Clinical Global Impression of
Severity (CGI-S; Guy, 1976) score  4; 5) no current psychotherapy.
This study was approved by the clinical research ethics review
board at our centre. After giving a full description of the study,
written informed consent was obtained from all participants.
Study design and procedure
This was a single-centre, randomised, single-blind, two-group
clinical trial. Blocks of four generated using the SPSS software
program served for the randomisation to DBT-ST or SGT.
Subjects included in the study had two interview visits to
establish a pre-intervention baseline. No therapeutic intervention
was carried out in this phase. All participants were then randomised to DBT-ST or SGT group psychotherapy intervention
(13 weekly sessions). During the therapy period, participants were
evaluated every 2 weeks by experienced psychiatrists. Subjects
were instructed not to disclose any information about the group
(topics, group members or therapists) to maintain blind conditions.
Both interventions, DBT-ST and SGT, consisted of thirteen psychotherapy sessions of 120 min each, conducted by 2 therapists (a male
and a female) for each group, in groups of 911 participants. During
the study, participants did not receive any other individual or group
psychotherapy. The two therapies were conducted at different
times to avoid participants meeting the members of the other
group. The DBT format used was adapted from the standard version
(Linehan, 1993a, 1993b), applying one of the four modes of intervention: skills training. DBT-ST included all the original skills. These
skills can be divided into those that promote change, interpersonal
effectiveness and emotional regulation skills, and those that
promote acceptance, mindfulness and distress tolerance skills.
Interpersonal effectiveness: training in interpersonal problem
solving and assertion. It deals with learning strategies to ask for
what one needs, to say no to requests when appropriate, and to
achieve interpersonal goals, while taking care of relationships and
self-respect.
Emotion regulation: learning skills to decrease labile affect. It
includes learning to identify, label and describe emotions, using
mindfulness on emotion experience, reducing vulnerability to
negative emotions, increasing the occurrence of positive emotions,
and acting in an opposite manner to motivational tendency associated with negative emotion.
Mindfulness: developing attentional control, nonjudgemental
awareness and sense of true self. Participants learn to simply
observe and then describe events, thoughts, emotions and body
sensations, and fully participate in their actions and experiences in
a non-evaluative manner, focusing on one thing at a time and
reorienting attention when distracted.
Distress tolerance: focusing on acceptance of painful emotions
without trying to change them. The module is divided into crisis
survival skills which are short-term strategies to tolerate a stressful

Please cite this article in press as: Soler, J., et al., Dialectical behaviour therapy skills training compared to standard group therapy in..., Behaviour
Research and Therapy (2009), doi:10.1016/j.brat.2009.01.013

