Dialectical behavior therapy skills use as a mediator and outcome of treatment for borderline personality disorder
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A central component of Dialectical Behavior Therapy (DBT) is the teaching of specific behavioral skills with the aim of helping individuals with Borderline Personality Disorder (BPD) replace maladaptive behaviors with skillful behavior. Although existing evidence indirectly supports this proposed mechanism of action, no study to date has directly tested it. Therefore, we examined the skills use of 108 women with BPD participating in one of three randomized control trials throughout one year of treatment and four months of follow-up. Using a hierarchical linear modeling approach we found that although all participants reported using some DBT skills before treatment started, participants treated with DBT reported using three times more skills at the end of treatment than participants treated with a control treatment. Significant mediation effects also indicated that DBT skills use fully mediated the decrease in suicide attempts and depression and the increase in control of anger over time. DBT skills use also partially mediated the decrease of nonsuicidal self-injury over time. Anger suppression and expression were not mediated. This study is the first to clearly support the skills deficit model for BPD by indicating that increasing skills use is a mechanism of change for suicidal behavior, depression, and anger control.
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Of the four modes of DBT, the skills group has received the most research attention.
“Of the four modes of DBT, the skills group has received the most research attention, given the relative ease of transferability of the skills, and also the fact that DBT skills have been found to be key processes underlying clinical outcomes resulting from DBT [15, 16].”
From Implementation of brief dialectical behavior therapy skills training among borderline personality disorder patients in Malaysia: feasibility, acceptability, and preliminary outcomes (2021) · cites this paper as [15]
The Discussion (page unavailable) reports that DBT skills use mediated some treatment outcomes, supporting the sentence’s point about a clinical process. It does not compare research attention across DBT’s four modes or say that ease of transferring skills explains attention to the skills group; it distinguishes skills use from skills training. (LLM, conf=0.85)
Experimental — accuracy not yet measuredThe DBT-WCCL skills subscale has demonstrated adequate to excellent reliability and validity, including the ability to discriminate between treatment conditions that provide DBT skills and those that do not.
“The measure has demonstrated adequate to excellent reliability and validity, including the ability to discriminate from treatment conditions providing DBT skills versus those that do not (Neacsiu, Rizvi, & Linehan, 2010; Neacsiu, Rizvi, Vitaliano, Lynch, & Linehan, 2010).”
From Differential role of CBT skills, DBT skills and psychological flexibility in predicting depressive versus anxiety symptom improvement (2016) · cites this paper as Neacsiu, Rizvi, & Linehan, 2010
DBT skills include methods of self-regulation mediating outcomes of the therapy in the area of suicidality.
“For example, DBT skills include methods of self-regula-tion mediating outcomes of the therapy in the area of suicidality 104 .”
From “Third-wave” cognitive and behavioral therapies and the emergence of a process-based approach to intervention in psychiatry (2021) · cites this paper as [104]
Previous DBT studies in adults have suggested that teaching specific behavioral skills may be an important factor in the reduction of self-harm and depression.
“Previous DBT studies in adults have suggested that teaching specific behavioral skills may be an important factor in the reduction of self-harm and depression.43”
From Dialectical Behavior Therapy for Adolescents With Repeated Suicidal and Self-harming Behavior: A Randomized Trial (2014) · cites this paper as [43]
Interventions that included DBT skills training may be more effective than interventions without.
“interventions that included DBT skills training may be more effective than interventions without.”
From The use of CAMS and DBT to effectively treat patients who are suicidal (2024) · cites this paper as [53]
Increased skills use is a mechanism for change in suicidal behaviour, depression and anger control.
“Increased skills use has been statistically shown to be a mechanism for change in suicidal behaviour, depression and anger control (Neacsiu et al. 2010).”
From Brief psychological intervention for distress tolerance in an adult secondary care community mental health service: an evaluation (2020) · cites this paper as Neacsiu et al. 2010
DBT skills have been found to be key processes underlying clinical outcomes resulting from DBT.
