A r t ic le

D ia le c tic a l B e h a v io r T h e ra p y C o m p a re d W ith
G e n e ra l P sy c h ia tric M a n a g e m e n t fo r B o rd e rlin e
P e rso n a lity D iso rd e r: C lin ic a l O u tc o m e s a n d F u n c tio n in g
O v e r a 2 -Ye a r F o llo w -U p

Shelley F. McMain, Ph.D. O b je c tiv e : The authors conducted a
2-year prospective naturalistic follow -up
study to evaluate posttreatm ent clinical
Tim Guimond, M.D.
outcom es in outpatients w ho w ere ran-
dom ly selected to receive 1 year of either
David L. Streiner, Ph.D. dialectical behavior therapy or general
psychiatric m anagem ent for borderline
Robert J. Cardish, M.D. personality disorder.
M e th o d : Patients w ere assessed by blind
Paul S. Links, M.D. raters 6, 12, 18, and 24 m onths after
treatm ent. The clinical effectiveness of
treatm ent w as assessed on m easures of
suicidal and nonsuicidal self-injurious
behaviors, health care utilization, gen-
eral sym ptom distress, depression, anger,
quality of life, social adjustm ent, bor-
derline psychopathology, and diagnostic
status. The authors conducted betw een-
group com parisons using generalized es-
tim ating equation, m ixed-effects m odels,
or chi-square statistics, depending on the
distribution and nature of the data.
R e s u lts : Both treatm ent groups show ed
sim ilar and statistically significant im -
provem ents on the m ajority of outcom es
2 years after discharge. The original ef-
fects of treatm ent did not dim inish for
any outcom e dom ain, including suicidal
and nonsuicidal self-injurious behaviors.
Further im provem ents w ere seen on m ea-
sures of depression, interpersonal func-
tioning, and anger. How ever, even though
tw o-thirds of the participants achieved
diagnostic rem ission and significant in-
creases in quality of life, 53% w ere neither
em ployed nor in school, and 39% w ere re-
ceiving psychiatric disability support after
36 m onths.
C o n c lu s io n s : O ne year of either dialec-
tical behavior therapy or general psychi-
atric m anagem ent w as associated w ith
long-lasting positive effects across a broad
range of outcom es. D espite the benefits
of these specific treatm ents, one im por-
tant finding that replicates previous re-
search is that participants continued to
exhibit high levels of functional im pair-
m ent. The effectiveness of adjunctive re-
habilitation strate gies to im prove general
functioning deserves additional study.

(A m J P sy c h ia try 2 0 1 2 ; 1 6 9 :6 5 0 –6 6 1 )

W hile several studies have established the effective-

ness of cognitive-behavioral and psychodynamic treat-
ments of borderline personality disorder, relatively few
have addressed the long-term effects of these treatments.
With a few exceptions (1–3), the duration of follow-up in
these treatment studies has been short (<1 year). Conclu-
sions about effectiveness require information on the sus-
tained effects of treatment. Although dialectical behavior
therapy is a multimodal cognitive-behavioral approach
that has the largest empirical base of any psychosocial
treatment for borderline personality disorder, the follow-
up time frames in the five controlled trials evaluating the
lasting effects of this treatment were 1 year or less (4–8).
The available long-term data reveal a mixed picture, with
some evidence suggesting that the strength of the treat-
ment effects on some outcomes diminishes by 6 months
after discharge (4, 6, 8).
We report the results of a 2-year naturalistic follow-up
study of 180 individuals enrolled in a randomized con-
trolled trial in Toronto between 2003 and 2006. The design,
procedures, and treatment outcomes of the original study
are described elsewhere (9). Briefly, patients diagnosed
with borderline personality disorder were randomly as-
signed to receive 1 year of outpatient treatment consist-
ing of either dialectical behavior therapy or general psy-
chiatric management. After discharge, participants in
both groups showed significant improvements on a broad
range of clinical outcomes, including suicidal and non-
suicidal self-injurious behaviors, health care utilization
(emergency department visits, inpatient days, and psy-

This article is featured in this m onth’s AJP A u d io and is discussed in an E d ito ria l by D r. Batem an (p. 560)

650 a jp.p sych ia tryo n lin e.o rg A m J Psych ia try 1 6 9 :6 , Ju n e 2 0 1 2