ARTICLE IN PRESS
J. Soler et al. / Behaviour Research and Therapy xxx (2009) 16

situation without reacting, and reality acceptance skills which are


long-term abilities for those aversive situations that are unlikely to
change.
Similar to other skills training in behavioural treatments, DBT-ST
includes teaching, in-session practice of new skills and homework
assignments to practice each skill every week. The homework
assignments are reviewed in the next session.
So as to shorten the length of therapy in our application, the
modules were not repeated. We aimed to compensate for this
absence of repetition, rstly, by giving a printout of reinforcement
exercises from previous modules as additional homework each
week, and secondly, enhancing the acquisition of the mindfulness
skill by doing a brief mindfulness exercise at the beginning of each
session.
DBT-ST intervention was led by two cognitive behavioural
psychotherapists with prior experience in BPD group therapy (Soler
et al., 2001, 2005) and trained in DBT in courses organised by the
Behavioural Technology Transfer Group.
The SGT format was oriented to provide a relational experience,
allowing people with BPD to share their characteristic difculties.
Prominent techniques used were interpretation (although this was
not used systematically), highlighting, exploration, clarication and
confrontation. The therapists mainly played a role of conductor in
group interactions, and targeted specially nihilistic or destructive
interactions, characteristic BPD interactions and those that could
interfere with group functioning. SGT interventions were led by
two experienced psychodynamic-oriented psychotherapists. All
patients in both treatment groups continued pharmacological
therapy if it had been initiated prior to inclusion. Type and doses of
medication could not be modied during the study period.
Assessment and drug control were carried out by two psychiatrists who were masked to the experimental conditions. Each
patient had a fortnightly appointment with the same evaluator and
the following observer-rater and self-report scales were
administered.
Instruments
The outcome measures included a wide range of symptom
scales, the Clinical Global Impression-Borderline Personality
Disorder (CGI-BPD; Perez et al., 2007) for BPD core symptoms, the
17-item Hamilton Rating Scale-Depression (HRSD-17; Hamilton,
1960) for affective symptoms; the Hamilton Rating Scale-Anxiety
(HRSA; Hamilton, 1959) for anxiety symptoms; and the Brief
Psychiatric Rating Scale (BPRS; Overall & Gorham, 1962) for
psychotic symptoms. Psychiatric symptoms were assessed by
Derogatis Symptom Checklist, Revised (SCL90-R; Derogatis, Lipman, & Covi, 1973); hostility/irritability with the BussDurkee
Inventory (BDI; Buss & Durkee, 1957); and Impulsivity with the
Barrat Inventory (BI; Barratt, 1995). In addition to clinical scales, we
rated self-injury, suicide attempts, and visits to psychiatric emergency service.
Data analyses
All analyses were conducted on an intention-to-treat basis.
Patients were included in the analyses only if they had a baseline
measure and at least one post-baseline measure.
Demographic and clinical variables were compared using the
chi-square test for categorical variables and t-test for continuous
variables. A paired t-test was also used for the before and after
treatment intervention comparisons. KaplanMeier survival analysis was used for time to dropout.
Hierarchical Linear Modelling (HLM) was used as the primary
method to investigate treatment, time and the interaction with the

Total screened : 114


BaseLine : 63
Not randomized : 3
(All cases patient decision)
Randomized : 60
Allocated to DBT-ST : 29

Allocated to UGT : 30

End of the study : 19

End of the study : 11

Drop out : 10
3 Inpatient hospitalization
7 Patient decision

Drop out : 19
6 Inpatient hospitalization
13 Patient decision

Retention : 65.5%

Retention : 36.6%

Fig. 1. Flow diagram of patient progress through phases of the study.

MIXED procedure of SPSS. We determined the appropriate covariance structure using Akaikes and Schwarzs information criteria. The
method used was restricted maximum likelihood, and the normality
for residuals was evaluated with a KolmogorovSmirnov test.
All tests were performed using a two-sided approximation, and
with a signicance level set at 0.05. All analyses were performed
using SPSS 15.0 software.

Results
Patient demographics and baseline clinical characteristics
From a total of 114 subjects evaluated, 63 met the inclusion
criteria. Patient ow and reason for dropout are presented in Fig. 1.
Three patients dropped out of the study during baseline visits.
A total of sixty subjects were randomised (1:1). As shown in Table 1,
there were no signicant differences between the two groups in
terms of demographic variables, pharmacological treatment or
clinical severity. One patient in the DBT-ST group was excluded
from the analysis as she did not attend any psychotherapy sessions
Table 1
Demographic and clinical variables at baseline.
Variable

DBT-ST
N

Female sex*
Completed Study*

23
19

79.3
65.5

26
11

86.7
36.6

ns.
.027

72.4
82.8
51.7
51.7

22
24
14
9

73.3
80
46.7
30

ns.
ns.
ns.
ns.

SD
6.55
4.89
5.46
5.58
.88
.91
.79
17.38
11.56

Mean (Range)
29.97 (2139)
19.23 (1227)
19.17 (1127)
14.23 (731)
2.45 (1.373.65)
7.2 (69)
4.9 (47)
77.33 (60102)
47.23 (1964)

SD
5.63
4.20
4.46
5.83
.60
.99
.71
11.33
12.09

p
ns.
ns.
ns.
ns.
ns.
ns.
ns.
ns.
ns.

Pharmacological Treatment
Antidepressants
21
Benzodiazepines
24
Antipsychotics
15
Mood Stabilizers
15
Age
HRSD
HRSA
BPRS
SCL90-R (GSI)
DIB-R
CGI-BPD (global)
BI
BDI

Mean (Range)
28.45 (1941)
17.83 (829)
20.28 (1234)
15 (832)
2.34 (.633.63)
7.52 (69)
4.71 (47)
70 (3399)
46.08 (2166)

SGT

Note: Continuous variables were compared using t-tests. Proportions (*) were
compared using Chi-square tests. P values are 2-tailed.

