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Thought Control Strategies As Predictors of Borderline Personality Disorder and Suicide Risk PDF
Thought Control Strategies As Predictors of Borderline Personality Disorder and Suicide Risk PDF
PII: S0165-0327(19)32709-0
DOI: https://doi.org/10.1016/j.jad.2020.01.163
Reference: JAD 11612
Please cite this article as: Caitlin E. Titus M.S. , Hilary DeShong M.S., Ph.D. , Thought Control Strate-
gies as Predictors of Borderline Personality Disorder and Suicide Risk, Journal of Affective Disorders
(2020), doi: https://doi.org/10.1016/j.jad.2020.01.163
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Highlights
Results demonstrated that distraction was negatively associated with BPD symptoms and
suicide risk across all three measures of NPD.
Reappraisal was positively related to BPD symptoms on two out of the three measures.
Worry and punishment were positively related to BPD symptoms on all three measures
and suicide risk.
Social control decreased suicide risk and was negatively related to one measure of BPD
symptoms.
Study represents initial findings of thought control strategies as possible predictors of
BPD symptoms and suicide risk.
THOUGHT CONTROL, BPD AND SUICIDE RISK 2
Thought Control Strategies as Predictors of Borderline Personality Disorder and Suicide Risk
Abstract
impulsivity including suicidal ideation and attempts. Additionally, individuals with BPD tend to
engage in maladaptive ruminative thinking that is also related to suicidal ideation and attempts.
Given these relations, this study aims to understand the 5 strategies of thought control
(distraction, punishment, reappraisal, worry, and social control) as predictors of BPD symptoms
and suicide risk. Methods: The sample was collected at a Southeastern University using a
convenience sample of undergraduate participants. The final sample (n =403) had an age range
of 18 to 27 (M = 19.67, SD = 1.45), was 74.4% female and 25.6% male, and was primarily
Caucasian (69.7%) and African American (24.8%). Results: Results demonstrate that distraction
was negatively associated with BPD and suicide risk while worry and punishment were
positively associated with BPD and suicide risk across three different measures of BPD. Social
control was negatively associated with suicide risk and BPD but only on one of the BPD
measures. Lastly, reappraisal was positively related to BPD symptoms on two measures.
Limitations: Given the sample characteristics, there may be limitations in the generalizability of
the findings. Conclusions: The findings represent a first step towards examining thought control
strategies as possible predictors of BPD symptoms and suicide that can inform clinical
Thought Control Strategies as Predictors of Borderline Personality Disorder and Suicide Risk
Introduction
begins in adolescence or early adulthood and occur across multiple life domains (e.g.,
characterized by other maladaptive behaviors such as substance abuse (Trull et al., 2000),
suicidal gestures and non-suicidal self-injury (Andover et al., 2005; Paris, 2018), and rumination
individuals with this disorder have a higher rate of suicide as compared to community samples
(Pompili et al., 2005) with an average of 3.4 attempts in a lifetime (Soloff et al., 1994).
BPD (APA, 2013; Linehan et al., 2008). Given the high rates of suicidal behavioral within BPD,
work. One possible pathway to decreasing suicide risk and symptoms of BPD is by decreasing
rumination.
Broadly, rumination is a tendency to repetitively think about one’s own negative emotion
experience, including the causes, contextual factors, and consequences of the experience (Nolen-
Hoeksema, 1991). Rumination has been found to be a larger cognitive process that can
encapsulate more adaptive forms such as self-reflection or deliberate rumination which are
linked to post-traumatic growth and recovery from a depressive episode (Arditte and Joormann,
2011; García et al., 2017). The maladaptive forms of rumination are separate and involve
negatively valanced repetitive thoughts and include perseveration about one’s feelings and
THOUGHT CONTROL, BPD AND SUICIDE RISK 5
problems (Nolen-Hoeksema et al., 2008). More recent research indicates that not only is
psychopathology including depression, anxiety, and BPD (Nolen-Hoeksema and Watkins, 2011;
De Raedt et al, 2015). Although rumination is linked to several disorders, it has a particularly
strong connection with BPD. For instance, research has demonstrated that anger and depressive
rumination are strongly associated with borderline features, even after controlling for current
A potential explanation for the role of rumination in BPD is through the Emotional
Cascade Model, which posits that emotional and behavioral dysregulation is due to intense
cycles of negative affect and repetitive negative thinking (Selby et al., 2009). Individuals with
BPD tend to experience more intense negative affect with greater reactivity, even when
controlling for current depressive symptoms (Selby et al., 2009). When this intense negative
emotion occurs, individuals may engage in a rumination process, which increases the intensity of
emotion, leading to more rumination. The repetitive aspects of this process may eventually lead
to dysregulated behavior to cope with the now overwhelmingly strong emotional affect (Selby et
al., 2009). A recent study also provides evidence that not only does this emotional cycle exist,
behaviors (Selby et al., 2016). Overall, there have been several studies demonstrating these
Martino et al., 2018; Moberly and Watkins, 2008). This pernicious cycle coupled with
dysregulated behavior illustrates the importance of better understanding the role of rumination as
it relates to BPD.