chotropic medication use), borderline psychopathology,
symptom distress, depression, interpersonal functioning,
and anger. There were no differences between the treat-
ment groups in clinical outcomes.
In the present study, we prospectively evaluated wheth-
er these effects were sustained 2 years after treatment (i.e.,
3 years after random assignment to a treatment group).
Consistent with the original study, our primary outcome
measures were the frequency and severity of suicidal and
nonsuicidal self-injurious behaviors. We also examined
health care utilization, symptom distress, anger, depres-
sion, interpersonal functioning, overall quality of life, bor-
derline psychopathology, and remission from borderline
personality disorder. Finally, given accumulating evidence
from long-term follow-up studies of borderline person-
ality disorder that show persistent impairment in social
functioning (10–12), we also examined overall functioning.
M e th o d
In the original study, 180 adults meeting DSM-IV criteria (13)
for borderline personality disorder were randomly assigned to 1
year of either dialectical behavior therapy (N=90) or general psy-
chiatric management (N=90). Participants were between 18 and
60 years old and had at least two suicidal or nonsuicidal self-in-
jurious episodes in the past 5 years, with at least one occurring in
the past 3 months. Exclusion criteria included substance depen-
dence in the preceding 30 days; a diagnosis of psychotic disorder,
bipolar I disorder, delirium, dementia, or mental retardation; a
medical condition that precluded psychiatric medications; a seri-
ous medical condition requiring hospitalization within the com-
ing year; living outside of a 40-mile radius of Toronto; and having
plans to leave the province in the next 2 years.
Dialectical behavior therapy was implemented according to
the treatment manuals (14, 15). General psychiatric manage-
ment was implemented as a comprehensive approach to bor-
derline personality disorder, developed and manualized for this
trial, consisting of psychodynamic psychotherapy, case manage-
ment, and pharmacotherapy (P.S. Links, Y. Bergmans, J. Novick,
J. LeGris, unpublished 2009 manuscript). The psychotherapeutic
model in this approach emphasized the relational aspects of the
disorder and focused on disturbed attachment patterns and the
enhancement of emotion regulation in relationships. Case man-
agement strategies were integrated into weekly individual ses-
sions. No restrictions were placed on ancillary pharmacotherapy
in either condition; in general, pharmacotherapy was based on
a symptom-targeted approach but prioritized mood lability, im-
pulsivity, and aggressiveness as presented in APA guidelines (16).
Therapists in both treatment arms were well experienced in the
treatment of borderline personality disorder, were trained in their
respective approaches, and attended weekly supervision meet-
ings. Treatment fidelity was evaluated using modality-specific
adherence scales (17).
All participants underwent 24 months of naturalistic posttreat-
ment follow-up, regardless of whether they completed treatment.
Assessments were conducted 18, 24, 30, and 36 months after ran-
dom treatment assignment, with the exception of the Interna-
tional Personality Disorder Examination (18), which was adminis-
tered only at 24 and 36 months. Assessments were conducted by a
board-certified psychiatrist and doctoral-level clinicians who were
blinded to treatment group. Interrater reliability was maintained
on assessment of borderline personality disorder diagnostic cri-
teria (intraclass correlation coefficients, 0.83–0.92), and treatment
history data were collected by an unblinded study coordinator.
A m J Psych ia try 1 6 9 :6 , Ju n e 2 0 1 2 a jp.p sych ia tryo n lin e.o rg 651
M c M ain , G uim o nd, S t r e in e r , e t a l .
Although participants were required to discontinue the study
treatment at the end of 1 year, three patients in the general psy-
chiatric management arm received an additional 3, 14, and 24
months, respectively, because of therapist concerns about the
risks of discontinuing treatment. To determine whether this pro-
tocol violation caused meaningful differences in the results, we
conducted outcome analyses with and without the inclusion of
these three patients.
The study protocol was approved by each center’s research eth-
ics board, and participants provided written informed consent
for follow-up before enrolling in the original study. Participants
were compensated $10/hour for completing each assessment.
A sse ssm e n ts
The follow-up study included the same measures as the origi-
nal study. As before, the primary outcome measures were the
frequency and severity of suicidal and nonsuicidal self-injurious
behaviors, as assessed with the Suicide Attempt Self-Injury In-
terview (19). To determine whether any of the participants who
failed to complete the 36-month follow-up assessment had died
by suicide, we searched the Ontario death registry.
Secondary outcome measures included health care utilization,
borderline personality symptom severity, symptom distress, an-
ger, depression, interpersonal functioning, and quality of life. We
measured health care utilization using the semistructured Treat-
ment History Interview (M.M. Linehan, H.L. Heard, unpublished
1987 manuscript) to obtain self-reported counts of the number of
admissions to and number of days in a psychiatric hospital, emer-
gency department visits, medication use, outpatient psychosocial
and psychiatric treatment, and use of community and crisis sup-
port services. Other secondary outcome measures included the
total score on the Zanarini Rating Scale for Borderline Personality
Disorder (20); the global score on the Symptom Checklist 90–Re-
vised (SCL-90-R; 21); the expressed anger subscore on the State-
Trait Anger Expression Inventory (22); the total score on the Beck
Depression Inventory-II (BDI-II; 23); and the total score on the
Inventory of Interpersonal Problems (24). The International Per-
sonality Disorder Examination (18) was used to assess remission;
consistent with a major prospective follow-up study (10), remis-
sion was defined as meeting no more than two criteria for border-
line personality disorder for 1 year.
Overall functioning was assessed based on the EuroQol-5D (25)
thermometer, a measure of health-related quality of life and over-
all disability, occupational functioning, and receipt of psychiatric
disability benefits. Additionally, we assessed whether participants
attained normal functioning in terms of their level of symptom
distress severity (i.e., SCL-90-R) at 24 and 36 months.
S ta tistic a l A n a ly sis o f C h a n g e
We conducted analyses on both the intent-to-treat population
(N=180) and on the per protocol population, defined as the 167 par-
ticipants who attended at least eight treatment sessions (dialectical
behavior therapy, N=85; general psychiatric management, N=82).
All primary and secondary outcomes were reanalyzed without data
from the three participants who received study treatment during
the follow-up phase to determine whether this altered study results.
Several count measures, such as self-harm behaviors, hospital-
ization days, and emergency department visits, were nonnormal-
ly distributed and therefore analyzed using a negative binomial
distribution.
We analyzed outcomes that were nonnormally distributed us-
ing a generalized estimating equation model, which accounts
for collinearity between repeated measurements (26). Normally
distributed outcomes were analyzed using mixed-effects growth
curve models. Using these methods, the statistics are based on
full information, since participants with partially missing data
were included in the analyses.
D ia l e c t ica l B e havio r Th e rapy f o r B o rd e r l in e P e rs o na l it y D is o rd e r
We analyzed changes between the treatment and follow-up
phases on normally distributed outcomes using a piecewise lin-
ear response for rate; negative binomial-distributed outcomes
were analyzed using step functions for level of response. We mod-
eled each outcome using an initial intercept, a rate or level of im-
provement for the treatment phase, and a separate rate or level
of change for the follow-up phase; each model included a term
within each period for a between-group difference in rate.
Chi-square tests were used to compare between-group dif-
ferences in categorical responses (e.g., number of participants
meeting borderline personality disorder criteria at endpoints). We
used the twofold criterion of Jacobson et al. (27) to assess clini-
cally significant improvement based on general psychopathology.
For these analyses, the SCL-90-R global severity index was select-
ed as the metric because it had been used in two previous trials of
dialectical behavior therapy (3, 28). The criteria for clinically sig-
nificant change were 1) individual shifts from the dysfunctional
to the functional range based on nonclinical population norms
(i.e., clinically significant improvement) and 2) a statistically reli-
able magnitude of change, defined as a difference greater than
1.96 standard errors of measurement estimated from Cronbach’s
alpha with our baseline data. Participants had to meet both cri-
teria to be classified as achieving clinically significant change. To
correct for multiple testing, the Holms-Bonferroni correction was
applied, and a threshold of p<0.0015 was considered significant.
R e su lts
Of the 180 participants who entered the original study,
30 (16.7%) failed to attend any follow-up assessments; 131
(73%), 128 (71%), 118 (66%), and 110 (61%) completed as-
sessments at 18, 24, 30, and 36 months, respectively. Com-
pletion of all four follow-up assessments was achieved by
87 participants (48%). There were no statistically signifi-
cant differences between groups in the loss to follow-up
(dialectical behavior therapy, N=18/90 [20%] compared
with general psychiatric management, N=12/90 [13%]).
Overall, participants completed an average of 3.51 out
of four assessments (SD=0.89). There were no between-
group differences in the number of follow-up assessments
attended (dialectical behavior therapy, N=2.53, SD=1.62;
general psychiatric management, N=2.88, SD=1.44).
The characteristics of the original 180 participants are
described in detail elsewhere (9). Briefly, they were 30.4
years old on average (SD=9.9) and were mostly women
(86.1%); two-thirds (65.0%) were unemployed, and less
than half (42.2%) had a college education. With one ex-
ception, there were no differences in demographic and
diagnostic data, or suicidal and nonsuicidal self-injurious
behaviors at baseline between participants who attended
one or more follow-up assessments and those lost to fol-
low-up. The prevalence of cluster C personality disorders
was higher in those who attended one or more follow-up
assessments than those lost to follow-up (44.0% compared
with 23.3%, p=0.04).
Tre a tm e n t R e c e iv e d D u rin g F o llo w -U p
Table 1 presents findings on the utilization of mental
health care services during the follow-up phase. The pro-
portion of participants utilizing psychosocial treatments
ranged from 51.1% to 62.1% in the dialectical behavior
652 a jp.p sych ia tryo n lin e.o rg A m J Psych ia try 1 6 9 :6 , Ju n e 2 0 1 2
therapy group and from 54.2% to 58.6% in the general
psychiatric management group across follow-up assess-
ments. The overall number of psychosocial treatments
used by both groups increased significantly from the end
of treatment (z=3.28, p=0.001). After correcting for mul-
tiple testing, no between-group differences were found
(z=1.95, p=0.05).
The proportion of participants who reported any psy-
chiatric hospitalization at each follow-up assessment
ranged from 8.5% to 13.8% in the dialectical behavior
therapy group and from 10.0% to 15.0% in the general
psychiatric management group. The number of posttreat-
ment admissions to psychiatric hospitals remained stable
in both groups (z=–0.72, p=0.47), with no between-group
differences (z=0.39, p=0.70). The total number of days in
psychiatric hospitals remained unchanged from treat-
ment to follow-up for both groups (z=0.49, p=0.63), and
there were no between-group differences (z=0.09, p=0.93).
With regard to emergency department visits, the pro-
portions at each follow-up assessment ranged from 24.0%
to 43.1% for participants assigned to dialectical behavior
therapy and from 27.1% to 36.7% for those assigned to
general psychiatric management. The number of emer-
gency department visits over the follow-up phase re-
mained unchanged from treatment level for both groups
(z=–1.60, p=0.11), and there were no between-group dif-
ferences (z=–0.81, p=0.42.).
Participants in both groups showed similar patterns of
psychotropic medication use, with the overall proportion
for the entire sample across follow-up assessments rang-
ing from 61.9% to 70.3%, compared with 81.0% at base-
line. Participants assigned to the dialectical behavior ther-
apy group reported a range from 1.65 to 1.98 psychotropic
medications at each follow-up assessment, compared
with 1.95 to 2.39 for those assigned to general psychiatric
management. During follow-up, no significant differences
in the average number of psychotropic medications used
compared with the treatment phase were found between
participants (z=–0.10, p=0.92). There were no between-
group differences in the change in level of psychotropic
medications reported (z=–0.18, p=0.86)
S u ic id a l a n d N o n su ic id a l S e lf-In ju rio u s B e h a v io rs
Table 2 summarizes the frequency of suicidal and non-
suicidal self-injurious behaviors by group, with statistics
based on generalized estimating equations. The effects of
both treatments on the frequency and severity of these be-
haviors persisted after treatment. The proportion of partic-
ipants reporting suicide attempts at each follow-up assess-
ment ranged from 6.9% to 13.3% in the dialectical behavior
therapy group and from 7.4% to 13.2% in the general psy-
chiatric management condition. At 36 months, these pro-
portions were 8.2% and 12.1%, respectively. The reduced
rate of suicide attempts observed during the treatment
phase was maintained for both groups during follow-up
(z=0.47, p=0.64), and this did not differ between groups
 M c M ain , G uim o nd, S t r e in e r , e t a l .