Please cite this article in press as: Soler, J., et al., Dialectical behaviour therapy skills training compared to standard group therapy in..., Behaviour
Research and Therapy (2009), doi:10.1016/j.brat.2009.01.013

ARTICLE IN PRESS
4

J. Soler et al. / Behaviour Research and Therapy xxx (2009) 16

Table 2 presents a summary of the mean pre- and post-intervention measurements for those patients that completed the study
and the signicant group  time interactions on intent to treat HLM
analysis. The DBT-ST group showed a signicant improvement in
more psychopathology scales.
In the HLM analysis of differences between DBT-ST and SGT
groups, the former showed a greater decrease in depression,
anxiety and general psychiatric symptoms compared with the SGT
group. The difference between treatment groups in HRSD was,
F(37.93) 4.59, p .001, as can be observed in Fig. 3. The HRSA
scale and the BPRS scale also showed signicant differences
between groups, F(39.97) 2.45, p .034, and F(32.95) 2.90,
p .018, respectively (see Table 2).
Regarding the SCL90-R, HLM analysis showed statistically
signicant differences in the psychoticism subscale, F(21.92) 3.95,
p .034, and in the BDI irritability subscale, F(17.72) 4.37,
p .028. A greater decrease was detected in the DBT-ST condition.
Both treatment conditions showed signicant reductions in
CGI-BPD global severity scores. However, no signicant differences
were displayed between groups in HLM analysis. In this measure,
several specic sub-scales, such as: anger, F(38.69) 3.26, p .008,
emptiness, F(37.47) 2.80, p .019, and affect instability,
F(37.65) 3.74, p .004, had a signicantly greater reduction in
DBT-ST compared to SGT. No differences were seen in the other
scales (BI) or behavioural reports (number of self-harm behaviours,
suicides or emergency visits) used in the study.

100

Percent survival

DBT
SGT

50

0
1

10

11

12

13

Time to drop out


Fig. 2. Survival analysis for time to dropout. The treatment period ended at 13 weeks.
Note: Hazard Ratio .67, p .029, CI 1.132.33.

and failed to complete any assessments. Fifty-nine patients initiated the experimental phase.
Efcacy
Patients were considered dropout if they directly expressed
their intention to dropout, if they failed to attend three or more
consecutive group sessions, or if they required psychiatric inpatient
hospitalisation. This latter criterion was used as it might compromise attendance to the group session on more than one occasion
and because it normally implies signicant changes in medication.
Signicant differences were observed in time to dropout, Hazard
Ratio .67, p .029, CI 1.132.33 (Fig. 2). Ten DBT patients (34.5%)
and 19 SGT patients (63.4%) failed to complete the study, c2 (1,
N 59) 4.911, p .027. Both groups were similar in needs for
inpatient hospitalisation but they differed signicantly in dropout
related to patient decision, c2 (1, N 59) 3.860, p .049. We did
not observe signicant differences regarding the mean number of
attended sessions between the two groups.

Discussion
In this study we found that DBT-ST was associated with higher
retention rates than SGT. Patients treated with DBT-ST had almost
a 30% greater probability of completing treatment than the SGT
group and only half the number of dropouts. Participant retention
procedures in DBT rely mainly on individual therapy and telephone
consultation and previous studies have reported good retention
rate in DBT interventions (over 70%). By means of DBT-ST intervention over three months we obtained a retention rate of 65.5%,
similar to that in study where DBT-ST was accompanied with
telephone consultation (Soler et al., 2005). Behavioural therapies

Table 2
Pre- and post-intervention measures and signicant interactions on HLM analysis.
Scales

DBT-ST

SGT

Pre-treatment

Post-treatment

Mean

SD

Mean

17.05
19.63
13.74

3.83
5.20
4.13

11.11
13.00
8.74

9.63
7.06

1.02
1.61

8.38
6.75

SCL90-R
GSI
Interpersonal Sensitivity
Hostility
Psychoticism

2.47
23.81
15.93
22.00

.85
8.32
6.23
9.04

2.09
18.50
13.00
16.37

CGI-BPD
Global
Unstable relations
Impulsivity
Suicide
Affect Instability
Anger
Emptiness
CGI -Global Improv-Patient