THOUGHT CONTROL, BPD AND SUICIDE RISK 6
Rumination has also been directly linked to suicide (e.g., Grassia and Gibb, 2009).
Morrison and O’Connor (2008) conducted a meta-analysis of studies examining rumination with
suicidal ideation and attempts using community and inpatient samples. Results indicated that all
studies demonstrated a significant positive link between rumination and suicidal thoughts and
behaviors, with one exception. There was one study that used a measure of rumination that
samples examining suicide risk and rumination, Rogers and Joiner (2017) found that global
rumination, brooding rumination, and reflective rumination were significantly related to suicidal
ideation. Global and brooding rumination were also significantly related to suicide attempts, but
reflection was unrelated. Cumulatively, these findings suggest that rumination, especially
negative repetitive thinking styles such as brooding, are associated with suicidal ideation and
attempts across populations. Thought control is one potential pathway by which interventions
may be able to target ruminative thinking and thus may decrease the effects of rumination on
relatively normal experience, it is the excessive and recurrent avoidance and suppression of these
1996). Since research has established a link between rumination with suicide and BPD (Grassia
and Gibb, 2009; Moberly and Watkins, 2008; Rogers and Joiner, 2017), understanding the
strategies that an individual may employ to control unwanted thoughts and feelings may offer
insight into possible factors that decrease or increase suicide risk. The Thought Control
unwanted thoughts or worries (TCQ; Wells and Davies, 1994). The TCQ includes five
THOUGHT CONTROL, BPD AND SUICIDE RISK 7
dimensions of thought control strategies including distraction (e.g., “I think about something
else”), punishment (e.g., “I tell myself to not be so stupid”), reappraisal (e.g., “I challenge the
thoughts validity”), worry (e.g., “I try to think about past worries instead”), and social control
(e.g., “I talk to a friend about the thought”). Dimensions of the TCQ, specifically punishment and
worry, have been positively linked with Generalized Anxiety Disorder and Major Depressive
Disorder among an inpatient sample, whereas distraction and social control were negatively
associated with trait-anxiety and more likely to be used by the control group (non-inpatients;
Wells and Carter, 2009). In another study looking at the TCQ and suicide outcomes, both
punishment and worry were positively correlated with suicidal ideation and worry was
significantly correlated with total suicide risk. Distraction was negatively correlated with both
suicidal ideation and total suicide risk (Tucker et al., 2017). Considering these different strategies
impact suicide risk in different ways, the present study aims to explore these specific strategies
Specifically, it may be that thought control strategies are one way that an individual may
attempt to disrupt rumination and in turn the emotional cascade process. Therefore, these
strategies may be one area that can be targeted by clinical interventions to potentially decrease
symptoms of BPD and suicidal ideation. To design such interventions, a better understanding of
the link between thought control strategies with BPD and suicide is needed. Therefore, the
current study will investigate which of the five control strategies predict BPD and suicide. It is
hypothesized that the reappraisal, distract, and social control strategies measured by the TCQ
would be negatively associated with suicide risk and BPD symptoms. The other two strategies,
worry and punishment, were hypothesized to be positively related to BPD and suicide risk.
