Dialectical Behavior Therapy for High Suicide Risk in Individuals With Borderline Personality Disorder: A Randomized Clinical Trial and Component Analysis
Abstract
IMPORTANCE: Dialectical behavior therapy (DBT) is an empirically supported treatment for suicidal individuals. However, DBT consists of multiple components, including individual therapy, skills training, telephone coaching, and a therapist consultation team, and little is known about which components are needed to achieve positive outcomes. OBJECTIVE: To evaluate the importance of the skills training component of DBT by comparing skills training plus case management (DBT-S), DBT individual therapy plus activities group (DBT-I), and standard DBT which includes skills training and individual therapy. DESIGN, SETTING, AND PARTICIPANTS: We performed a single-blind randomized clinical trial from April 24, 2004, through January 26, 2010, involving 1 year of treatment and 1 year of follow-up. Participants included 99 women (mean age, 30.3 years; 69 [71%] white) with borderline personality disorder who had at least 2 suicide attempts and/or nonsuicidal self-injury (NSSI) acts in the last 5 years, an NSSI act or suicide attempt in the 8 weeks before screening, and a suicide attempt in the past year. We used an adaptive randomization procedure to assign participants to each condition. Treatment was delivered from June 3, 2004, through September 29, 2008, in a university-affiliated clinic and community settings by therapists or case managers. Outcomes were evaluated quarterly by blinded assessors. We hypothesized that standard DBT would outperform DBT-S and DBT-I. INTERVENTIONS: The study compared standard DBT, DBT-S, and DBT-I. Treatment dose was controlled across conditions, and all treatment providers used the DBT suicide risk assessment and management protocol. MAIN OUTCOMES AND MEASURES: Frequency and severity of suicide attempts and NSSI episodes. RESULTS: All treatment conditions resulted in similar improvements in the frequency and severity of suicide attempts, suicide ideation, use of crisis services due to suicidality, and reasons for living. Compared with the DBT-I group, interventions that included skills training resulted in greater improvements in the frequency of NSSI acts (F1,85 = 59.1 [P < .001] for standard DBT and F1,85 = 56.3 [P < .001] for DBT-S) and depression (t399 = 1.8 [P = .03] for standard DBT and t399 = 2.9 [P = .004] for DBT-S) during the treatment year. In addition, anxiety significantly improved during the treatment year in standard DBT (t94 = -3.5 [P < .001]) and DBT-S (t94 = -2.6 [P = .01]), but not in DBT-I. Compared with the DBT-I group, the standard DBT group had lower dropout rates from treatment (8 patients [24%] vs 16 patients [48%] [P = .04]), and patients were less likely to use crisis services in follow-up (ED visits, 1 [3%] vs 3 [13%] [P = .02]; psychiatric hospitalizations, 1 [3%] vs 3 [13%] [P = .03]). CONCLUSIONS AND RELEVANCE: A variety of DBT interventions with therapists trained in the DBT suicide risk assessment and management protocol are effective for reducing suicide attempts and NSSI episodes. Interventions that include DBT skills training are more effective than DBT without skills training, and standard DBT may be superior in some areas. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00183651.
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DBT is a gold-standard treatment for borderline personality disorder, which involves struggles with emotion dysregulation and distress tolerance.
“DBT is a gold-standard treatment for those with borderline personality disorder, who struggle with emotion dysregulation and distress tolerance (Linehan, 2015; Linehan et al., 1991, 2015).”
From Psychological Treatment of Persistent Genital Arousal Disorder/Genitopelvic Dysesthesia Using an Integrative Approach (2023) · cites this paper as Linehan et al., 2015
In the component analysis study, all three treatment conditions resulted in similar improvements in frequency and medical severity of suicide attempts, suicide ideation, and use of crisis services.
“Results from the component analysis study indicated that all conditions result in similar improvements in frequency and medical severity of suicide attempts, suicide ideation, and use of crisis services.”
From The use of CAMS and DBT to effectively treat patients who are suicidal (2024) · cites this paper as [49]
A variety of DBT interventions could be useful for reducing suicidal behavior.
“These results suggested that a variety of DBT interventions could be useful for reducing suicidal behavior.”
From The use of CAMS and DBT to effectively treat patients who are suicidal (2024) · cites this paper as [49]
In the component analysis study, the two conditions with DBT skills training had statistically greater improvements in frequency of NSSI acts compared to the DBT individual therapy only condition.
“The two conditions with DBT skills training had statistically greater improvements in frequency of NSSI acts compared to the DBT individual therapy only condition.”
From The use of CAMS and DBT to effectively treat patients who are suicidal (2024) · cites this paper as [49]
Mindful meditation is a key strategy involved in MBT and multicomponent treatments such as ACT and DBT.
“Finally, mindful meditation is a key strategy involved in MBT and multicomponent treatments such as Acceptance and Commitment Therapy (ACT) (Hayes, 2004) and Dialectical Behaviour Therapy (DBT) (Kliem et al., 2010;Linehan et al., 2015).”