4.78
5.06
4.67
3.17
5.39
3.89
4.66
4.18

.80
1.21
1.45
1.38
0.77
1.18
1.53
.75

3.50
4.22
3.61
2.44
3.61
3.11
4.33
3.27

HRSD-17
HRSA
BPRS
BDI
Irritability
Indirect Hostility

Pre-treatment
SD

Post-treatment

HLM

Mean

SD

Mean

SD

20.67
22.67
15.89

3.67
3.57
6.73

16.00
16.56
11.89

5.78
5.00
4.40

.001
.034
.018

3.34
1.88

9.71
8.29

0.48
0.75

9.86
7.57

0.90
1.27*

.028
.787

1.07*
10.05*
8.59*
11.09*

2.69
27.42
18.57
19.28

.51
5.06
4.50
7.27

2.50
26.00
15.85
22.28

.86
8.34
8.17
9.19

.458
.364
.978
.034

4.89
4.78
5.00
3.00
5.22
4.22
4.78
4.42

.33
0.83
1.32
0.70
0.44
1.20
1.78
.78

4.44
4.44
4.11
2.55
4.66
3.88
5
3.57

.52*
0.72
0.60*
0.88
0.70
0.78
1.50
1.13

.218
.125
.095
.077
.004
.008
.019
.832

3.99**
5.46**
5.06**

1.20**
0.80*
0.97*
1.24*
1.19**
1.02*
1.57
.90*

Note: t-test *<.05, **<.001.

Please cite this article in press as: Soler, J., et al., Dialectical behaviour therapy skills training compared to standard group therapy in..., Behaviour
Research and Therapy (2009), doi:10.1016/j.brat.2009.01.013

ARTICLE IN PRESS
J. Soler et al. / Behaviour Research and Therapy xxx (2009) 16

20
18
16

HRSD Score

14
12
10
8
6

DBT-ST

SGT

4
2
0
Baseline

11

13

Experimental Period
Fig. 3. HSRD expected mean scores from baseline during the study. In the HLM
analysis of differences between DBT-ST and SGT groups. Note: HLM analysis (F 4,59,
p .001).

are more structured than dynamic-oriented therapies and place


more emphasis on psychoeducation and the active role of the
therapist. One or a combination of these factors might explain the
differences in retention rates between DBT-ST and SGT groups.
Regarding the clinical rating scales, DBT-ST seems to have an
impact on depression, anxiety, psychoticism, irritability and general
psychiatric symptom reduction. Besides, anger, and affect instability assessed by CGI-BPD also improve with this intervention.
DBT-ST psychotherapy is oriented to acquire a wide set of skills that
can be conceptualised as useful for managing life and seem
congruent with the changes induced by DBT-ST in this study.
Outcomes are mainly associated with moodemotion improvement and general psychopathological reduction. This mood
improvement is consistent with the core target of DBT-ST intervention, which aims at the dysregulation of emotions (Linehan,
1993a, 1993b), and it can likely lead to a further decrease in general
psychopathology. This result resembles the ndings of a study in
which DBT-ST was successfully used as treatment for depressed
older adults (Lynch et al., 2003). The results observed in the
emptiness CGI-BPD subscale might be explained by a slight
improvement in the DBT-ST group versus a slight worsening in the
SGT group, rather than the result of a therapeutic effect of DBT-ST.
The main ndings in this study contrast with previous data
regarding DBT-ST (Linehan, 1993a; Springer et al., 1996) that do not
support the utility of skills training alone. This might be attributed
to the small samples used in these previous studies. In our study
however, DBT-ST did not decrease some characteristic borderline
behaviours (e.g. suicide or self-harm). One explanation could be
that only a single mode of DBT is insufcient to make a signicant
impact on the target problem behaviour of BPD.
Most data on DBT derives from studies in which DBT is
compared to treatment as usual (TAU) (Koons et al., 2001; Linehan
et al., 1991, 1999; Verheul et al., 2003). Although TAU provides
a useful comparison, it usually includes no more than one or two
visits with a psychiatrist per month, constituting a weaker treatment condition than SGT. The present study was designed with SGT
instead of TAU in order to provide a more comparative treatment,
offering group therapy of the same type, quantity and frequency as
the experimental condition. The choice of a psychodynamicoriented intervention for the SGT condition was to clearly differentiate it from a behavioural-oriented therapy such as DBT.

