Research

Original Investigation

Dialectical Behavior Therapy for High Suicide Risk

in Individuals With Borderline Personality Disorder
A Randomized Clinical Trial and Component Analysis
Marsha M. Linehan, PhD; Kathryn E. Korslund, PhD; Melanie S. Harned, PhD; Robert J. Gallop, PhD; Anita Lungu, PhD; Andrada D. Neacsiu, PhD;
Joshua McDavid, MD; Katherine Anne Comtois, PhD; Angela M. Murray-Gregory, MSW

IMPORTANCE Dialectical behavior therapy (DBT) is an empirically supported treatment for

suicidal individuals. However, DBT consists of multiple components, including individual

therapy, skills training, telephone coaching, and a therapist consultation team, and little is
known about which components are needed to achieve positive outcomes.

Author Audio Interview at

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OBJECTIVE To evaluate the importance of the skills training component of DBT by comparing
skills training plus case management (DBT-S), DBT individual therapy plus activities group
(DBT-I), and standard DBT which includes skills training and individual therapy.
DESIGN, SETTING, AND PARTICIPANTS We performed a single-blind randomized clinical trial from
April 24, 2004, through January 26, 2010, involving 1 year of treatment and 1 year of follow-up.
Participants included 99 women (mean age, 30.3 years; 69 [71%] white) with borderline
personality disorder who had at least 2 suicide attempts and/or nonsuicidal self-injury (NSSI) acts
in the last 5 years, an NSSI act or suicide attempt in the 8 weeks before screening, and a suicide
attempt in the past year. We used an adaptive randomization procedure to assign participants to
each condition. Treatment was delivered from June 3, 2004, through September 29, 2008, in a
university-affiliated clinic and community settings by therapists or case managers. Outcomes
were evaluated quarterly by blinded assessors. We hypothesized that standard DBT would
outperform DBT-S and DBT-I.
INTERVENTIONS The study compared standard DBT, DBT-S, and DBT-I. Treatment dose was

controlled across conditions, and all treatment providers used the DBT suicide risk
assessment and management protocol.
MAIN OUTCOMES AND MEASURES Frequency and severity of suicide attempts and NSSI

episodes.
RESULTS All treatment conditions resulted in similar improvements in the frequency and
severity of suicide attempts, suicide ideation, use of crisis services due to suicidality, and
reasons for living. Compared with the DBT-I group, interventions that included skills training
resulted in greater improvements in the frequency of NSSI acts (F1,85 = 59.1 [P < .001] for
standard DBT and F1,85 = 56.3 [P < .001] for DBT-S) and depression (t 399 = 1.8 [P = .03] for
standard DBT and t399 = 2.9 [P = .004] for DBT-S) during the treatment year. In addition,
anxiety significantly improved during the treatment year in standard DBT (t94 = 3.5
[P < .001]) and DBT-S (t94 = 2.6 [P = .01]), but not in DBT-I. Compared with the DBT-I group,
the standard DBT group had lower dropout rates from treatment (8 patients [24%] vs 16
patients [48%] [P = .04]), and patients were less likely to use crisis services in follow-up (ED
visits, 1 [3%] vs 3 [13%] [P = .02]; psychiatric hospitalizations, 1 [3%] vs 3 [13%] [P = .03]).
CONCLUSIONS AND RELEVANCE A variety of DBT interventions with therapists trained in the
DBT suicide risk assessment and management protocol are effective for reducing suicide
attempts and NSSI episodes. Interventions that include DBT skills training are more effective
than DBT without skills training, and standard DBT may be superior in some areas.
TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00183651
JAMA Psychiatry. doi:10.1001/jamapsychiatry.2014.3039
Published online March 25, 2015.

Author Affiliations: Department of

Psychology, Behavioral Research and
Therapy Clinics, University of
Washington, Seattle (Linehan,
Korslund, Harned, Lungu, Neacsiu,
McDavid, Comtois, Murray-Gregory);
Department of Mathematics, West
Chester University, West Chester,
Pennsylvania (Gallop); Department of
Psychiatry and Behavioral Sciences,
Duke University, Durham, North
Carolina (Neacsiu); Department of
State, Washington, DC (McDavid).
Corresponding Author: Marsha M.
Linehan, PhD, Behavioral Research
and Therapy Clinics, Department of
Psychology, Box 355915, University of
Washington, Seattle, WA 98195
(linehan@u.washington.edu).

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Research Original Investigation

DBT for High Suicide Risk in Borderline Personality Disorder

vidence continues to accumulate supporting the efficacy of standard dialectical behavior therapy (DBT)1 for
the treatment of suicidal individuals with borderline
personality disorder (BPD). A meta-analysis of 16 studies of DBT
for BPD2 found a low overall dropout rate (27.3%) and moderate before-and-after effect sizes for global outcomes as well as
suicidal and self-injurious behaviors. The most recent Cochrane review3 concluded that DBT is the only treatment with
sufficient replication to be considered evidence based for BPD.
Although DBT is clearly efficacious and increasingly available in practice settings, demand for DBT far exceeds existing
resources.4 The multicomponent nature of DBT (individual
therapy, group skills training, between-session telephone coaching, and a therapist consultation team) lends itself to dismantling in clinical settings. Group skills training in DBT is frequently offered alone or, in community mental health settings,
with standard case management instead of DBT individual
therapy. Other clinicians, often those in private practice, offer
DBT individual therapy without any DBT group skills training.
The relative importance of DBT skills training compared with
other DBT components has not been studied directly, and the
overarching aim of the present study was to conduct a dismantling study of DBT to evaluate this question. We predicted that
standard DBT, including DBT individual therapy and DBT group
skills training, would be significantly better than DBT skills training without DBT individual therapy but with manualized case
management (DBT-S) and better than DBT individual therapy
without DBT skills training but with an activities group (DBT-I)
in reducing suicide attempts, nonsuicidal self-injury (NSSI) episodes, inpatient and emergency department (ED) admissions,
depression, anxiety, and treatment dropout. We made no predictions for differences between DBT-S and DBT-I.