TA B LE 1 . M e n ta l H e a lth S e rv ic e U tiliz a tio n fo r 1 8 0 O u tp a tie n ts W ith B o rd e rlin e P e rso n a lity D iso rd e r, b y Tre a tm e n t G ro u p
Treatment Group
Dialectical Behavior General Psychiatric
Therapy (N=90) Management (N=90) Time Effecta Group Effect
Health Care Relative Relative
Utilization Mean SD % Mean SD % Rate b 95% CI z p Rate b 95% CI z p
Emergency depart-
ment visits
  Baseline 1.99 3.01 66.7 2.08 3.53 57.8 0.77 0.56–1.06 –1.60 0.11 0.82 0.52–1.32 –0.81 0.42
  12 months 0.93 1.45 41.4 1.00 2.20 35.1
  18 months 0.76 1.06 43.1 0.70 1.51 34.3
  24 months 0.42 0.91 25.4 0.79 2.30 27.1
  30 months 0.84 2.33 32.8 0.83 1.43 36.7
  36 months 0.68 1.54 24.0 0.67 1.22 31.7
Emergency depart-
ment visits for
suicidal behavior
  Baseline 1.01 1.47 47.8 0.77 1.65 35.6 0.78 0.44–1.36 –0.89 0.38 0.43 0.18–1.03 –1.90 0.06
  12 months 0.41 1.00 20.0 0.29 1.13 13.0
  18 months 0.16 0.59 10.3 0.23 0.89 10.0
  24 months 0.10 0.30 10.2 0.24 0.79 12.9
  30 months 0.12 0.59 5.2 0.18 0.70 8.3
  36 months 0.30 1.22 6.0 0.20 0.58 13.3
Days in psychiatric
hospital
  Baseline 10.52 24.42 31.1 8.90 25.16 33.0 1.17 0.62–2.19 0.49 0.63 0.95 0.33–2.74 –0.09 0.93
  12 months 3.73 14.90 12.9 2.23 6.56 15.6
  18 months 4.26 17.92 13.8 2.06 7.44 10.0
  24 months 2.14 10.92 8.5 2.69 14.76 10.0
  30 months 2.62 8.85 12.1 2.57 8.90 13.3
  36 months 2.76 13.27 10.0 3.03 9.56 15.0
Number of psychiat-
ric admissions
  Baseline 0.60 1.15 32.2 0.70 1.23 35.6 0.77 0.38–1.57 –0.72 0.47 1.20 0.48–2.99 0.39 0.70
  12 months 0.21 0.66 11.5 0.29 0.81 12.8
  18 months 0.22 0.70 13.8 0.16 0.58 10.0
  24 months 0.10 0.36 8.5 0.11 0.36 10.0
  30 months 0.24 0.80 12.1 0.20 0.71 13.3
  36 months 0.22 0.91 10.0 0.42 1.85 15.0
Number of psycho-
tropic medications
  Baseline 2.66 1.81 86.5 2.41 1.94 75.6 0.99 0.89–1.12 –0.10 0.92 0.98 0.82–1.18 –0.18 0.86
  12 months 1.58 1.52 65.2 2.23 1.93 68.8
  18 months 1.77 1.65 68.3 2.21 1.72 72.1
  24 months 1.81 1.72 66.1 2.04 1.89 64.8
  30 months 1.98 1.88 65.5 1.95 2.00 58.3
  36 months 1.65 1.78 60.4 2.39 2.16 67.8
Number of psycho-
social treatments
  Baseline 1.53 1.35 82.0 1.46 1.17 79.8 1.51c 1.18–1.59 3.28 0.001 1.53 0.99–2.34 1.95 0.05
  12 months 0.34 0.76 22.9 0.56 0.71 46.2
  18 months 0.82 0.85 60.0 0.86 0.94 57.1
  24 months 0.81 0.95 51.7 0.86 0.95 55.7
  30 months 0.93 0.99 62.1 0.93 0.99 58.6
  36 months 0.76 0.88 51.1 0.93 1.10 54.2
a
Time-effect coefficients were based on generalized estimating equation analyses estimating step reduction between baseline and follow-
up time points, and group-effect coefficients were based on generalized estimating equation analyses estimating differences by treatment
group at follow-up visits.
b
The relative rate was calculated by using the parameter estimate of the general estimating equation model. As this was a logarithmic model,
the exponential of this estimate is reported.
c
Significant after correcting for multiple comparisons.