Method
THOUGHT CONTROL, BPD AND SUICIDE RISK 8
The sample was collected at a Southeastern University via the psychology SONA
participant research pool. All participants were provided with the link to the online survey on
Qualtrics. Participants earned 1.5 research credit hours for completing the study. Overall, 538
individuals signed up and began the study. Participants (n =132) who discontinued early or
completed less than 80% of the survey because they chose “prefer not to respond” for large
portions were screened out. Second, the Personality Assessment Inventory includes the
Infrequency Validity Scale which helps to detect random responding (Morey, 1991). Using this
scale, three participants had a score of five or higher and were dropped from subsequent
The final sample (n =403) had an age range of 18 to 27 (M = 19.67, SD = 1.45) with
74.4% female and 25.6% male. The participant ethnicities were primarily Caucasian (69.7%),
with the remaining sample including 24.8% African American, .7% Hispanic, 1.5%
Asian/Pacific Islander, .2% American Indian, with 2.5% identifying as multiracial and .5%
choosing not to respond. In the current sample, 14.9% were currently seeking treatment for a
psychological disorder and 12.2% were currently taking medication for a psychological disorder.
Measures
survey. The information includes age, gender, ethnicity, and psychological and psychiatric
Five Factor Borderline Inventory-Short Form (FFBI-SF; DeShong et al., 2016). The
FFBI-SF is a 48-item self-report measure that assesses BPD from the dimensional perspective of
THOUGHT CONTROL, BPD AND SUICIDE RISK 9
the Five Factor Model (FFM). The measure is based on the 120-item FFBI (Mullins-Sweatt et
al., 2012) and includes a total score and 12 subscale scores that are coordinated with respective
facets of the FFM. Previous research has demonstrated strong reliability and validity of the full
and short forms in student samples (Mullins-Sweatt et al., 2012; DeShong et al., 2015; DeShong
et al., 2016). For the current study, the internal consistency coefficient for the total score was
good (α=.97).
Personality Assessment Inventory (PAI; Morey, 1991). The PAI is a self-report inventory
that measures normal and abnormal personality traits and clinical constructs. The 344 items use a
four-point Likert response format that includes the following options: “False, not at all true,”
“Slightly true,” “Mainly True,” and “Very True.” The PAI contains 22 nonoverlapping scales
that break into four validity scales, 11 clinical scales, two interpersonal scales, and five
treatment-relevant scales. The current study utilized two scales from this measure for the
The borderline personality features scale (BOR) contains 24 items which assess
borderline personality features from a categorical perspective. The BOR scale is further broken
into four subscales, though only the full scale is included within the following analyses. The
BOR scale has previously demonstrated good reliability and validity in college populations
(Kurtz et al., 1993; Trull, 1995, 1997). The internal consistency for the BOR scale in the current
The suicidal ideation scale (SUI) is a clinical subscale of the PAI that consists of 12 items
that ask about feelings of hopelessness, vague thoughts about suicide, distinct plans, and
previous attempt. The current study used this subscale to measure suicidal risk. This subscale has
demonstrated convergent (Morey, 2007) and construct validity (Patry and Magaletta, 2015).
THOUGHT CONTROL, BPD AND SUICIDE RISK 10
Other studies have demonstrated good internal consistency ranging from α = .88 (Frazier et al.,
2006) to α=.90 (Boone, 1998). The internal consistency for the SUI scale in the current sample
PDQ-4 is a 99-item true/false self-report questionnaire that is designed to measure the DSM-IV-
TR/DSM-5 categorical personality disorders. Internal consistency for the PDQ-4 within
psychiatric outpatients has ranged from .54 (Histrionic) to .77 (Borderline; Trull and Goodwin,
1993). The analyses of the current study specifically used the BPD subscale of the PDQ-4. The
PDQ_BPD scale includes 9 items. The current study had poor internal consistency (α=.69). This
is likely in part due to the small number of items (Bagby and Farvolden, 2004); these are similar
values to other studies utilizing the same measure (DeShong et al., 2016; Mullins-Sweatt et al.,
Thought Control Questionnaire (TCQ; Wells and Davies, 1994). The TCQ scale is a 30-
item scale assessing strategies for controlling unpleasant and unwanted thoughts. The items are
answered on a four-point Likert scale on how often a person uses each technique, ranging from 1