Participants were 99 women aged 18 to 60 years who met

criteria for BPD on the International Personality Disorder
Examination6 and the Structured Clinical Interview for DSM-IV,
Axis II7 and had at least 2 suicide attempts and/or NSSI episodes
in the past 5 years, at least 1 suicide attempt or NSSI act in the
8-week period before entering the study, and at least 1 suicide
attempt in the past year. Owing to recruitment difficulties, inclusion criteria were relaxed late in the study, which allowed 1
participant to enter who had a suicide attempt in the 8 weeks before the study but no additional NSSI episodes and 5 participants
to enter who met the recurrent NSSI criteria but did not have a
suicide attempt in the past year. Individuals were excluded if they
had an IQ score of less than 70 on the Peabody Picture Vocabulary TestRevised8; met criteria for current psychotic or bipolar
disorders on the Structured Clinical Interview for DSM-IV, Axis
I9; had a seizure disorder requiring medication; or required primary treatment for another life-threatening condition (eg, severe
anorexia nervosa). Recruitment was via outreach to health care
practitioners.

Measures
The Suicide Attempt Self-injury Interview10 measured the frequency, intent, and medical severity of suicide attempts and
NSSI acts. The Suicidal Behaviors Questionnaire11 assessed suicide ideation. The importance of reasons for living was assessed with the Reasons for Living Inventory.12 Use of crisis services and psychotropic medications was assessed via the
Treatment History Interview (M.M.L., unpublished data, 1987),
which has been shown to have high (90%) agreement with hospital records. The severity of depression and anxiety was assessed via the Hamilton Rating Scale for Depression13 and Hamilton Rating Scale for Anxiety.14

Therapists

Methods
Study Design
We conducted a 3-arm, single-blind randomized clinical trial
from April 24, 2004, through January 26, 2010. A computerized adaptive randomization procedure5 matched participants on age, number of suicide attempts, number of NSSI episodes, psychiatric hospitalizations in the past year, and
depression severity. Assessments were conducted before treatment and quarterly during 1 year of treatment and 1 year of follow-up by blinded independent assessors trained by instrument developers or approved trainers (including K.A.C. and
A.M.M.-G.) and evaluated as reliable for each instrument. The
participant coordinator, who was not blinded to the treatment condition, executed the randomization and collected
treatment-related data. Participants were informed of their
treatment assignment at the first therapy session. All study procedures were approved by the institutional review board of the
University of Washington and were performed at the Behavioral Research and Therapy Clinics and community settings in
Seattle. The full study protocol can be found in the trial protocol in Supplement 1. All participants provided written informed consent after the study procedures were explained. The
flow of participants through the study is shown in the Figure.
E2

Participants

Therapists who delivered individual DBT (n = 15), DBT group

therapists (n = 3), and case managers (n = 5) did not differ by
sex (17 female [74%]) or clinical experience (18 [78%] had received their degree <10 years earlier). Fifteen therapists delivering individual DBT (93%) had a doctoral degree compared with 1 therapist delivering group DBT (33%) and none
of the case managers ( 22 = 15.9 [P < .001]). Therapists and case
managers were trained independently and monitored by experts in their respective interventions. A licensed psychiatric
nurse practitioner provided psychotropic medications under
the supervision of a psychiatrist.

Treatments
A detailed description of the treatment conditions and associated protocols is provided in Table 1. The DBT Adherence
Scale (M.M.L. and K.E.K, unpublished data, 2003) was used to
code randomly selected DBT individual and group therapy sessions, and 10% of the coded sessions were evaluated for interrater reliability (intraclass correlation, 0.93).
Standard DBT
Standard DBT1,15,16 is a comprehensive multicomponent intervention designed to treat individuals at high risk for sui-

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DBT for High Suicide Risk in Borderline Personality Disorder