“DBT skills have been found to be key processes underlying clinical outcomes resulting from DBT [15, 16].”
Other studies show that emotion regulation skill gains during treatment correlate with better outcomes across several evidence-based therapies, including CBT, DBT, ACT, and Emotion Regulation Therapy.
“Other research has demonstrated that improvements in ER skills during treatment are associated with positive treatment outcomes for a variety of evidence-based psychological treatments, including Cognitive-Behavioral Therapy (CBT), Dialectical Behavior Therapy (DBT), Acceptance and Commitment Therapy (ACT), and Emotion Regulation Therapy, among others.42–48”
From A meta-analysis of emotional regulation outcomes in psychological interventions for youth with depression and anxiety (2021) · cites this paper as [43]
Improvements in intrapersonal ER skills may be a common active ingredient across psychological interventions for young people.
“Improvements in intrapersonal ER skills may represent a common “active” ingredient across psychological interventions for young people, consistent with a substantial treatment literature in adult samples demonstrating a similar effect.42–48”
From A meta-analysis of emotional regulation outcomes in psychological interventions for youth with depression and anxiety (2021) · cites this paper as [43]
Increasing use of DBT skills is a mechanism of change for suicidal behavior, depression, and anger control in the treatment of BPD.
“Neacsiu et al. (2010) showed that increasing use of DBT skills is a mechanism of change for suicidal behavior, depression, and anger control in the treatment of BPD.”
From Emotion regulation in schema therapy and dialectical behavior therapy. (2016) · cites this paper as Neacsiu et al., 2010
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“Since presentation, discussion and training of behavioral, cognitive, and emotional skills serve as one of the main therapeutic tools in overcoming pervasive emotion dysregulation (25, 26), we decided to focus on this component.”
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Treating the Suicidal Patient: Cognitive Therapy and Dialectical Behavior Therapy
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- Authors
- Neacsiu, A. D., Rizvi, S. L., & Linehan, M. M.
- Affiliations
- University of Washington (US)
- Rutgers, The State University of New Jersey (US)
- Corresponding author
- Neacsiu, Andrada D.
- Venue
- Behaviour Research and Therapy
- Publisher
- Elsevier BV
- Published
- 2010-09
- Volume
- 48
- Issue
- 9
- Pages
- 832-839
- ISSN
- 0005-7967 (ISSN-L)
- PMC
- PMC2914145
- OpenAlex
- W1981262084
- Cited by
- 426
- References
- 70
- Citations by year
- 2026: 22 · 2025: 21 · 2024: 21 · 2023: 40 · 2022: 21 · 2021: 47 · 2020: 39 · 2019: 28 · 2018: 33 · 2017: 27 · 2016: 25 · 2015: 29 · 2014: 29 · 2013: 18 · 2012: 15
- FWCI
- 15.06
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- Behaviour Research and Therapy (publishedVersion)
- PubMed (publishedVersion)
- Europe PMC (PubMed Central) (acceptedVersion)
- PubMed Central (acceptedVersion)
- Funders
- Department of Biotechnology, Ministry of Science and Technology, India
- National Institutes of Health
- National Institute of Mental Health (MH01593, MH-34486, R01MH034486, K05MH001593)
- National Institute on Drug Abuse (R01DA008674)
- Topics
- Social Sciences › Psychology › Clinical Psychology › Personality Disorders and Psychopathology
- Social Sciences › Psychology › Clinical Psychology › Psychotherapy Techniques and Applications
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
- Keywords
- dialectical behavior therapy, borderline personality disorder, mechanisms of change, mediation analysis, suicide attempts, depression, anger management, non-suicidal self-injury, anger suppression, anger expression, women
- MeSH terms
- Suicide Prevention, Adaptation, Psychological, Adult, Anger, Awareness, Borderline Personality Disorder, Female, Follow-Up Studies, Humans, Cognitive Behavioral Therapy, Linear Models, Self-Injurious Behavior, Treatment Outcome, Self Efficacy, Mind-Body Therapies
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