Dialectical behavior therapy skills use as a mediator and outcome of treatment for borderline personality disorder

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Abstract

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.

Section snippets

Participants & procedure

Participants for the current study were drawn from three larger outcome studies on DBT in which DBT skills use was measured. Participants included 63 recurrently suicidal BPD women (Linehan, Comtois, Murray, et al., 2006) and 45 BPD women with drug dependence (Linehan et al., 1999, Linehan et al., 2002) for a total of 108 women with BPD. Demographic information is provided in Table 1. There were no significant differences in demographic characteristics between the suicidal group and the drug

DBT skills use as an outcome of treatment

To assess the hypothesis that DBT would increase behavioral skills use significantly more than control treatments, participants who received DBT were compared to participants in the three control conditions. In order to determine whether control conditions had differential effects on skills use, or whether we could combine them into one control group, an HLM analysis was conducted assessing the interaction between time and each control condition in predicting skills use. The analysis revealed a

Discussion

The present study examined BPD individuals’ DBT skills use throughout treatment and its relationship to primary outcome variables. Four main findings emerged. First, all participants reported using at least some DBT skills about 50% of the time before treatment started. Second, participants treated with DBT reported using skills throughout treatment significantly more than participants in the control condition. Third, DBT skills use fully mediated the likelihood of suicide attempts and

Acknowledgement

This study was supported by the MH34486 and MH01593 grants from the National Institute of Mental Health, as well as by grant DA08674 from the National Institute of Drug Abuse, National Institute of Health, awarded to Marsha M. Linehan, PhD, Principal Investigator. We thank the clients, therapists, assessors and staff at the Behavioral Research and Therapy Clinics, without whom this research would have not been possible. We also thank Bob Gallop, Ph.D., Melanie Harned, Ph.D. and Tom Lynch, Ph.D.

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