A m J Psych ia try 1 6 9 :6 , Ju n e 2 0 1 2 a jp.p sych ia tryo n lin e.o rg 653

D ia l e c t ica l B e havio r Th e rapy f o r B o rd e r l in e P e rs o na l it y D is o rd e r

TA B LE 2 . S u ic id a l a n d N o n su ic id a l S e lf-In ju rio u s B e h a v io rs fo r 1 8 0 O u tp a tie n ts W ith B o rd e rlin e P e rso n a lity D iso rd e r, b y

Tre a tm e n t G ro u p
Treatment Group
Dialectical Behavior General Psychiatric
Therapy (N=89) Management (N=88) Time Effect for Follow-Up Phase a Group Effect for Follow-Up Phase
Relative Relative
Measures Mean SD % Mean SD % Rate b 95% CI z p Rate b 95% CI z p
Number of suicidal
episodes
  Baseline 1.30 3.60 39.3 1.86 6.31 37.5 1.26 0.48–3.28 0.47 0.64 0.87 0.23–3.21 –0.21 0.83
  12 months 0.33 1.31 10.1 0.32 2.09 6.6
  18 months 0.27 0.80 13.3 0.54 2.26 13.2
  24 months 0.07 0.26 6.9 0.09 0.33 7.4
  30 months 0.14 0.69 7.0 0.24 0.84 10.2
  36 months 0.55 2.42 8.2 0.29 1.15 12.1
Number of nonsui-
cidal self-injurious
behaviors
  Baseline 21.65 35.20 84.3 20.41 39.98 87.5 0.56 0.30–1.05 –1.82 0.07 1.17 0.35–3.87 0.26 0.80
  12 months 4.12 9.23 47.8 6.74 19.70 44.7
  18 months 8.17 44.39 36.7 7.01 23.96 32.4
  24 months 2.48 7.34 29.3 2.06 8.01 33.8
  30 months 2.98 7.53 38.6 2.00 7.90 20.3
  36 months 2.18 7.77 24.5 1.09 4.31 31.0
a Time-effect
coefficients were based on generalized estimating equation analyses estimating step reduction between baseline and follow-
up time points, and group-effect coefficients were based on generalized estimating equation analyses estimating differences by treatment
group at follow-up visits.
b The relative rate was calculated by using the parameter estimate of the general estimating equation model. As this was a logarithmic model,

the exponential of this estimate is reported.

(z=–0.21, p=0.83). The proportion of participants who re-
ported any nonsuicidal self-injurious behaviors during
follow-up ranged from 24.5% to 38.6% in the dialectical
behavior therapy condition and from 20.3% to 33.8% in the
general psychiatric management condition. The effect of
treatment on rates of nonsuicidal self-injurious behaviors
was maintained after treatment for both groups (z=–1.82,
p=0.07). The medical severity of these behaviors was un-
changed from the end of treatment through the follow-
up for both groups, indicating that treatment gains were
maintained (t=0.78, df=933, p=0.44), and no between-
group differences were found (t=1.50, df=933, p=0.14).
No participants died from suicide over the course of fol-
low-up. There were two deaths from natural causes; both
of those participants had been assigned to dialectical be-
havior therapy.
S e c o n d a ry C lin ic a l O u tc o m e s
Table 3 summarizes secondary clinical outcomes based
on mixed-effects linear growth-curve models. After treat-
ment, participants in both groups showed either further
improvements or maintenance of treatment effects on all
outcomes. Figure 1 illustrates that the pattern of change
from baseline to end of treatment was similar for both
groups across a broad range of outcomes. After treatment,
both groups showed further improvements in measures of
anger, interpersonal functioning, and depression.
On measures of borderline psychopathology, both
groups remained unchanged from the end of treatment,
indicating that the treatment effects were sustained.
Mixed-effects analyses of borderline symptom clusters re-
vealed no differences from 12 to 36 months on affect (t=
–0.68, df=923, p=0.50), cognitive (t=–1.10, df=923, p=0.27),
impulsivity (t=–0.50, df=923, p=0.95), and interpersonal
(t=–1.05, df=921, p=0.29) symptom clusters, and there
were no between-group differences. One-year diagnostic
remission of borderline personality disorder was achieved
in 50% of participants in the dialectical behavior thera-
py group and in 55% of those in the general psychiatric
management group at 24 months, and by 57% and 68%,
respectively, at 36 months. There were no between-group
differences in diagnostic remission rates after treatment.
On measures of general psychopathology, over the
2-year follow-up both groups maintained the benefits that
had been achieved during treatment. Figure 2 illustrates
the number of participants who achieved reliable change
and clinically significant change as assessed on the SCL-
90-R. Between baseline and 36-month follow-up, 63%
of participants in the dialectical behavior therapy group
and 70% in the general psychiatric management group
achieved clinically reliable change, while 38% and 41%, re-
spectively, fulfilled both criteria and could be considered
recovered in a clinically significant way. There were no sta-
tistically significant between-group differences.
With regard to health-related quality of life, scores on the
EuroQol-5D were in the poor range at baseline, and while
both groups showed significant improvements during the
follow-up phase (slope=0.29, t=2.17, df=843, p=0.007),

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 M c M ain , G uim o nd, S t r e in e r , e t a l .

TA B LE 3 . N o rm a lly D istrib u te d O u tc o m e s fo r 1 8 0 O u tp a tie n ts W ith B o rd e rlin e P e rso n a lity D iso rd e r, b y Tre a tm e n t G ro u p

