Standalone DBT Group Skills Training Versus Standard (i.e. All Modes) DBT for Borderline Personality Disorder: A Natural Quasi-experiment in Routine Clinical Practice

  • Jim LyngEmail author
  • Michaela A. Swales
  • Richard P. Hastings
  • Tracy Millar
  • Daniel J. Duffy
  • Richard Booth
Original Paper


We describe a naturally occurring, real-world comparison of outcomes following 6 months in standalone DBT skills training group for adults with Borderline Personality Disorder (BPD) without recent suicidal or severe self-harming behaviours and standard (i.e. all modes) DBT for BPD including patients with recent high-risk behaviours. 34 patients chose standalone skills over waiting for standard DBT and 54 were offered standard DBT. Dropout was higher for standalone skills than standard DBT (38.2% vs. 16.7%). No statistically or clinically significant differences were found among completers between conditions on borderline symptoms, general psychopathology, and suicide ideation. There was a moderate effect for standalone skills on hopelessness and emotion regulation difficulties which may have reflected non-equivalence of treatment groups. Significant methodological factors limit generalisability of findings which offer support for feasibility of standalone DBT skills as an effective alternative to waitlist for standard DBT for at least some patients with BPD in the community.


DBT Dialectical behaviour therapy Standalone skills training group Skills-only Borderline personality disorder 


Compliance with Ethical Standards

Conflict of interest

The first and second authors (JL and MS) receive consultancy fees for the delivery of training in dialectical behaviour therapy (DBT) through British Isles DBT Training Ltd. ( The second author (MS) receives royalties for books authored on the subject of DBT and is an owner of British Isles DBT Training Ltd. There are no further conflicts of interests. No other authors receive fees for training in DBT. With the exception of the second author, there is no ownership of public or private firms with relevance to the study, no authors receive commercial sponsorships, and besides the book royalties of the second author there are no other patents or royalties due to any authors in relation to the subject matter. We, the authors, certify full responsibility for the manuscript. In so doing, we certify that we accept responsibility for the conduct of the study and for the analysis and interpretation of the data, that we helped write the manuscript and agree with the decisions about it, that we each meet the definition of an author as stated by the International Committee of Medical Journal Editors, and we have seen and approved the final manuscript. In certifying responsibility for the manuscript, we, the authors, also certify that neither the article nor any essential part of it, including tables and figures, will be published or submitted elsewhere before appearing in the Journal.