Original Investigation Research

Figure. Participant Flowchart

187 Individuals assessed for
eligibility

99 Randomized

88 Excluded
69 Did not meet inclusion
criteria
19 Refused to participate

33 Randomized to standard DBT

25 Completed intervention

33 Randomized to DBT-I
17 Completed intervention

33 Randomized to DBT-S
20 Completed intervention

6 Lost to follow-up

11 Lost to follow-up

9 Lost to follow-up

33 Included in the primary

analysis

33 Included in the primary

analysis

33 Included in the primary

analysis

cide who meet criteria for multiple disorders. Standard DBT

is divided into the following 4 weekly components: individual therapy, group skills training, therapist consultation
team, and as-needed between-session telephone coaching.
Strategies drawn from cognitive and behavioral interventions (eg, behavioral assessment, contingency management,
exposure, cognitive restructuring, and skills training), dialectics, and the radical acceptance practices of validation and
mindfulness are used across all 4 DBT components, as are an
array of DBT protocol-based suicide interventions, including
use of the Linehan Suicide Risk Assessment and Management Protocol (LRAMP).17
DBT Skills Training
The DBT skills training condition (DBT-S) was designed to
evaluate the effect of DBT skills training by providing DBT
group skills training while removing the DBT individual therapy
component. To control for treatment dose and to ensure crisis and suicide management, individual therapy was replaced by a manualized case management intervention.18 Case
management followed a strengths-based needs assessment
model and involved finding resources, providing information, managing suicidal crises, and assisting with solving
problems.
DBT Individual Therapy
The DBT individual therapy condition (DBT-I) was designed
to eliminate all DBT skills training from the treatment by removing group skills training and prohibiting individual therapists from teaching DBT skills. Instead, individual therapists
focused on helping patients use the skills they already had and
only offered suggestions, using standard behavioral vocabulary, when patients were unable to generate their own solutions. To control for treatment dose, an activity-based support group was added and delivered by case managers that
included psychoeducation and activities commonly used in
recreational and activity therapy (eg, drawing, movies, or
social outings).
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The CONSORT diagram shows the

randomization of participants to
standard dialectical behavior therapy
(DBT) consisting of individual
therapy, group skills training,
therapist consultation team, and
as-needed between-session
telephone coaching; DBT individual
therapy (DBT-I) consisting of
individual therapists focused on
helping patients use the skills they
already have; and skills training DBT
(DBT-S) consisting of group skills
training while removing the individual
therapy component.

Statistical Analysis
Primary outcome analyses implemented mixed-effects modeling, including mixed-model analysis of variance for nonlinear
data,19 hierarchical linear models for linear data,20 zero-inflated
negative binomial models for outcomes with a preponderance
of zeroes,21 and generalized linear mixed models for binary
outcomes.22 Pairwise contrasts from the mixed-effects models
were used to evaluate between-group differences. Patternmixture models were used to assess whether estimates in the
mixed-effects models were dependent on missing data patterns.
For the time to events outcomes, survival curves using the Cox
proportional hazards model with censoring for patients who were
lost to or unavailable for follow-up or who never achieved the
event of interest were used. Cross-sectional comparisons were
conducted using analysis of variance, Kruskal-Wallis tests, and
2 tests. The study was powered for 1-tailed tests to demonstrate
superiority of standard DBT to each of the component treatment
conditions. Therefore, all predicted differences were tested with
1-tailed tests, and exploratory analyses comparing DBT-S and
DBT-I were conducted with 2-tailed tests. With a sample size of
33 per condition, we estimated 83% power to detect a 1-tailed difference on the primary outcomes of suicide attempts and NSSI
acts with an effect size of 0.55.

Results
Treatment Dropout, Implementation, and Adherence
The treatment groups did not differ significantly on pretreatment characteristics (Table 2). As shown in Table 3, more clients dropped out of treatment in DBT-I than in standard DBT.
Time to treatment dropout was more than 2 times faster for
DBT-I than for standard DBT ( 21 = 3.7 [P = .03]; hazard ratio,
2.3 [95% CI, 1.1-4.7]). Participants in standard DBT received significantly more individual sessions than those in DBT-S owing to weekly sessions in standard DBT and as-needed sessions in DBT-S. Participants in standard DBT and DBT-S received
more group therapy sessions than those in DBT-I owing to the
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Research Original Investigation

DBT for High Suicide Risk in Borderline Personality Disorder

Table 1. Components of the Study Treatment Conditions

Study Treatment
Component
Individual
sessions

Standard DBTa
DBT individual therapy
(1 h/wk)

Group
sessions
Approach to
teaching skills

DBT group skills training

(2.5 h/wk)
Highly suicidal patients and
those with BPD need training
to learn new behavioral skills
and active coaching in using
old and new skills to solve
their problems in living
Available as needed during
and after hours within the
therapists limits

Telephone
coaching

Consultation
team

Definition
of treatment
dropout

Medication
management

Crisis
management
protocols

DBT-Sa
Standardized case
management (as needed
with a minimum of
1 in-person or telephone
contact per month and
a maximum mean of
1 session/wk)
Identical to standard DBT
Identical to standard DBT

Available with case manager

during office hours;
after-hours calls managed
by Seattle Crisis Clinic
DBT consultation team
Case managers have group
meeting (1 h/wk)
supervision meeting (1 h/wk);
DBT skills trainers identical
to standard DBT
For DBT skills training,
Missing 4 consecutive weeks
missing 4 consecutive weeks
of scheduled individual or
of scheduled group therapy
group therapy sessions
sessions; for case
management, missing
monthly contact
Patient- or case
Individual therapists encouraged
managerinitiated
patients to work with prescriber
medication requests made
to taper medication therapy where
feasible (replacing pills with skills); only after an 8-wk trial
of DBT skills
patient- or therapist-initiated
medication requests made only
after an 8-wk trial of targeted
behavioral treatment
All providers used the
All providers used the LRAMP;
LRAMP; DBT skills trainers
DBT skills trainers were provided
were provided with a
with a crisis management plan
crisis management plan
from the individual DBT therapist
from the case manager;
case managers also filed plans
with the Seattle Crisis Clinic

optional nature of group therapy in DBT-I. Participants in standard DBT attended more groups than those in DBT-S owing to
trend-level differences in treatment retention. Treatment adherence did not differ between standard DBT and DBT-S for
group skills training, but it did differ between standard DBT
and DBT-I for individual therapy. We found no betweengroup differences in use of psychotropic medications.

Missing Data Patterns

We found no difference in the rate of dropout from study assessments (standard DBT, 6 participants [18%]; DBT-I, 11 [33%];
and DBT-S, 9 [27%] [P >.15]). No evidence indicated that the
findings on any major outcome variable were biased by group
differences in missing data.