Overlapping of procedures and techniques, a common limitation in


comparing psychotherapies, was thus avoided. It should be pointed
out that the SGT condition is neither a mentalization-based treatment (Bateman & Fonagy, 1999, 2001) nor transference focused
therapy (Clarkin et al., 2007), both of which have already proven to
be effective psychodynamic therapies for BPD.
Considering the short duration of the intervention (13 weeks) in
the present study and the severity and persistence of BPD, effects
will probably fade over time. However, no data are yet available on
the follow-up of this mode of treatment. Extending the treatment
time or repeating the DBT-ST so as to strengthen the acquisition of
the skills might improve the effectiveness of such intervention. In
a recently published study (Blum et al., 2008) using cognitive
behavioural skills training for 20 weeks, the gains attributed to the
group intervention remained at 1 year follow-up.
Motivation for change and treatment readiness are essential
requirements for psychotherapy. Taking a drug every day, as in drug
trials, does not require the effort needed in skills training and can
be achieved by external pressures (e.g. legal coercion or family
pressure). Controlled psychotherapy studies should include some
kind of procedure to check treatment compliance as in pharmacotherapy trials (e.g. counting returned pills). However, in
psychotherapy it is difcult to verify whether a sufcient level of an
active intervention has been accomplished. Weekly attendance to
therapy is necessary but an additional effort (e.g. fullling homework assignments) is also required to optimise skills training
therapy. Several procedures to enhance motivation for change and
to increase commitment can be implemented, such as offering
individual psychotherapy to those patients who have fully
completed a previous group skills training, or assessing motivation
for change, so as to improve treatment matching (Soler et al., 2008)
or motivational interviewing (Ben-Porath, 2004).
A common limitation in controlled studies in psychotherapy
with a single-blind design is the difculty to keep the evaluators
masked to the treatment condition. This is an important issue in
assessing the results of comparative psychotherapy studies as the
rst authors allegiance with one of the therapies under study may
inuence outcome (Luborsky et al., 1999). We are unable to afrm
that all participants refrained from disclosing information about
the therapy or the therapists with the psychiatric raters during
assessment visits. However, the fact that therapy was conducted
only over a period of 3-months made masking easier than in longer
trials (Giesen-Bloo et al., 2006). Indeed, the observer-rater scales
obtained during the interview visits and the results from selfreported measures lled in by patients during the study showed
a good concordance.
In summary, the results from the present study indicate that
DBT-ST is associated with low dropout rates and greater clinical
improvements than with SGT. Increasing the behavioural capabilities could be implicated in the overall efcacy of DBT in BPD
patients. This kind of intervention can be implemented in many
mental health settings and provides the additional advantage that
it is cost effective.
Acknowledgments
Study supported by grants from the Fondo de Investigacion
Sanitaria (REF 03/434) and by the Spanish Ministry of Health,
Instituto de Salud Carlos III, CIBERSAM.
References
American Psychiatric Association. (2001). Practice guideline for the treatment of
patients with borderline personality disorder. American Journal of Psychiatry,
158(10 Suppl.), 152.

Please cite this article in press as: Soler, J., et al., Dialectical behaviour therapy skills training compared to standard group therapy in..., Behaviour
Research and Therapy (2009), doi:10.1016/j.brat.2009.01.013