(never) to 4 (almost always). The scale is broken into five broad techniques: distraction (e.g., I
do something that I enjoy), social control (e.g., I ask my friends if they have similar thoughts),
worry (e.g., I focus on different negative thoughts), punishment (e.g., I get angry at myself for
having the thoughts), and re-appraisal (e.g., I analyze the thought rationally). Previous research
has demonstrated adequate test-retest reliability, internal consistency, and convergent validity
(Wells and Davies, 1994). The subscale internal consistency coefficients for this sample ranged
Results
THOUGHT CONTROL, BPD AND SUICIDE RISK 11
Analytic Strategy
Before analyses were conducted, all data were evaluated for normality and checked for
skewness and kurtosis, with skewness values over 3 (Chou and Bentler, 1995) and kurtosis
values higher than 10.00 considered problematic (Kline, 2005). All data were within normal
limits, Table 1 provides descriptive statistics. AMOS 25 was utilized to estimate path analyses
using maximum likelihood estimation to determine the model that offered the best fit to the data
as well as controlling for spuriousness (Kenny, 1975). Using a model trimming approach, three
models were tested using the Thought Control Questionnaire factors (i.e., distraction, social
control, worry, punishment, and reappraisal). These factors were evaluated as predictors of BPD
and the PAI suicide scale. In each model, a different BPD measure was used to assess for
replicability (i.e., FFBI, PDQ_BPD, and BPD_PAI). Each model was evaluated using CFI, TLI,
and RMSEA. CFI and TLI values between .90 to .94 and RMSEA values between .07 to .10
indicate adequate model fit (Browne and Cudeck, 1993). CFI and TLI values at .95 or above and
RMSEA values of .06 or below indicates good model fit (Hu and Bentler, 1999). Of note, in the
following models, the intercorrelations were included during analyses but were not included in
Correlations
Table 2 provides Pearson correlations between all variable. Overall, the TCQ distraction
significantly correlated with suicidal ideation and PDQ_BPD measure, whereas the social control
dimension was significantly correlated with suicidal ideation and PAI_BOR and FFBI.
Additionally, worry, punishment, and reappraisal were all significantly correlated with each
Path Analyses
THOUGHT CONTROL, BPD AND SUICIDE RISK 12
Next, path analyses were conducted using the 5 dimensions of the TCQ as predictors for
each of the BPD scales and PAI_SUI. This allowed for comparison of models across different
types of measurement of BPD including two categorical (PDQ_BPD, PAI_BOR) and one
dimensional (FFBI) measure of BPD. See Table 3 for a summary of the findings that were
FFBI
The first path analysis was conducted to assess which factors of the TCQ are positively or
negatively related to the FFBI and suicide. As suggested by Kline (2011) and Joreskog (1993),
the model trimming approach was used so a model in which all paths were free to be estimated
was evaluated first. Given that this was a saturated model, fit indices were not evaluated. In
model 1, TCQ Reappraisal was not significantly related to suicide and thus this pathway was set
to zero. The model was then reanalyzed, and all pathways remained significant. In this final
model, fit indices demonstrate good fit, 2 (1) = , p = .95, CFI =1.00 , TLI = 1.04, RMSEA= .00
(see Figure 1.). This model suggests that when using the FFBI, the social control and distract
dimensions were negatively associated with suicide risk and BPD symptoms. Worry and
punishment positively related to BPD and suicide while reappraisal was positively related to
BPD symptoms only. Overall, this model accounted for approximately 34% of the variance in
The same procedure was used for the next two BPD measures. For the PDQ_BPD, social control
was not related to BPD and reappraisal was not related to suicide. Therefore, these two pathways
were set to zero. Upon reevaluation, this new model retained all significant pathways. The model
provided good fit to the data, 2 (2) = 1.21, p = .55, CFI =1.00 , TLI = 1.01 , RMSEA= .000 (see
THOUGHT CONTROL, BPD AND SUICIDE RISK 13
Figure 2.). Similar to the FFBI, distraction was negatively associated with both BPD symptoms
and suicide risk while social control was negatively related to suicide only. Similar to the FFBI,
worry and punishment were positively related to both borderline symptoms and suicidal ideation.
Reappraisal was also positively related to borderline, but not suicide risk. Overall, this model
accounted for 30% of the variance in the PDQ and 19% in suicide risk.