Outcome Analyses
Results of all outcome analyses are shown in the eTable in
Supplement 2. These results indicate that participants experienced significant improvements over time on all outcomes.
Suicide-Related Outcomes
One participant in the standard DBT intervention committed
suicide during the study 1.5 years after the individual dropped
E4

DBT-I
Identical to standard DBT
except specific teaching
and coaching in DBT skills
was prohibited

Activity-based support
group (2.5 h/wk)
Highly suicidal patients
and those with BPD need
active coaching in using
skills they already have but
are not using to solve their
problems in living
Identical to standard DBT

Identical to standard DBT

Missing 4 consecutive
weeks of scheduled
individual therapy sessions

Identical to standard DBT

All providers used the

LRAMP; activity group
leaders were provided
with a crisis management
plan from the individual
DBT therapist

Abbreviations: BPD, borderline

personality disorder; DBT, dialectical
behavioral therapy; DBT-I, individual
DBT; DBT-S, skills training DBT;
LRAMP, Linehan Suicide Risk
Assessment and Management
Protocol.
a

The skills used were the new

updated and expanded set of DBT
skills.15,16

out of the study treatment. We found no significant differences between groups in the occurrence of any suicide attempt, the mean number of suicide attempts among those who
attempted suicide, the occurrence of any NSSI act, the highest medical risk for suicide attempts and NSSI acts, suicide ideation, or reasons for living. Survival analysis also indicated no
difference between groups in the time to the first suicide attempt ( 22 = 1.4 [P = .50]). The only significant betweengroup difference was in the mean number of NSSI acts among
participants who engaged in the behavior. Specifically, the frequency of NSSI acts among those engaging in the behavior was
significantly higher in DBT-I than in standard DBT (F1,85 = 59.1
[P < .001]) and DBT-S (F1,85 = 56.3 [P < .001]) during the treatment year but not during the follow-up year.
Use of Crisis Services
During the treatment year, we found no differences between
groups in the rates of ED visits or hospital admissions for any
psychiatric reason. During the follow-up year, fewer participants in the standard DBT group than in the DBT-I group visited an ED for any psychiatric reason (1 [3%] vs 3 [13%]; t72 = 2.0
[P = .02]) or were admitted to a psychiatric hospital for any psychiatric reason (1 [3%] vs 3 [13%]; t72 = 2.0 [P = .03]). We found

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DBT for High Suicide Risk in Borderline Personality Disorder

Original Investigation Research

Table 2. Baseline Demographic and Diagnostic Characteristicsa

Variable
Demographic Characteristic
Age, mean (SD), y

Study Treatment
Standard DBT
(n = 33)

DBT-I
(n = 33)

DBT-S
(n = 33)

All
(N = 99)

31.1 (8.2)

30.1 (9.6)

29.8 (8.9)

30.3 (8.9)
69 (71)

Raceb
White

24 (75)

21 (66)

24 (73)

Asian American

1 (3)

3 (9)

1 (3)

5 (5)

Biracial

6 (19)

8 (25)

7 (21)

21 (22)

Other

1 (3)

2 (2)

25 (76)

1 (3)

28 (85)

31 (94)

84 (85)

Less than high school

1 (3)

4 (12)

2 (6)

7 (7)

High school graduate or certificate of GED

4 (12)

3 (9)

2 (6)

9 (9)

19 (58)

20 (61)

18 (55)

57 (58)

9 (27)

6 (18)

11 (33)

26 (26)

<15 000

17 (53)

25 (76)

17 (52)

59 (60)

15 000-29 999

10 (31)

6 (18)

12 (36)

28 (29)

5 (16)

2 (6)

4 (12)

11 (11)

Single, divorced, or separated

Educational level

Some college or technical school

College graduate
Annual income, $b

30 000
Lifetime Axis I Psychiatric Diagnosisb
Major depressive disorder

32 (97)

32 (100)

31 (97)

95 (98)

Any anxiety disorder

30 (91)

30 (94)

27 (84)

87 (90)

Any substance use disorder

27 (82)

23 (72)

19 (59)

69 (71)

Any eating disorder

13 (39)

15 (47)

10 (31)

38 (39)

Current Axis I Psychiatric Diagnosisb

Major depressive disorder

21 (64)

24 (75)

25 (78)

70 (72)

Any anxiety disorder

29 (88)

27 (84)

25 (78)

81 (84)

Any substance use disorder

15 (46)

12 (38)

10 (31)

37 (38)

5 (15)

5 (16)

5 (16)

15 (16)

Paranoid

5 (15)

3 (10)

4 (13)

12 (13)

Schizoid

Schizotypal

1 (3)

Antisocial

5 (15)

4 (13)

3 (10)

Histrionic

2 (6)

2 (7)

4 (4)

Narcissistic

Any eating disorder

Axis II Psychiatric Diagnosisb

Avoidant

12 (36)

9 (29)

5 (16)

Dependent

2 (6)

1 (3)

Obsessive-compulsive

6 (18)

5 (16)

4 (13)

No. of current psychotropic medications, mean (SD)

3.6 (3.2)

3.3 (2.5)

2.5 (2.3)

no differences between groups in the rate of ED visits or hospital admissions for suicidality during the treatment or the
follow-up year.
Mental Health Outcomes
During the treatment year, depression improved less in DBT-I
than in standard DBT (t399 = 1.8 [P = .03]) and DBT-S (t399 = 2.9
[P = .004]). During the follow-up year, depression improved
more in the DBT-I than the standard DBT (t399 = 3.8 [P < .001])
and DBT-S (t399 = 3.1 [P < .01]) groups. The rate of change in anxiety did not significantly differ between groups during the treatment year, although anxiety significantly improved in the standard DBT (t94 = 3.5 [P < .001]) and DBT-S (t94 = 2.6 [P = .01])
groups but not in the DBT-I group (t94 = 0.8 [P = .42]). We found
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Abbreviations: DBT, dialectical

behavioral therapy; DBT-I, individual
DBT; DBT-S, skills training DBT;
GED, General Education
Development.
a

All demographic data were obtained

via self-report. Data are given as
number (percentage) of participants
unless otherwise indicated.
Continuous variables were
compared using analysis of
variance, and categorical data were
compared using 2 tests. No
significant between-group
differences were found.