ARTICLE IN PRESS
6

J. Soler et al. / Behaviour Research and Therapy xxx (2009) 16

Barrachina, J., Soler, J., Campins, M. J., Tejero, A., Pascual, J. C., Alvarez, E., et al.
(2004). Validation of a Spanish version of the diagnostic interview for borderolas de Psiquiatra, 32, 293298.
lines-revised (DIB-R). Actas Espan
Barratt, E. S. (1995). Impulsiveness and aggression. Chicago: The University of Chicago Press.
Bateman, A. T., & Fonagy, P. (1999). Effectiveness of partial hospitalization of
borderline personality disorder: a randomized controlled trial. American Journal
of Psychiatry, 156, 15631569.
Bateman, A. T., & Fonagy, P. (2001). Treatment of borderline personality disorder
with psychoanalytically oriented partial hospitalization: a 18-month follow-up.
American Journal of Psychiatry, 158, 3642.
Bender, D. S., Skodol, A. E., Pagano, E., Dyck, I. R., Grilo, C. M., Shea, M. T., et al.
(2006). Prospective assessment of treatment use by patients with personality
disorder. Psychiatric Services, 57, 254257.
Ben-Porath, D. D. (2004). Strategies for securing commitment to treatment for
individuals diagnosed with borderline personality disorder. Journal of Contemporary Psychotherapy, 34, 247263.
Blum, N., St John, D., Pfohl, B., Stuart, S., McCormick, B., Allen, J., et al. (2008).
Systems training for emotional predictability and problem solving (STEPPS) for
outpatients with borderline personality disorder: a randomized controlled trial
and 1-year follow-up. American Journal of Psychiatry, 165, 468478.
Bohus, M., Haaf, B., Simms, T., Limberger, M. F., Schmahl, C., Unckel, C., et al. (2004).
Effectiveness of inpatient dialectical behavioral therapy for borderline
personality disorder: a controlled trial. Behaviour Research and Therapy, 42,
487499.
Buss, A. H., & Durkee, A. (1957). An inventory for assessing different kinds of
hostility. Journal of Consulting Psychiatry, 21, 345348.
Clarkin, J. F., Kenneth, N. L., Lenzenweger, M. F., & Kernberg, O. F. (2007). Evaluating
three treatments for borderline personality disorder: a multiwave study.
American Journal of Psychiatry, 164, 922928.
Davidson, K., Norrie, J., Tyrer, P., Gumley, A., Tata, P., Murray, H., et al. (2006). The
effectiveness of cognitive behavior therapy for borderline personality disorder:
results from the borderline personality disorder study of cognitive therapy
(BOSCOT) trial. Journal of Personality Disorders, 20, 450465.
Derogatis, L. R., Lipman, R. S., & Covi, L. (1973). SCL-90: an outpatient psychiatric
rating scale: preliminary report. Psychopharmacologic Bulletin, 9, 1328.
Giesen-Bloo, J., Van Dyck, R., Spinhoven, P., Van Tilburg, W., Dirksen, C., Van
Asselt, T., et al. (2006). Outpatient psychotherapy for borderline personality
disorder: randomized trial of schema-focused therapy vs transference focused
psychotherapy. Archives of General Psychiatry, 63, 649658.
Gomez-Beneyto, M., Villar, M., Renovell, M., Perez, F., Hernandez, M., Leal, C., et al.
(1994). The diagnosis of personality disorder with a modied version of the
SCID-II in a Spanish clinical sample. Journal of Personality Disorders, 8,
104110.
Guy, W. (1976). Clinical global impressions. Rockville, MD: National Institute of
Mental Health.
Hamilton, M. (1959). The assessment of anxiety states by rating. British Journal of
Medical Psychology, 32, 5055.
Hamilton, M. (1960). A rating scale for depression. Journal of Neurology Neurosurgery, and Psychiatry, 23, 5662.
Koons, C. R., Robins, C. J., Tweed, J. L., Lynch, T. R., Gonzalez, A. M., Morse, J. Q., et al.
(2001). Efcacy of dialectical behavior therapy women veterans with borderline
personality disorder. Behavioral Therapy, 32, 371390.
Lieb, K., Zanarini, M. C., Schmahl, C., Linehan, M. M., & Bohus, M. (2004). Borderline
personality disorder. Lancet, 364, 453461.