Treatment Group
Dialectical General
Behavior Psychiatric
Therapy Management Time Effect for Follow-Up Group Effect for Follow-Up
(N=90) (N=90) Phase Phase
Measure and Coeffi- Coeffi-
Assessmenta Mean SD Mean SD cientb 95% CI t df p cientc 95% CI t df p
Maximum medical risk
of suicide and self-
injurious episodesd
  Baseline 2.86 1.21 2.63 1.27 0.01 –0.02 to 0.78 933 0.44 –0.03 –0.07 to –1.50 933 0.14
0.04 0.01
  12 months 2.49 1.07 2.14 0.80
  18 months 2.93 2.45 2.54 1.27
  24 months 2.45 1.10 2.25 1.08
  30 months 2.08 0.83 2.63 1.26
  36 months 2.19 0.66 2.62 1.20
Symptom severity
(ZAN-BPD)
  Total score
   Baseline 15.49 6.14 14.94 6.59 –0.03 –0.09 to –0.93 921 0.35 0.07 –0.02 to 1.50 921 0.13
0.03 0.16
   12 months 7.93 6.11 8.16 5.79
   18 months 6.92 5.54 8.35 5.98
   24 months 8.17 6.10 8.09 5.89
   30 months 6.66 5.24 7.82 7.00
   36 months 8.29 6.35 6.66 5.49
  Cognitive subscale
   Baseline 3.64 2.01 3.97 2.10 –0.01 –0.03 to –1.10 923 0.27 0.02 –0.01 to 1.08 923 0.28
0.01 0.05
   12 months 1.84 1.92 1.94 1.81
   18 months 1.80 1.89 2.15 1.95
   24 months 1.95 1.91 1.86 1.96
   30 months 1.54 1.76 1.98 2.24
   36 months 1.88 2.03 1.41 1.57
  Impulsivity subscale
   Baseline 2.76 1.96 2.36 1.81 –0.001 –0.02 to –0.50 923 0.95 –0.001 –0.02 to 0.09 923 0.92
0.02 0.02
   12 months 1.47 1.54 1.31 1.43
   18 months 1.25 1.31 1.09 1.35
   24 months 1.33 1.41 1.42 1.68
   30 months 1.09 1.24 1.27 1.46
   36 months 1.38 1.51 1.24 1.60
  Interpersonal subscale
   Baseline 3.06 1.94 2.70 1.86 –0.01 –0.03 to –1.05 921 0.29 0.02 0.0002 to 1.99 921 0.047
0.01 0.048
   12 months 1.47 1.43 1.65 1.48
   18 months 1.35 1.31 1.65 1.47
   24 months 1.52 1.47 1.63 1.49
   30 months 1.29 1.49 1.32 1.32
   36 months 1.77 1.84 1.34 1.53
  Affect subscale
   Baseline 6.03 2.33 5.92 2.67 –0.01 –0.04 to –0.68 923 0.50 0.03 –0.01 to 1.43 923 0.15
0.02 0.07
   12 months 3.14 2.37 3.26 2.54
   18 months 2.72 2.49 3.47 2.52
   24 months 3.38 2.73 3.20 2.20
   30 months 2.75 2.27 3.25 2.93
   36 months 3.27 2.73 2.66 2.21
(continued)

A m J Psych ia try 1 6 9 :6 , Ju n e 2 0 1 2 a jp.p sych ia tryo n lin e.o rg 655

D ia l e c t ica l B e havio r Th e rapy f o r B o rd e r l in e P e rs o na l it y D is o rd e r

TA B LE 3 . N o rm a lly D istrib u te d O u tc o m e s fo r 1 8 0 O u tp a tie n ts W ith B o rd e rlin e P e rso n a lity D iso rd e r, b y Tre a tm e n t G ro u p

(c o n tin u e d )
Treatment Group
Dialectical General
Behavior Psychiatric
Therapy Management Time Effect for Follow-Up Group Effect for Follow-Up
(N=90) (N=90) Phase Phase
Measure and Coeffi- Coeffi-
Assessmenta Mean SD Mean SD cientb 95% CI t df p cientc 95% CI t df p
Depression (BDI-II)
  Baseline 37.15 12.46 35.4 10.60 –0.28 e –0.43 to –3.70 825 0.0002 0.32 0.10 to 2.89 825 0.004
–0.13 0.54
  12 months 22.48 16.20 25.19 15.05
  18 months 21.00 16.68 23.05 14.94
  24 months 22.24 16.40 21.67 14.82
  30 months 20.76 16.82 19.31 15.33
  36 months 24.45 18.65 18.05 13.77
Anger (STAXI, Anger
Expression Scale score)
  Baseline 17.92 5.19 17.6 5.51 –0.07 e –0.12 to –3.02 853 0.0006 0.07 0.01 to 2.23 853 0.02
–0.03 0.14
  12 months 16.05 5.50 15.90 5.10
  18 months 16.13 5.20 15.38 4.63
  24 months 14.48 4.41 15.79 5.12
  30 months 15.70 4.43 14.84 3.93
  36 months 15.95 4.80 14.40 3.47
Health status rating qual-
ity of life (EuroQol-5D
Visual Analogue Scale)
  Baseline 57.19 21.93 55.29 19.41 0.29 e 0.08 to 2.71 843 0.007 –0.28 –0.59 to –1.72 843 0.09
0.50 0.04
  12 months 63.45 20.53 59.23 21.89
  18 months 64.40 21.60 60.55 21.53
  24 months 64.80 21.63 63.18 20.43
  30 months 64.44 22.20 63.75 18.23
  36 months 64.31 21.12 67.69 20.97
Symptom distress
(SCL-90-R total score)
  Baseline 1.91 0.77 1.85 0.76 –0.01 –0.02 to –3.42 836 0.006 0.01 –0.002 to 1.54 836 0.12
–0.01 0.02
  12 months 1.35 0.89 1.37 0.82
  18 months 1.23 0.91 1.31 0.85
  24 months 1.20 0.85 1.20 0.85
  30 months 1.24 0.84 1.16 0.83
  36 months 1.26 0.95 1.03 0.80
Interpersonal function-
ing (IIP-64 total score)
  Baseline 119.00 44.02 121.30 37.13 –0.82 e –1.19 to –4.29 833 <0.0001 0.48 –0.07 to 1.70 833 0.09
–0.44 1.04
  12 months 100.85 50.52 102.99 45.61
  18 months 91.96 45.76 98.68 45.58
  24 months 94.93 49.88 97.11 48.46
  30 months 96.20 48.22 89.62 47.40
  36 months 94.48 47.96 84.36 45.46
a
ZAN-BPD=Zanarini Rating Scale for Borderline Personality Disorder; BDI-II=Beck Depression Inventory-II; STAXI=State-Trait Anger Expression
Inventory; SCL-90-R=Symptom Checklist 90-Revised; IIP-64=Inventory of Interpersonal Problems–64.
b Based on mixed-effects generalized linear regression analysis estimates of slope.
c Based on mixed-effects generalized linear regression analysis estimates of change in slope by treatment group.
d The medical risk is calculated using lethality of method and treatment received for each suicidal and self-injurious episode.
e Significant after correction for multiple comparisons.

656 a jp.p sych ia tryo n lin e.o rg A m J Psych ia try 1 6 9 :6 , Ju n e 2 0 1 2

 M c M ain , G uim o nd, S t r e in e r , e t a l .

