Our findings replicate those of previous studies of DBT and suggest that the effectiveness of DBT cannot reasonably be attributed to general factors associated with expert psychotherapy. Dialectical behavior therapy appears to be uniquely effective in reducing suicide attempts.

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. 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 (F 1,85 = 59.1 [P < .001] for standard DBT and F 1,85 = 56.3 [P < .001] for DBT-S) and depression (t 399 = 1.8 [P = .03] for standard DBT and t 399 = 2.9 [P = .004] for DBT-S) during the treatment year. In addition, anxiety significantly improved during the treatment year in standard DBT (t 94 = −3.5 [P < .001]) and DBT-S (t 94 = −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 with...

Objective This study evaluates the efficacy of integrating PTSD treatment into Dialectical Behavior Therapy (DBT) for women with borderline personality disorder, PTSD, and intentional self-injury. Methods Participants were randomized to DBT (n=9) or DBT with the DBT Prolonged Exposure (DBT PE) protocol (n=17) and assessed at 4-month intervals during the treatment year and 3-months post-treatment. Results Treatment expectancies, satisfaction, and completion did not differ by condition. In DBT + DBT PE, the DBT PE protocol was feasible to implement for a majority of treatment completers. Compared to DBT, DBT + DBT PE led to larger and more stable improvements in PTSD and doubled the remission rate among treatment completers (80% vs. 40%). Patients who completed the DBT PE protocol were 2.4 times less likely to attempt suicide and 1.5 times less likely to self-injure than those in DBT. Among treatment completers, moderate to large effect sizes favored DBT + DBT PE for dissociation, trauma-related guilt cognitions, shame, anxiety, depression, and global functioning. Conclusions DBT with the DBT PE protocol is feasible, acceptable, and safe to administer, and may lead to larger improvements in PTSD, intentional self-injury, and other outcomes than DBT alone. The findings require replication in a larger sample.