From A mixed methods study of autistic adults' mental health therapy experiences (2023) · cites this paper as Linehan et al., 2015
DBT-SG is similarly as effective as full-model DBT at reducing suicidal behaviors, non-suicidal self-injurious behaviors, and anxiety.
“Further, research found DBT-SG is similarly as effective to “full-model” DBT at reducing suicidal behaviors and non-suicidal self-injurious behaviors and reducing anxiety (Linehan et al., 2015).”
From Can dialectical behavior therapy skills group treat social anxiety disorder? A brief integrative review (2024) · cites this paper as Linehan et al., 2015
Skills training alone leads to better results concerning the frequency of self-harm than individual DBT, as well as overall similar rates concerning other symptoms of BPD addressed within therapy.
“Also, Linehan et al. (27) could show that skills training alone leads to better results concerning the frequency of self-harm than individual DBT®, as well as overall similar rates concerning other symptoms of BPD addressed within therapy (e.g., suicidal ideations, suicide attempts).”
From Radical Acceptance of Reality: Putting DBT®-A Skill Groups Online During the COVID-19 Pandemic: A Qualitative Study (2022) · cites this paper as [27]
Dialectical behavior therapy (DBT) can reduce suicidal risks by coaching participants mindfulness, distress tolerance, emotion regulation, interpersonal effectiveness, and self-regulation skills.
“Previous studies demonstrated that dialectical behavior therapy (DBT) could reduce suicidal risks by coaching participants mindfulness, distress tolerance, emotion regulation, interpersonal effectiveness, and self‐regulation skills (Fleischhaker et al., 2011; Linehan et al., 2015).”
Both treatment conditions, one-year DBT skills training and DBT individual therapy alone, were equally effective in reducing suicidal ideation and attempts.
“Both treatment conditions were equally effective in reducing suicidal ideation and attempts.”
One year of DBT skills training was more effective in reducing self-harm behaviors and depressive symptoms among suicidal BPD patients compared to DBT individual therapy alone.
“Another study found that one-year of DBT skills training was more effective in reducing self-harm behaviors and depressive symptoms among suicidal BPD patients compared to DBT individual therapy alone [20].”
Compared to those receiving skills training alone, patients receiving individual therapy in conjunction with skills training were less likely to drop out.
“Compared to those receiving skills training alone, patients receiving individual therapy in conjunction with skills training were less likely to drop out [20].”
Engaging non-DBT trained therapists as case managers or primary attending clinicians for BPD patients attending a skills group has received some empirical support in a study involving dismantling of components of DBT.
“This treatment approach has received some empirical support in a study involving dismantling of components of DBT [20].”
Traditional DBT skills training is proving to be a valuable element of DBT for treating borderline personality disorder and a growing number of other psychological problems.
“In clinical studies, traditional DBT® skills training is proving to be a valuable element of DBT® for treating borderline personality disorder [1, 14, 15], and a growing number of other psychological problems [16].”
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- Authors
- Linehan, M. M., Korslund, K. E., Harned, M. S., Gallop, R. J., Lungu, A., Neacsiu, A. D., McDavid, J., Comtois, K. A., & Murray-Gregory, A. M.
- Affiliations
- West Chester University (US)
- United States Department of State (US)
- Corresponding author
- Linehan, Marsha M.
- ORCID
- Venue
- JAMA Psychiatry
- Publisher
- American Medical Association (AMA)
- Published
- 2015-05-01
- Volume
- 72
- Issue
- 5
- Pages
- 475
- ISSN
- 2168-622X (ISSN-L)
- OpenAlex
- W2159212729
- Cited by
- 714
- References
- 47
- Citations by year
- 2026: 74 · 2025: 60 · 2024: 59 · 2023: 65 · 2022: 55 · 2021: 88 · 2020: 94 · 2019: 52 · 2018: 56 · 2017: 53 · 2016: 44 · 2015: 11 · 2014: 1
- FWCI
- 67.79
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- JAMA Psychiatry (publishedVersion)
- PubMed (publishedVersion)
- Funders
- National Institute of Mental Health (R01MH034486)
- Topics
- Social Sciences › Psychology › Clinical Psychology › Personality Disorders and Psychopathology
- Social Sciences › Psychology › Clinical Psychology › Suicide and Self-Harm Studies
- Social Sciences › Psychology › Clinical Psychology › Psychotherapy Techniques and Applications
- Keywords
- dialectical behavior therapy, borderline personality disorder, suicide risk, skills training, individual psychotherapy, case management, non-suicidal self-injury, suicide attempts, suicidal ideation, depression, treatment dose, women, reasons for living, adaptive randomization
- MeSH terms
- Suicide Prevention, Adaptation, Psychological, Adult, Anxiety, Behavior Therapy, Borderline Personality Disorder, Depression, Female, Humans, Male, Middle Aged, Risk Factors, Severity of Illness Index, Suicide, Suicide, Attempted, Single-Blind Method, Self-Injurious Behavior, Treatment Outcome, Risk Assessment, Suicidal Ideation
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