Data were incomplete for these

categories.

0
1 (1)
12 (13)

26 (27)
3 (3)
15 (16)
3.1 (2.7)

a significant difference between groups in the rate of change in

anxiety during the follow-up year, with the DBT-I group improving more than the standard DBT (t94 = 2.5 [P = .01]) and
DBT-S (t94 = 2.0 [P = .048]) groups. In sum, the pattern of change
was similar for depression and anxiety, with the DBT-I group
improving less than the other groups during the treatment year
and then catching up during the follow-up year.

Discussion
The focus of this randomized clinical trial was to determine
whether the skills training component of DBT is necessary
and/or sufficient to reduce suicidal behaviors and improve
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DBT for High Suicide Risk in Borderline Personality Disorder

Table 3. Treatment Dropout, Implementation, and Adherencea

Study Treatment
Standard DBT
(n = 33)

DBT-I
(n = 33)

DBT-S
(n = 33)

16 (48)

13 (39)b

22.5 (11.0-37.8)

21.0 (5.5-33.5)

Treatment Dropout
No. (%)

8 (24)

Weeks before

25.5 (8.5-40.0)

Treatment Implementation
Treatment year
No. of individual therapy sessions by study therapists

41.0 (32.0-51.0)

30.0 (12.0-48.0)

19.0 (10.5-34.5)c

No. of all individual therapy sessionsd

42.0 (32.0-52.5)

33.0 (12.0-48.0)

20.0 (12.5-34.5)c

No. of group therapy sessions with study therapists

32.0 (23.5-40.0)

6.0 (2.0-11.0)

23.0 (13.5-34.5)b,c,e

No. of all group therapy sessionsd

32.0 (24.0-40.0)

6.0 (2.0-12.5)

26.0 (13.5-36.0)b,e

Total treatment hoursf

55.3 (42.2-67.0)

40.0 (14.0-55.0)

31.7 (16.8-47.3)b,c

Weeks in study treatmentg

52.0 (48.5-54.0)

49.0 (25.0-55.0)

50.0 (27.5-55.0)

Follow-up year
Any outpatient therapy, No. (%)

15 (52)

10 (44)

12 (50)

Individual therapy, No. (%)

15 (52)

10 (44)

12 (50)

No. of individual therapy sessions

2 (0-19.0)

0 (0-10.0)

1.5 (0-18.5)

Total treatment hours

3 (0-31.8)

3.3 (0-35.0)

8.5 (0-22.7)

Treatment Adherenceh
DBT individual therapy sessions, mean (SD)

4.20 (0.18)

DBT group therapy sessions, mean (SD)

4.20 (0.12)

4.16 (0.18)b
NA

NA
4.20 (0.11)

Psychotropic Medication
No. during treatment year, mean (SD)

1.5 (1.6)

1.7 (1.6)

1.7 (1.6)

No. during follow-up year, mean (SD)

2.4 (2.9)

2.5 (2.6)

2.5 (2.1)

Abbreviations: DBT, dialectical behavioral therapy; DBT-I, individual DBT;

DBT-S, skills training DBT; NA, not applicable.
a

Unless otherwise indicated, data are given as median (interquartile range).

Proportions were compared using 2 tests, and continuous variables were
compared with Kruskal-Wallis tests and t tests. P values are 2 tailed.

P < .05, standard DBT compared with DBT-I.

P < .05, standard DBT compared with DBT-S.

Includes sessions outside of the study.

other outcomes among individuals at high risk for suicide. To

that end, we compared standard DBT, which included DBT
group skills training and DBT individual therapy, with a treatment that evaluated DBT group skills training with manualized case management and removed DBT individual therapy
(DBT-S) and a treatment that removed DBT skills training by
providing only DBT individual therapy with an activities group
and prohibited individual therapists from teaching DBT skills
(DBT-I). All 3 conditions resulted in significantly reduced suicide attempts, suicide ideation, medical severity of intentional self-injury, use of crisis services owing to suicidality, and
improved reasons for living. Contrary to our expectations, standard DBT was not superior to either comparison condition for
any suicide-related outcome, and no significant differences
were detected between DBT-S and DBT-I. Thus, all 3 versions
of DBT were comparably effective at reducing suicidality among
individuals at high risk for suicide.
In contrast, findings suggested that DBT interventions that
included DBT skills training (standard DBT and DBT-S) were more
effective in reducing NSSI acts and improving other mental health
problems than a DBT intervention without skills training (DBT-I).
E6

P < .05, DBT-S compared with DBT-I.

Indicates total inpatient and outpatient treatment time. Each session of

individual therapy, family therapy, and vocational counseling was counted as 1
hour of therapy; each group therapy session, 20 minutes of therapy; each day
of day treatment, 30 minutes of therapy; and each psychiatric inpatient day,
3.5 hours of therapy.