Finally, the PAI_BOR scale was tested within the model. The initial path analysis
conducted in the saturated model indicated that reappraisal was not linked to suicide or BPD, and
the social control dimension was not related to borderline and thus these pathways were trimmed
from the model. This final model indicated good fit, 2 (3) = 4.01, p = .26, CFI =1.00, TLI = .99,
RMSEA= .03 (see Figure 3.). More specifically, distraction was negatively associated with both
suicide and borderline symptoms while social control was associated with suicide risk only.
Punishment and worry were again positively related to both BPD and suicide. Overall, this
model accounted for 33% of the variance in BPD symptoms and 19% of the suicidal ideation
variance. Please see Table 2 for a summary of the consistent results across the three models.
Discussion
The results demonstrated partial support for the hypotheses in the current study. Across
all three measures of BPD, distract was negatively associated with symptoms of BPD and
suicidal ideation. These findings are consistent with other research indicating that focusing on
something positive (e.g., “I call to mind positive images instead,” “I do something that I enjoy”)
or moving away from recurrent thoughts would be beneficial overall and thus reduce both BPD
symptoms and suicidal ideation (Tucker et al., 2017; Wells and Carter, 2009). The worry strategy
was positively related to both BPD and suicidal ideation and is also consistent with other
THOUGHT CONTROL, BPD AND SUICIDE RISK 14
research (Tucker et al., 2017; Wells and Carter, 2009), and logically follows that continuing to
Surprisingly, reappraisal was positively related to BPD symptoms on the FFBI and
PDQ_BPD. This finding is unexpected, given previous research demonstrating that individuals
with BPD utilize reappraisal techniques less often than non-BPD participants (Daros et al.,
2018). Additionally, there are targeted interventions designed to increase the use of reappraisal
amongst individuals with BPD to improve emotion regulation and overall measures of well-
being (Gross and John, 2013; Koenigsberg, et al., 2019). One possible explanation for this
finding is that the reappraisal dimension might overlap with rumination as both are cognitively
based processes which include thinking, focusing, and analyzing one’s own thoughts and
feelings. Therefore, reappraisal may generally function as a slightly more adaptive cognitive
strategy but may be related to rumination, and thus related to symptoms of BPD. A secondary
explanation may be that the reappraisal scale is not truly assessing reappraisal but instead may be
Another unforeseen finding related to reappraisal was that it was not negatively
associated with suicidal ideation in any of the three models. This is counterintuitive, given the
use of reappraisal in targeting emotional regulation and improving emotional experience and
wellbeing (Daros et al., 2018; Gross and John, 2013). Similarly, there is research demonstrating
that individuals with difficulty using cognitive reappraisal strategies were more likely to have a
history of suicidal ideation and may increase suicide risk (Kudinova et al., 2015). One reason
that may account for this null finding is the link between reappraisal and other thought control
domains, such that reappraisal was moderately to largely correlated to three of the other thought
control techniques. Thus, it may be that reappraisal is highly linked to other thought control
THOUGHT CONTROL, BPD AND SUICIDE RISK 15
domains that are more directly linked to suicide. Further research is needed to assess for these
potential relationships.
Consistent with the hypotheses, social control was negatively related to suicide risk and
BPD symptoms on the FFBI, but unexpectedly, was no longer significant on the BPD_PAI or
PDQ_BPD subscales. The PAI and PDQ Borderline subscales are both considered to be
categorical measures of BPD, whereas the FFBI is a dimensional measure of BPD. According to
Skodol and colleagues (2005), the threshold used to distinguish individuals with and without a
diagnosable personality disorder is subjective and does not capture nuances in the level of
impairment. Additionally, work by Zimmerman et al., (2013) demonstrated that across two
studies, dimensional ratings of borderline personality disorder were more strongly related to
indicators of illness severity than individuals with a dichotomous categorical measure of BPD
(diagnosis or not, according to DSM-IV criteria). This is an important finding because social
control may only be negatively related to certain symptoms linked to BPD and the overall
diagnosis of the disorder is not conclusive in determining the level of impairment. A secondary
explanation is that this may be a spurious finding and therefore future research is necessary to
determine whether social control is negatively associated with specific BPD symptoms whether
the diagnostic criteria of personality disorders broadly to a more dimensional approach (e.g.,
Overall, the findings suggest the distraction is negatively associated with all three
measures of BPD and suicide risk while social control was consistently negatively related to
suicide specifically. The importance of these findings is highlighted by the fact that they are
significant across three different measures of BPD symptoms demonstrating the robustness of the
THOUGHT CONTROL, BPD AND SUICIDE RISK 16
results. Also, both of these thought control strategies are skills that can be potentially targeted in
clinical interventions to reduce BPD symptoms and suicide risk. Currently, metacognitive
rumination, perseverative thinking, and low control over negative thoughts and emotions
(Normann et al., 2014). In a trial using MCT targeting rumination, depression, anxiety, and
metacognitions, there was a large effect size in symptom reduction in depression worry, and
rumination (Hjemdal et al., 2017). Future research may benefit from investigating MCT as a
This study is the first of its kind to examine the specific thought control strategies as
predictors of BPD symptoms and suicide risk. Therefore, this is the first study to attempt to
identify strategies that may decrease or increase BPD symptoms and suicide risk. Future research
should be directed at replicating and expanding upon these findings. Furthermore, this line of
research may eventually lead to the development of new interventions that, like MCT, can target
dysfunction cognitive strategies to improve BPD symptoms and decrease suicide risk.