F IG U R E 1 . O u tc o m e s fo r D ia le c tic a l B e h a v io r T h e ra p y (N =9 0 ) a n d G e n e ra l P sy c h ia tric M a n a g e m e n t (N =9 0 ) O v e r 3 6 M o n th s
A fte r R a n d o m iz e d Tre a tm e n t A ssig n m e n t a

Dialectical Behavior Therapy General Psychiatric Management

Predicted Predicted
Actual Actual

25 2.0 2.0
Nonsuicidal Self-Injurious Episodes

Psychological Treatments
20
1.5 1.5
Mean Number of

Mean Number of

Mean Number of
Suicide Attempts
15
1.0 1.0
10

0.5 0.5
5

0 0.0 0.0
0 12 24 36 0 12 24 36 0 12 24 36
Time (Months) Time (Months) Time (Months)

20 0.8 2.0
Personality Disorder Symptoms

Symptom Distress (SCL-90-R)

Quality of Life (EuroQol-5D)
Mean Score for Borderline

15 0.7
Mean Score for

Mean Score for

1.5
(ZAN-BPD)

10 0.6

1.0
5 0.5

0 0.4 0.5
0 12 24 36 0 12 24 36 0 12 24 36
Time (Months) Time (Months) Time (Months)

20 40
Interpersonal Functioning (IIP-64)

120
35
Anger Expression (STAXI)

18
Depression (BDI-II)

110
Mean Score for

Mean Score for

Mean Score for

30
16
100
25
14
90
20

12 80
15

10 10 70
0 12 24 36 0 12 24 36 0 12 24 36
Time (Months) Time (Months) Time (Months)
a
ZAN-BPD=Zanarini Rating Scale for Borderline Personality Disorder; BDI-II=Beck Depression Inventory-II; STAXI=State-Trait Anger Expression
Inventory; SCL-90-R=Symptom Checklist 90–Revised; IIP-64=Inventory of Interpersonal Problems–64. Estimates for the mean number of
nonsuicidal self-injurious episodes and mean number of suicide attempts were derived from the generalized estimating equation models
for assessing treatment effect. All other estimates come from mixed-effects models.

A m J Psych ia try 1 6 9 :6 , Ju n e 2 0 1 2 a jp.p sych ia tryo n lin e.o rg 657

D ia l e c t ica l B e havio r Th e rapy f o r B o rd e r l in e P e rs o na l it y D is o rd e r

F IG U R E 2 . C lin ic a lly R e le v a n t C h a n g e , b y Tre a tm e n t A ssig n ­ ly, 51.8% of the sample were neither working nor in school
m e n t, 2 4 a n d 3 6 M o n th s A fte r R a n d o m iz e d Tre a tm e n t at the end of follow-up, compared with 60.3% at the be-
A ssig n m e n t a
ginning of treatment. In the dialectical behavior therapy
Dialectical Behavior Therapy (N=45) group, 57.9% were working or in school, compared with
General Psychiatric Management (N=59) 40.4% of the general psychiatric management group. No
between-group differences were found. Before treatment,
4
39.7% of the participants had been receiving psychiatric
disability benefits (48.2% of those in dialectical behavior
therapy and 40.3% of those in general psychiatric man-
agement), compared with 38.8% at the end of follow-up.
3
At the end of follow-up, 29.0% of the dialectical behavior
SCL-90-R 24 Months

therapy group and 46.8% of the general psychiatric man-

agement group were supported by psychiatric disability
benefits, and there were no between-group differences.
2
The pattern of results was not altered after removing
from the analysis the three participants who received
study treatment during the follow-up phase, nor after
removing participants who received less than 8 weeks of
1
treatment.

D isc u ssio n
0 Two years after treatment, participants in both groups
0 1 2 3 4 exhibited sustained benefits of the 1-year intervention. The
SCL-90-R Baseline effects of treatment persisted on all assessed outcomes, in-
cluding the frequency and severity of suicidal and nonsui-
Dialectical Behavior Therapy (N=40) cidal self-injurious behaviors, decreased health service uti-
General Psychiatric Management (N=54) lization, symptom severity, and general psychopathology.
Participants also continued to improve during follow-up
4
on measures of interpersonal functioning, anger, depres-
sion, and quality of life. However, although quality of life
increased after treatment, participants still exhibited con-
siderable functional impairment, as indicated by low rates
3
of full-time employment and continuing high reliance on
psychiatric disability benefits.
SCL-90-R 36 Months

These findings are noteworthy because they confirm

that the effects of both treatments extend beyond ini-
2
tial symptom relief and are associated with long-lasting
changes across a broad range of outcomes. The findings
from this trial add to a growing number of studies (1, 2, 7,
30) demonstrating the sustained benefits of specific forms
1 of manualized psychotherapies delivered by trained clini-
cians working within a team. The effects of treatment did
not diminish over time for either group, suggesting that
participants continued to derive benefits from what they
0 had gained in treatment. Over time, participants became
0 1 2 3 4 less depressed, had less anger, and had better interper-
SCL-90-R Baseline
sonal functioning, which we speculate was because of the
a Individuals
in the gray zone achieved reliable change and clinically
treatments’ shared focus on enhancing patients’ emotion
significant change as assessed on the Symptom Checklist 90–Re-
vised (SCL-90-R). regulation capacities.
The overall rate of diagnostic remission 2 years after
treatment (62%) was higher than the rate attained over
their scores remained below normal and in a range com- a comparable time frame (42%) in another prospective
parable to patients with comorbid major depression and follow-up study of borderline personality disorder (10).
anxiety disorders (29). No significant between-group dif- Disorder-specific treatments likely hastened recovery, un-
ferences were found (t=–1.72, df=843, p=0.09). Important- derscoring the value of such treatments.

658 a jp.p sych ia tryo n lin e.o rg A m J Psych ia try 1 6 9 :6 , Ju n e 2 0 1 2