Indicates total number of weeks clients saw any study therapist.

Rated for 439 individual therapy sessions and 49 group therapy sessions.

Specifically, among patients who engaged in at least 1 episode

of NSSI during the treatment year, those with skills training engaged in fewer NSSI acts than those without skills training. Those
without skills training were also slower to improve on measures
of depression and anxiety during the treatment year. These findings are consistent with research indicating that increasing DBT
skills use mediates reductions in NSSI and depression,23 and they
suggest that DBT skills training is a necessary component to
achieve optimal outcomes in these areas.
Overall, our findings suggest that standard DBT may have
several potential benefits compared with both dismantled conditions. Compared with DBT-I, standard DBT was superior in
retaining patients in treatment, reducing the frequency of NSSI,
improving mental health outcomes during treatment, and reducing ED visits and hospitalizations after treatment. In addition, although not reaching the level of statistical significance, several clinically meaningful differences emerged during
the follow-up year between standard DBT and DBT-S. Specifically, during the follow-up year, the rates of suicide attempts,
ED visits, and hospitalizations were each 2.0 to 2.4 times lower
in the standard DBT than in the DBT-S groups. Together, our

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DBT for High Suicide Risk in Borderline Personality Disorder

findings suggest that standard DBT and DBT-S show advantages over DBT-I during the acute treatment year, and standard DBT may be particularly effective in maintaining gains
in the year after treatment.
Several characteristics of our design are important to remember when interpreting these results. First, because we believed that standard DBT would be superior, we were not willing to let someone die by suicide to make a point. Therefore,
every treatment provider, including the study pharmacotherapist, was trained in the DBT suicide risk assessment and management protocol (the LRAMP17). Several notable effects resulted from such a decision. First, all practitioners were required
to fill out the LRAMP whenever there was an increase in suicidality, a credible suicide threat, or an actual NSSI act or suicide attempt. The impact was to enforce consistent monitoring of suicidality on all treatment providers. Although routine
assessment of suicide risk is a critical component of competent care for suicidal individuals,24 it is not the norm among
mental health care professionals.25 Moreover, monitoring of behavior inevitably leads to targeting of problem behaviors and,
based on our clinical experience, we believe that behaviors
monitored and targeted are those most likely to change.
Second, by virtue of training in the LRAMP, treatment providers across conditions had specialized training in the assessment and management of suicidal behavior. Specialized training in suicide management may be a critical factor in the
management and reduction of suicidal behaviors. For example, in a study that compared rates of suicide attempts
among individuals discharged from inpatient units for
suicidality,26 those who continued treatment with their inpatient psychiatrist had higher rates of suicide attempts than
those referred to a suicide crisis center. Similarly, in a large
study finding no significant differences in suicidality between DBT and an emotion-focused psychodynamic treatment plus medications,27 both conditions were led by experts in suicide interventions.
Third, DBT has always had a strong bias toward having 1
and only 1 practitioner in charge of treatment planning, including managing risk. Therefore, across all conditions, patients believed to be at imminent risk for suicide were referred immediately to their individual treatment provider for
risk management. This practice is in contrast to many settings where the treatment providers interacting with the client routinely make independent decisions for or against admission to the ED or the inpatient unit. This procedure
combined with DBTs bias toward outpatient rather than inpatient treatment for suicidality may have been instrumental

ARTICLE INFORMATION
Submitted for Publication: August 1, 2014; final
revision received October 13, 2014; accepted
November 19, 2014.
Published Online: March 25, 2015.
doi:10.1001/jamapsychiatry.2014.3039.
Author Contributions: Drs Harned and Gallop had
full access to all of the data in the study and take
responsibility for the integrity of the data and the
accuracy of the data analysis.

jamapsychiatry.com

Original Investigation Research

in keeping ED and inpatient admissions reasonably low. Although we know of no research on this issue to date, hospitalizing suicidal individuals might be iatrogenic rather than
therapeutic, as is suggested by the well-documented findings that individuals leaving psychiatric inpatient units have
a very high risk of committing suicide in the week and year after discharge.28 To our knowledge, no credible evidence suggests that hospitalization is more effective than outpatient
treatment in keeping suicidal individuals alive. The 2 small
studies that have compared inpatient with outpatient
interventions29,30 found no differences in subsequent suicide or suicide attempts. Furthermore, in several trials,31-33 use
of crisis services has been significantly lower in DBT than in
control conditions, whereas DBT simultaneously achieved a
significantly lower rate of suicide attempts and NSSI acts.
Should clinicians shift treatment from standard DBT to
DBT-S? Recent data suggest that DBT skills training alone is superior to wait lists (Shelly McMain, PhD, written communication, July 4, 2014) and standard group therapy34 for individuals with BPD. The skills training component of DBT alone has
also been shown to be effective across a range of clinical populations, such as individuals with major depression,35 treatmentresistant depression,36 high emotion dysregulation,37 attentiondeficit/hyperactivity disorder,38 and eating disorders39,40 and
in disabled adults with mental illness.41,42 Our study was not
powered to assess equivalence between DBT-S and standard
DBT, and equivalence should not be assumed. In addition, dropout rates were particularly high in the DBT-I and DBT-S groups,
although the latter did not have a higher dropout rate than the
standard DBT group. These high dropout rates together with low
power limit our ability to fully interpret our results.