The present study examined an undergraduate sample and consisted of mostly white,
female participants with an average age of 19.67 years. Given the sample characteristics, there
may be limitations in the generalizability of the findings. However, the range of scores for each
of the measures indicates that there is a wide range of severity throughout the measures. The PAI
Borderline subscale indicates approximately 11.4% of the sample endorsed clinically significant
symptoms of BPD indicating significant clinical difficulties (Bagby and Farvolden, 2004).
generalizability of the present findings (APA, 2013). The PAI suicide scale also demonstrated a
wide range of severity with 5.4% of the sample falling two standard deviations above the mean.
The range of severity across measures demonstrates that these findings can be generalized to a
community sample and may even conservatively generalized to a clinical sample. Future
research is needed to expand upon this study, particularly with clinical populations.
Finally, personality disorders cannot be diagnosed in individuals until the age of 18,
therefore the young sample may not be representing the full range of possible BPD symptoms or
adulthood rather than a personality disorder. While research has demonstrated that even one
symptom of BPD increased the likelihood of suicidal ideation, suicide attempt, and psychiatric
hospitalizations (Zimmerman et al., 2012), future research is needed to further understand the
link between thought control strategies and BPD within various populations. Therefore, future
research should seek to investigate these relations within clinical samples and among a more
Conclusion
To summarize, the current study indicates that certain thought control strategies may help
to buffer against or increase symptoms of BPD and suicide risk. Therefore, treatments focusing
on increasing or decreasing these strategies may in turn help increase or decrease BPD symptoms
and suicide risk. Future research should continue to investigate the link between thought control
and psychopathology.
THOUGHT CONTROL, BPD AND SUICIDE RISK 18
Contributors
Dr. Hilary L. DeShong designed and implemented the study after acquiring IRB approval, collected and
cleaned the data, in addition to writing the methods section and providing feedback. Ms. Caitlin E. Titus
wrote the introduction, results, and discussion. Statistical analyses were conducted by both authors,
together. All authors have approved the final article.
This work was supported by the Office of Research and Economic Development at Mississippi State
University.
Conflict of Interest
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or
publication of this article.
Acknowledgments
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Table 1
Table 2
Correlations, Means, and Standard Deviations of borderline, suicide risk, and thought control strategies.
Social
FFBI PDQ_BPD BPD_PAI PAI_SUI Distract Punish Reappraisal Worry Control
FFBI -
PDQ_BPD .67** -
BPD_PAI .76*** .74** -
PAI_SUI .54** .47** .55** -
Distract -.09 -.12* -.08 -.15** -
Punish .47** .48** .48** .35** .12* -
Reappraisal .31** .27** .27** .01 .43** .46** -
Worry .51** .46** .52** .32** .09 .68** .52** -
Social Control -.13* -.01 -.13* -.16** -.01 -.10* .12* -.11 -
Mean 105.85 2.70 25.02 4.45 16.25 10.52 13.82 11.33 13.52
Std. Deviation 38.02 2.08 11.29 5.58 3.81 3.72 3.90 3.88 3.97
Note. *p <.05, two-tailed;** p <.01, two-tailed; Bold=Large Effect; Italics=Medium Effect.
THOUGHT CONTROL, BPD AND SUICIDE RISK 28
Table 3