P a tie n t P e r s p e c tiv e s
D ia le c tic a l B e h a v io r T h e ra p y
A 3 2 -y e a r-o ld m a n w ith a le n g th y h isto ry o f p sy c h ia tric
h o sp ita l a d m issio n s a n d v isits to th e e m e rg e n c y d e p a rt-
m e n t w a s ra n d o m ly a ssig n e d to th e d ia le c tic a l b e h a v io r
th e ra p y g ro u p. H is h isto ry in c lu d e d c h ro n ic su ic id a l a n d
se lf-in ju rio u s b e h a v io rs ra n g in g fro m lo w to h ig h le th a l-
ity a n d d a tin g b a c k to th e a g e o f 1 0 . H e re p o rte d c u ttin g
a n d b u rn in g h im se lf se v e ra l tim e s a w e e k in a n e ffo rt to
re lie v e e m o tio n a l p a in . H e h a d b e e n tre a te d fo r 8 y e a rs
fo r d isso c ia tiv e id e n tity d iso rd e r a n d h a d trie d n u m e ro u s
m e d ic a tio n s w ith o u t su c c e ss. A s a c o n se q u e n c e o f h is
c h ro n ic se lf-in ju rio u s b e h a v io rs a n d o th e r d ra m a tic c o n -
d u c t, h e h a d fe w frie n d s a n d w a s fe e lin g m ise ra b le . T h e
p a tie n t w a s re fe rre d to th e stu d y a fte r p re se n tin g to p sy -
c h ia tric e m e rg e n c y se rv ic e s w ith su ic id a l b e h a v io r. D u rin g
h is fi rst se ssio n , th e p a tie n t’s b e h a v io r w a s d ra m a tic : h e
w a s in itia lly n o n re sp o n siv e w h e n sp o ke n to, m a d e lo u d
v o c a liza tio n s u p o n se e in g a fl y o n th e w a ll, a n d la te r
sp o ke in a q u ie t, c h ild like v o ic e , re fe rrin g to h im se lf a s
“w e .” A lth o u g h in itia lly h e sta te d th a t h e w a n te d to d ie ,
h e a c k n o w le d g e d th a t h e w a n te d a b e tte r life fo r h im se lf
a n d h e c o m m itte d to w o rk o n e lim in a tin g se lf-in ju rio u s
a n d su ic id a l b e h a v io rs. H e w a s a lso in te re ste d in im p ro v -
in g h is re la tio n sh ip s, a n d h e a g re e d to a d d re ss b iza rre b e -
h a v io rs, su c h a s sc re a m in g , th a t w e re iso la tin g h im fro m
o th e rs a n d c o m p ro m isin g h is e n g a g e m e n t in tre a tm e n t.
E a rly in th e ra p y, th e fo c u s w a s o n a n a ly zin g a n d a d d re ss-
in g th e fa c to rs c o n trib u tin g to h is in d ire c t c o m m u n ic a tio n
a n d d isso c ia tiv e b e h a v io rs.
D ia le c tic a l b e h a v io r th e ra p y w a s v e ry h e lp fu l fo r th is
p a tie n t. H e le a rn e d th a t h is u n h e a lth y b e h a v io rs w e re a
w a y o f c o p in g w ith u n e x p re sse d fe e lin g s; fo r e x a m p le ,
o v e rw h e lm in g fe e lin g s o f sh a m e in re sp o n se to p e rc e iv e d
c ritic ism w e re a fre q u e n t trig g e r to a n g ry o u tb u rsts a n d
se lf-h a rm b e h a v io rs. O v e r th e c o u rse o f tre a tm e n t, h e b e -
c a m e le ss c ritic a l o f h im se lf, m o re tru stin g o f h is e m o -
tio n a l re sp o n se s, m o re to le ra n t o f b e in g a lo n e , m o re
c o n fi d e n t a n d a sse rtiv e , a n d le ss o v e rw h e lm e d b y p a in fu l
e m o tio n s su c h a s sh a m e . B e c o m in g le ss a v o id a n t o f h is
e m o tio n s, h e c o u ld m o re e ffe c tiv e ly id e n tify a n d a d d re ss
h is n e e d s. H is re la tio n sh ip s w ith o th e rs im p ro v e d , a n d h e
b e c a m e le ss p ro n e to a n g ry o u tb u rsts. H is c o m m u n ic a tio n
No differences between treatment conditions were
found on any outcomes in our study. In contrast to pre-
vious studies comparing specific psychotherapy to non-
specific forms, we compared two manualized psycho-
therapeutic approaches that were specifically developed
for borderline personality disorder and delivered by clini-
cians with expertise. Considering the field of psychother-
apy outcome research more broadly, our findings are con-
sistent with evidence that the number of true differences
between psychotherapies developed for specific disorders
is zero. Future research needs to be directed toward un-
derstanding the effective mechanisms of these two treat-
A m J Psych ia try 1 6 9 :6 , Ju n e 2 0 1 2 a jp.p sych ia tryo n lin e.o rg 659
M c M ain , G uim o nd, S t r e in e r , e t a l .
w a s m o re d ire c t, a n d h is p se u d o d isso c ia tiv e b e h a v io rs
a n d su ic id a l a n d se lf-in ju rio u s b e h a v io rs c e a se d . To w a rd
th e e n d o f tre a tm e n t, h is re la tio n sh ip w ith h is p a rtn e r im -
p ro v e d . H e e n ro lle d in c o n tin u in g e d u c a tio n c o u rse s to
u p g ra d e h is sk ills a n d b e g a n lo o k in g fo r a b e tte r jo b.
G e n e ra l P sy c h ia tric M a n a g e m e n t
A 4 2 -y e a r-o ld w o m a n w ith a h isto ry o f su ic id a l b e h a v -
io r, b in g e d rin k in g , m a riju a n a a b u se , a n d e p iso d e s o f d e -
p re ssio n w a s ra n d o m ly a ssig n e d to th e g e n e ra l p sy c h ia tric
m a n a g e m e n t g ro u p. L e a d in g u p to h e r in v o lv e m e n t in th e
stu d y, th e p a tie n t w a s h a v in g fre q u e n t c rise s a c c o m p a n ie d
b y in te n se su ic id a l id e a tio n , a n x ie ty, a n d d e sp a ir, d u rin g
w h ic h sh e ty p ic a lly tu rn e d to a lc o h o l a n d m a riju a n a .
A t th e sta rt o f th e tria l, th e p a tie n t w a s a d a m a n t th a t
a tte n tio n n e e d e d to b e e n tire ly o n th e m e d ic a l m a n a g e -
m e n t o f h e r e p iso d e s o f d e p re ssio n . S h e q u ic k ly d e v e l-
o p e d a stro n g a llia n c e w ith h e r p sy c h ia trist, w h o v a lid a te d
h e r c o n c e rn a b o u t b rin g in g h e r d e p re ssiv e sy m p to m s u n -
d e r c o n tro l. A c c o rd in g ly, p a rts o f e a c h se ssio n w e re g iv e n
to m o n ito rin g o r a lte rin g h e r a n tid e p re ssa n t re g im e n , a n d
sh e b e c a m e m o re sta b le . A s th e sin g le m o th e r o f a te e n -
a g e so n , sh e re c e iv e d v a rio u s a c k n o w le d g m e n ts o f h e r
su c c e ss a t p a re n tin g ; fo r e x a m p le , h e r so n w a s g iv e n a n
e xc e lle n t le tte r o f re fe re n c e fro m h is su m m e r e m p lo y e r.
W h e n th e th e ra p ist u n d e rlin e d h e r p o sitiv e a ttrib u te s, th e
p a tie n t w a s a b le to a ssim ila te th e se a c k n o w le d g m e n ts a s
p a rt o f h e r o w n a c h ie v e m e n t o f b e in g a g o o d m o th e r. B y
e x a m in in g h e r m o th e rin g a b ilitie s, sh e b e g a n to re c o g -
n ize th e fe e lin g s o f a n g e r a n d re b e llio u sn e ss th a t sh e h a d
h e ld to w a rd h e r o w n p a re n ts a n d m o st a u th o rity fi g u re s.