Lindenboim, N., Comtois, K., & Linehan, M. (2007). Skills practice in dialectical
behaviour therapy for suicidal woman meeting criteria for borderline personality disorder. Cognitive and Behavioral Practice, 14, 147156.
Linehan, M. M. (1993a). Cognitive-behavioural treatment of borderline personality
disorder. New York: Guilford Press.
Linehan, M. M. (1993b). Skills training manual for treating borderline personality
disorder. New York: Guilford Press.
Linehan, M. M., Amstrong, H. E., Suarez, A., Allmon, D., & Heard, H. L. (1991).
Cognitive-behavioral treatment of chronically parasuicidal borderline patients.
Archives of General Psychiatry, 48, 10601064.
Linehan, M. M., Comtois, K. A., Murray, A. M., Brown, M. Z., Gallop, R. J., Heard, H. L.,
et al. (2006). Two-year randomized controlled trial and follow-up of dialectical
behavior therapy vs therapy by experts for suicidal behaviors and borderline
personality disorder. Archives of General Psychiatry, 63, 757766.
Linehan, M. M., Schmidt, H. I., Dimeff, L. A., Craft, J. C., Kanter, J., & Comtois, K. A.
(1999). Dialectical behavior therapy for patients with borderline personality
disorder and drug-dependence. The American Journal on Addictions, 8, 279292.
Luborsky, L., Diguer, L., Seligman, D. A., Rosenthal, R., Krause, E. D., Johnson, S., et al.
(1999). The researchers own therapy allegiances: a wild card in comparisons
of treatment efcacy. Clinical Psychology: Science and Practice, 6, 95106.
Lynch, T. R., Morse, J. Q., Mendelson, T., & Robins, C. J. (2003). Dialectical behavior
therapy for depressed older adults: a randomized pilot study. American Journal
of Geriatric Psychiatry, 11, 3345.
Overall, J. E., & Gorham, D. R. (1962). The brief psychiatric rating scale. Psychological
Reports, 10, 799812.
Paris, J. (2002). Implications of long-term outcome research for the management
of patients with borderline personality disorder. Harvard Review of Psychiatry,
10, 315323.
Perez, V., Barrachina, J., Soler, J., Pascual, J. C., Campins, M. J., Puigdemont, D., et al.
(2007). The clinical global impression scale for borderline personality disorder
olas de Psipatients (CGI-BPD): a scale sensible to detect changes. Actas Espan
quiatra, 35, 229235.
Soler, J., Campins, M. J., Perez, V., Puigdemont, D., Perez-Blanco, F., & Alvarez, E.
(2001). Olanzapine and cognitive-behavioural group therapy in borderline
olas de Psiquiatra, 29, 8590.
personality disorder. Actas Espan
Soler, J., Pascual, J. C., Campins, J., Barrachina, J., Puigdemont, D., Alvarez, E., et al.
(2005). Double-blind, placebo-controlled study of dialectical behavior therapy
plus olanzapine for borderline personality disorder. American Journal of
Psychiatry, 162, 12211224.
Soler, J., Trujols, J., Pascual, J. C., Portella, M. J., Barrachina, J., Campins, J., et al.
(2008). Stages of change in dialectical behaviour therapy for borderline
personality disorder. British Journal of Clinical Psychology, 47, 417426.
Springer, T., Lohr, N. E., Buchtel, H. A., & Silk, K. R. (1996). A preliminary report of
short-term cognitive-behavioral group therapy for inpatients with personality
disorders. Journal of Psychotherapy and Practice Research, 5, 5771.
Stone, M. H. (1998). The course of borderline personality disorder. Washington, DC:
American Psychiatric Press.
Telch, C. F., Agras, A. W., & Linehan, M. M. (2001). Dialectical behavior therapy for
binge eating disorder. Journal of Consulting and Clinical Psychology, 69,10611065.
Van Asselt, A. D., Dirksen, C. D., Arntz, A., & Severens, J. L. (2007). The cost of
borderline personality disorder: societal cost of illness in BPD-patients. European Psychiatry, 22, 354361.
Verheul, R., Van den Bosch, L., Koeter, M., De Ridder, M., Stijnen, T., & Van den
Brink, W. (2003). Dialectical behavior therapy with borderline personality
disorder. British Journal of Clinical Psychology, 182, 135140.

Please cite this article in press as: Soler, J., et al., Dialectical behaviour therapy skills training compared to standard group therapy in..., Behaviour
Research and Therapy (2009), doi:10.1016/j.brat.2009.01.013