Conclusions
In future studies, examination of the significance of suicide expertise, the LRAMP in particular, and the possible iatrogenic vs
therapeutic effects of hospitalization in terms of their effect on
suicide-related outcomes will be important. In addition, because therapists could not teach DBT skills within the DBT-I condition, we do not know whether DBT individual therapy without this restriction would look more like standard DBT or DBT-S
in terms of outcomes. Furthermore, the differences in dropout
rates led to differential treatment doses across conditions, which
might have affected the results. More research is needed before strong conclusions can be made as to what is the best DBT
intervention for highly suicidal individuals.

Study concept and design: Linehan, Korslund,

Harned, Comtois.
Acquisition, analysis, or interpretation of data:
Linehan, Korslund, Harned, Gallop, Lungu, Neacsiu,
McDavid, Murray-Gregory.
Drafting of the manuscript: Linehan, Korslund,
Harned, Gallop, Lungu.
Critical revision of the manuscript for important
intellectual content: Linehan, Korslund, Harned,
Neacsiu, Comtois, McDavid, Murray-Gregory.
Statistical analysis: Linehan, Harned, Gallop, Lungu.
Obtained funding: Linehan, Korslund, Comtois.

Administrative, technical, or material support:

Linehan, Korslund, Harned, Lungu, Neacsiu,
Murray-Gregory.
Study supervision: Linehan, Korslund, Harned,
McDavid.
Conflict of Interest Disclosures: Dr Linehan
receives royalties from Guilford Press for books she
has written on Dialectical Behavior Therapy (DBT)
and from Behavioral Tech, LLC, for DBT training
materials she has developed; she owns Behavioral
Tech Research, Inc, a company that develops online

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E7

Research Original Investigation

DBT for High Suicide Risk in Borderline Personality Disorder

learning and clinical applications that include

products for DBT. Drs Linehan, Korslund, Harned,
Neacsiu, and Comtois are compensated for
providing DBT training and consultation. No other
disclosures were reported.
Funding/Support: This study was supported by
grant R01MH034486 from the National Institute of
Mental Health for the design and conduct of the
study and for collection, management, analysis, and
interpretation of the data.
Role of the Funder/Sponsor: The funding source
had no role in the design and conduct of the study;
collection, management, analysis, and
interpretation of the data; preparation, review, or
approval of the manuscript; and decision to submit
the manuscript for publication.
Previous Presentation: Portions of these data
were presented at the 44th Annual Convention of
the Association for Behavioral and Cognitive
Therapies; November 19, 2010; San Francisco,
California.
REFERENCES
1. Linehan MM. Cognitive-Behavioral Treatment of
Borderline Personality Disorder. New York, NY:
Guilford Press; 1993.
2. Kliem S, Krger C, Kosfelder J. Dialectical
behavior therapy for borderline personality
disorder: a meta-analysis using mixed-effects
modeling. J Consult Clin Psychol. 2010;78(6):936951.
3. Stoffers JM, Vollm BA, Rucker G, Timmer A,
Huband N, Lieb K. Psychological therapies for
people with borderline personality disorder.
Cochrane Database Syst Rev. 2012;8:CD005652.
4. Swenson CR. How can we account for DBT's
widespread popularity? Clin Psychol Sci Pract.
2000;7(1):87-91.
5. White SJ, Freedman LS. Allocation of patients to
treatment groups in a controlled clinical study. Br J
Cancer. 1978;37(5):849-857.
6. Loranger AW. International Personality Disorder
Examination (IPDE) Manual. White Plains, NY: Cornell
Medical Center; 1995.
7. First MB, Spitzer RL, Gibbons M, Williams JBW,
Benjamin L. Users Guide for the Structured Clinical
Interview for DSM-IV Axis II Personality Disorders
(SCID-II). New York: Biometrics Research Dept, New
York State Psychiatric Institute; 1996.
8. Dunn LM. Peabody Picture Vocabulary
TestRevised. Circle Pines, MN: American Guidance
Service; 1981.
9. First MB, Spitzer RL, Gibbon M, Williams JBW.
Structured Clinical Interview for Axis I DSM-IV
DisordersPatient Edition (SCID-I/P). New York:
Biometrics Research Dept, New York State Psychiatric
Institute; 1995.
10. Linehan MM, Comtois KA, Brown MZ, Heard
HL, Wagner A. Suicide Attempt Self-injury Interview
(SASII): development, reliability, and validity of a
scale to assess suicide attempts and intentional
self-injury. Psychol Assess. 2006;18(3):303-312.
11. Addis M, Linehan MM. Predicting suicidal
behavior: psychometric properties of the Suicidal
Behaviors Questionnaire. Poster presented at:
Annual Meeting of the Association for the