S h e a rtic u la te d th a t a c tin g re b e llio u s h a d e n su re d th a t
sh e w o u ld b e “u n lo v a b le ,” so m e th in g sh e h a d a lw a y s fe lt
a b o u t h e rse lf. W ith g re a te r in sig h t in to h e r re b e llio u s a tti-
tu d e , th e p a tie n t m a d e a c o n sc io u s e ffo rt to c o m p ly m o re
fa ith fu lly w ith h e r m e d ic a tio n . B y th e tim e th e stu d y c a m e
to a c lo se , sh e h a d e x p e rie n c e d o n ly a fe w m in o r c rise s,
a n d w ith e n c o u ra g e m e n t h a d b e c o m e m u c h m o re so c ia l,
p a rtic u la rly o v e r th e In te rn e t. O v e r th e fo llo w -u p p e rio d ,
sh e im p ro v e d a n d c o n tin u e d th e c o m p le x re g im e n o f a n -
tid e p re ssa n t m e d ic a tio n u n d e r th e c a re o f a n o u tp a tie n t
p sy c h ia trist.
ments. One possible explanation for the absence of differ-
ences between the treatments is that there are common
factors that account for the effectiveness of both. We spec-
ulate that one common active ingredient is the inclusion
of protocols designed to de-escalate suicide crises.
The high rate of unemployment (52%) and reliance on
disability benefits (39%) among our participants at the
36-month follow-up is consistent with other follow-up
studies (10–12), which indicates that poor psychosocial
functioning persists even after symptomatic problems
diminish. While the dialectical behavior therapy group
had more participants who were employed and not on
D ia l e c t ica l B e havio r Th e rapy f o r B o rd e r l in e P e rs o na l it y D is o rd e r
disability at 36 months, between-group differences were
not statistically significant, suggesting insufficient power.
Future research should be powered to test improvements
in functioning, to examine barriers to engaging in produc-
tive functioning, such as financial disincentive of reem-
ployment or stigma, and to test therapies designed to im-
prove functioning in patients with borderline personality
disorder.
Strengths of this study include the fact that it is the larg-
est treatment follow-up study for borderline personality
disorder, the design is prospective, and the sample is well
characterized. The follow-up time frame is reasonably lon-
ger than those used in other studies of dialectical behavior
therapy, and the follow-up rates were good, with 83% of
participants attending at least 1 assessment and provid-
ing complete data on 3.5 of four assessments. In addition,
the assessments were based on face-to-face interviews,
the assessors were blind to treatment assignment, and the
outcomes were diverse and broad and were assessed with
standardized measures.
One limitation of our study is that data were not avail-
able for every participant at each assessment. However,
because our sample was relatively large, the study re-
mained adequately powered to detect differences even
with missing data. Furthermore, the statistical methods
used to analyze outcomes are based on all available data
from all participants. Another limitation is that it is pos-
sible that the participants who were lost to follow-up were
doing poorly, and the loss of their data may have biased
the outcomes in a positive direction. It should also be not-
ed that since this was a naturalistic study, access to treat-
ments (with the exception of the study treatments) was
uncontrolled. Additionally, self-report of treatment history
and suicidal behavior may be subject to response biases.
Approximately half of all participants reported receiving
treatment during the follow-up phase, and this may have
affected outcomes. Finally, in the absence of a control
group undergoing no treatment, the natural course of the
disorder is not known.
There are several directions for future research. For ex-
ample, modeling individual trajectories can help to de-
tect different patterns of treatment response. Addition-
ally, given the lack of availability of effective treatments
for borderline personality disorder, research is needed on
the effectiveness of less-intensive models of care in order
to help inform decisions about the allocation of scarce
health care resources.
P re se n te d in p a rt a t th e a n n u a l co n ve n tio n o f th e In te rn a tio n a l So -
cie ty fo r th e Im p ro ve m e n t a n d Te a ch in g o f D ia le ctica l B e h a v io r T h e r-
a p y, N o v. 1 5 –1 9 , 2 0 0 9 , N e w Yo rk; a t th e a n n u a l in te rn a tio n a l m e e t-
in g o f th e So cie ty fo r P sych o th e ra p y R e se a rch , Ju n e 2 3 –2 7 , 2 0 1 0 ,
A silo m a r, C a lif.; a n d a t th e a n n u a l m e e tin g o f th e A m e rica n P sych o -
a n a ly tic A sso cia tio n , Ja n . 1 2 –1 6 , 2 0 1 1 , N e w Yo rk. R e ce ive d Se p t. 2 2 ,
2 0 1 1 ; re v isio n s re ce ive d D e c . 1 0 , 2 0 1 1 , a n d Ja n . 3 0 , 2 0 1 2 ; a cce p te d
Fe b. 6 , 2 0 1 2 (d o i: 1 0 .1 1 7 6 /a p p i.a jp.2 0 1 2 .1 1 0 9 1 4 1 6 ). Fro m th e C e n tre
fo r A d d ictio n a n d M e n ta l H e a lth , To ro n to ; th e D e p a rtm e n t o f P sych i-
660 a jp.p sych ia tryo n lin e.o rg A m J Psych ia try 1 6 9 :6 , Ju n e 2 0 1 2
a try, U n ive rsity o f To ro n to ; M cM a ste r U n ive rsity, H a m ilto n , O n ta rio,
C a n a d a ; St. M ich a e l’s H o sp ita l, To ro n to ; th e D e p a rtm e n t o f P sych ia -
try, Sch u lich Sch o o l o f M e d icin e a n d D e n tistry, U n ive rsity o f W e ste rn
O n ta rio, Lo n d o n , O n ta rio, C a n a d a ; a n d th e Lo n d o n H e a lth Scie n ce s
C e n tre a n d St. Jo se p h ’s H e a lth C a re Lo n d o n , Lo n d o n , O n ta rio . A d -
d re ss co rre sp o n d e n ce to D r. M cM a in (sh e lle y _m cm a in @ca m h .n e t).
D r. Lin ks re ce ive d a n u n re stricte d e d u ca tio n a l g ra n t fro m E li Lilly
C a n a d a , In c . T h e re m a in in g a u th o rs re p o rt n o fin a n cia l re la tio n sh ip s
w ith co m m e rcia l in te re sts.
Su p p o rte d e n tire ly b y th e C a n a d ia n In stitu te s fo r H e a lth R e se a rc h
(g ra n t 2 0 0 2 0 4 M C T-1 0 1 1 2 3 ).
T h e a u th o rs th a n k D r. Su sa n W n u k, Jo sh u a M u rra y, a n d n u m e ro u s
re se a rch a n a ly sts, vo lu n te e rs, a n d co lle a g u e s a t th e C e n tre fo r A d d ic -
tio n a n d M e n ta l H e a lth , St. M ich a e l’s H o sp ita l, a n d th e U n ive rsity o f
To ro n to D e p a rtm e n t o f P sych ia try.
C lin ica ltria ls.g o v id e n tifie r: N C T 0 0 1 5 4 1 5 4 .
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