E8

Advancement Behavior Therapy; November 2-5,

1989; Washington, DC.
12. Linehan MM, Goodstein JL, Nielsen SL, Chiles
JA. Reasons for staying alive when you are thinking
of killing yourself: the Reasons for Living Inventory.
J Consult Clin Psychol. 1983;51(2):276-286.
13. Hamilton M. A rating scale for depression.
J Neurol Neurosurg Psychiatry. 1960;23:56-62.
14. Hamilton M. The assessment of anxiety states
by rating. Br J Med Psychol. 1959;32(1):50-55.
15. Linehan MM. DBT Skills Training Manual. 2nd ed.
New York, NY: Guilford Press; 2014.
16. Linehan MM. DBT Skills Training Handouts and
Worksheets. New York, NY: Guilford Press; 2014.
17. Linehan MM, Comtois KA, Ward-Ciesielski EF.
Assessing and managing risk with suicidal
individuals. Cognit Behav Pract. 2012;19(2):218-232.
18. King County Mental Health, Chemical Abuse
and Dependency Services. King County mental
health plan policies and procedures. Revision
2004-R1. 2015 version. http://www.kingcounty.gov
/healthservices/MentalHealth/Policies%20and
%20Procedures.aspx. Accessed February 23, 2015.
19. Khuri AI, Mathew T, Sinha BK. Statistical Tests
for Mixed Linear Models. New York, NY: John Wiley
& Sons; 1998.
20. Bryk AS, Raudenbush SW. Hierarchical Linear
Models: Applications and Data Analysis Methods.
Newbury Park, CA: Sage; 1992.
21. Lambert D. Zero-inflated Poisson regression,
with an application to defects in manufacturing.
Technometrics. 1992;34:1-14.
22. Stroup WW. Generalized Linear Mixed Models:
Modern Concepts, Methods and Applications. New
York, NY: Chapman & Hall/CRC Press; 2012.
23. Neacsiu AD, Rizvi SL, Linehan MM. Dialectical
behavior therapy skills use as a mediator and
outcome of treatment for borderline personality
disorder. Behav Res Ther. 2010;48(9):832-839.
24. Bongar B. The Suicidal Patient: Clinical and
Legal Standards of Care. Washington, DC: American
Psychological Association; 1991.
25. Coombs DW, Miller HL, Alarcon R, Herlihy C,
Lee JM, Morrison DP. Presuicide attempt
communications between parasuicides and
consulted caregivers. Suicide Life Threat Behav.
1992;22(3):289-302.
26. Torhorst A, Mller HJ, Brk F, Kurz A, Wchtler
C, Lauter H. The psychiatric management of
parasuicide patients: a controlled clinical study
comparing different strategies of outpatient
treatment. Crisis. 1987;8(1):53-61.
27. McMain SF, Links PS, Gnam WH, et al.
A randomized trial of dialectical behavior therapy
versus general psychiatric management for
borderline personality disorder. Am J Psychiatry.
2009;166(12):1365-1374.
28. Large M, Sharma S, Cannon E, Ryan C, Nielssen
O. Risk factors for suicide within a year of discharge
from psychiatric hospital: a systematic
meta-analysis. Aust N Z J Psychiatry. 2011;45(8):
619-628.
29. van der Sande R, van Rooijen L, Buskens E,
et al. Intensive in-patient and community

intervention versus routine care after attempted

suicide: a randomised controlled intervention
study. Br J Psychiatry. 1997;171:35-41.
30. Waterhouse J, Platt S. General hospital
admission in the management of parasuicide:
a randomised controlled trial. Br J Psychiatry. 1990;
156:236-242.
31. Linehan MM, Armstrong HE, Suarez A, Allmon
D, Heard HL. Cognitive-behavioral treatment of
chronically parasuicidal borderline patients. Arch
Gen Psychiatry. 1991;48(12):1060-1064.
32. Linehan MM, Comtois KA, Murray AM, et al.
Two-year randomized controlled trial and follow-up
of dialectical behavior therapy vs therapy by
experts for suicidal behaviors and borderline
personality disorder. Arch Gen Psychiatry. 2006;63
(7):757-766.
33. Barnicot K, Savill M, Bhatti N, Priebe S.
A pragmatic randomised controlled trial of
dialectical behaviour therapy: effects on
hospitalisation and post-treatment follow-up.
Psychother Psychosom. 2014;83(3):192-193.
34. Soler J, Pascual JC, Tiana T, et al. Dialectical
behaviour therapy skills training compared to
standard group therapy in borderline personality
disorder: a 3-month randomised controlled clinical
trial. Behav Res Ther. 2009;47(5):353-358.
35. Lynch TR, Morse JQ, Mendelson T, Robins CJ.
Dialectical behavior therapy for depressed older
adults: a randomized pilot study. Am J Geriatr
Psychiatry. 2003;11(1):33-45.
36. Harley R, Sprich S, Safren S, Jacobo M, Fava M.
Adaptation of dialectical behavior therapy skills
training group for treatment-resistant depression.
J Nerv Ment Dis. 2008;196(2):136-143.
37. Neacsiu AD, Eberle JE, Kramer R, Wiesmann T,
Linehan MM. Dialectical behavior therapy skills for
transdiagnostic emotion dysregulation: a pilot
randomized controlled trial. Behav Res Ther. 2014;
59:40-51.
38. Hirvikoski T, Waaler E, Alfredsson J, et al.
Reduced ADHD symptoms in adults with ADHD
after structured skills training group: results from a
randomized controlled trial. Behav Res Ther. 2011;
49(3):175-185.
39. Telch CF, Agras WS, Linehan MM. Dialectical
behavior therapy for binge eating disorder.
J Consult Clin Psychol. 2001;69(6):1061-1065.
40. Safer DL, Robinson AH, Jo B. Outcome from a
randomized controlled trial of group therapy for
binge eating disorder: comparing dialectical
behavior therapy adapted for binge eating to an
active comparison group therapy [published
correction appears in Behav Ther. 2010;41(3):432].
Behav Ther. 2010;41(1):106-120.
41. Koons CR, Chapman AL, Betts BB, O'Rourke B,
Morse N, Robins CJ. Dialectical behavior therapy
adapted for the vocational rehabilitation of
significantly disabled mentally ill adults. Cognit
Behav Pract. 2006;13(2):146-156.
42. Valentine SE, Bankoff SM, Poulin RM, Reidler
EB, Pantalone DW. The use of dialectical behavior
therapy skills training as stand-alone treatment:
a systematic review of the treatment outcome
literature. J Clin Psychol. 2015;71(1):1-20.

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