  1. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4, rev ed.). Washington, DC: American Psychiatric Association.Google Scholar
  2. Barnicot, K., Gonzalez, R., McCabe, R., & Priebe, S. (2016). Skills use and common treatment processes in dialectical behaviour therapy for borderline personality disorder. Journal of Behaviour Therapy and Experimental Psychiatry, 52, 147–156.CrossRefGoogle Scholar
  3. Barrett, M. S., Chua, W., Crits-Christoph, P., Gibbons, M. B., Casiano, D., & Thompson, D. (2008). Early withdrawal from mental health treatment: Implications for psychotherapy practice. Psychotherapy: Theory, Research, Practice, Training, 45, 247–267.CrossRefGoogle Scholar
  4. Beck, A. T., Kovacs, M., & Weissman, A. (1979). Assessment of suicide intention: The scale for suicide ideation. Journal of Consulting and Clinical Psychology, 47, 343–352.CrossRefPubMedGoogle Scholar
  5. Beck, A. T., & Steer, R. A. (1988). Manual for the Beck Hopelessness Scale. San Antonio: Psychological Corporation.Google Scholar
  6. Beck, A. T., & Steer, R. A. (1991). Manual for the beck scale for suicide ideation. San Antonio: Psychological Corporation.Google Scholar
  7. Beck, A. T., Steer, R. A., & Brown, G. (1997). Dysfunctional attitudes and suicidal ideation in psychiatric outpatients. Suicide and Life-Threatening Behaviour, 23, 11–20.Google Scholar
  8. Beck, A. T., Steer, R. A., & Ranieri, W. F. (1988). Scale for suicide ideation: Psychometric properties of a self-report version. Journal of Clinical Psychology, 44, 499–505.CrossRefPubMedGoogle Scholar
  9. Beck, A. T., Weissman, A., Lester, D., & Trexler, L. (1974). The measurement of pessimism: The Hopelessness Scale. Journal of Consulting and Clinical Psychology, 42, 861–865.CrossRefPubMedGoogle Scholar
  10. Blackford, J. U., & Love, R. (2011). Dialectical behaviour therapy group skills training in a community setting: A pilot Study. International Journal of Group Psychotherapy, 61, 645–657.CrossRefPubMedPubMedCentralGoogle Scholar
  11. Bohus, M., Kleindienst, N., Limberger, M. F., Stieglitz, R. D., Domsalla, M., Chapman, A. L., et al. (2009). The short version of the Borderline Symptom List (BSL-23): Development and initial data on psychometric properties. Psychopathology, 42, 32–39.CrossRefPubMedGoogle Scholar
  12. Brodsky, B. S., & Stanley, B. (2013). The dialectical behaviour therapy primer: How DBT can inform clinical practice. Oxford: Wiley-Blackwell.CrossRefGoogle Scholar
  13. Carmel, A., Rose, M. L., & Fruzzetti, A. E. (2014). Barriers and solutions to implementing dialectical behaviour therapy in a public behavioural health system. Administration and Policy in Mental Health and Mental Health Services Research, 41, 608–614.CrossRefPubMedGoogle Scholar
  14. Cohen, J. W. (1988). Statistical power analysis for the behavioural sciences (2nd ed.). Lawrence Erlbaum Associates: Hillsdale, NJ.Google Scholar
  15. Comtois, K. A., Koons, C. R., Kim, S. A., Manning, S. Y., Bellows, E., & Dimeff, L. A. (2007). Implementing standard dialectical behaviour therapy in an outpatient setting. In L. A. Dimeff & K. Koerner (Eds.), Dialectical behaviour therapy in clinical practice: Applications across disorders and settings (pp. 37–68). London: Guilford Press.Google Scholar
  16. Cowperthwait, C. M., Wyatt, K. P., Fang, C. M., & Neacsiu, A. D. (2019). Skills training in DBT: Principles and practicalities. In M. A. Swales (Ed.), The Oxford handbook of dialectical behaviour therapy (pp. 167–200). Oxford: Oxford University Press.Google Scholar
  17. Derogatis, L. R. (1994). Symptom Checklist-90-R: Administration, scoring, and procedures manual (3rd ed.). Minneapolis: Pearson.Google Scholar
  18. Dezetter, A., Briffault, X., Lakhdar, C. B., & Kovess-Masfety, V. (2013). Costs and benefits of improving access for common mental disorders. Journal of Mental Health Policy and Economics, 16, 161–177.PubMedGoogle Scholar
  19. Dozois, D. J. A., & Covin, R. (2004). The Beck Depression Inventory II (BDI-II), Beck Hopelessness Scale (BHS), and Beck Scale for Suicide Ideation (BSS). In M. J. Hilsenroth & D. L. Segal (Eds.), Comprehensive handbook of psychological assessment (Vol. 2, pp. 50–69). Hoboken, NJ: Wiley.Google Scholar
  20. Flynn, D., Kells, M., Joyce, M., Corcoran, P., Gillespie, C., Suarez, C., et al. (2017). Standard 12 month dialectical behaviour therapy for adults with borderline personality disorder in a public community mental health setting. Borderline Personality Disorder and Emotion Dysregulation, 4, 9.CrossRefGoogle Scholar
  21. Gibson, J., Booth, R., Davenport, J., Keogh, K., & Owens, T. (2014). Dialectical behaviour therapy-informed skills training for deliberate self-harm: A controlled trial with 3-month follow-up data. Behaviour Research and Therapy, 60, 8–14.CrossRefPubMedGoogle Scholar
  22. Glenn, C. R., Weinberg, A., & Klonsky, E. D. (2009). Relationship of the borderline symptom list to DSM-IV borderline personality disorder criteria assessed by semi-structured interview. Psychopathology, 42, 394–398.CrossRefPubMedGoogle Scholar
  23. Grant, B. F., Chou, S. P., Goldstein, R. B., Huang, B., Stinson, F. S., Saha, T. D., et al. (2008). Prevalence, correlates, disability, and comorbidity of DSM-IV borderline personality disorder: Results from wave 2 National Epidemiological Survey on alcohol and related conditions. Journal of Clinical Psychiatry, 69, 533–545.CrossRefPubMedGoogle Scholar
  24. Gratz, K. L., & Roemer, L. (2004). Multidimensinal assessment of emotion regulation and dysregulation: Development, factor structure, and initial validation of the difficulties in emotion regulation scale. Journal of Psychopathology and Behavioural Assessment, 26, 41–54.CrossRefGoogle Scholar
  25. Greene, S. M. (1981). Levels of measured hopelessness in the general population. British Journal of Clinical Psychology, 20, 11–14.CrossRefGoogle Scholar
  26. Hadjipavlou, G., Hernandez, C. A., & Ogrodniczuk, J. S. (2015). Psychotherapy in contemporary psychiatric practice. The Canadian Journal of Psychiatry, 60, 294–300.CrossRefPubMedGoogle Scholar
  27. Hamm, M., Williams, K., Celedonia, K. L., Frank, E., Swartz, H. A., Zickmund, S. L., et al. (2015). Readiness to implement an evidence-based psychotherapy: Perspectives of community mental health clinicians and administrators. Psychiatric Services, 66, 1109–1112.CrossRefPubMedGoogle Scholar
  28. Horowitz, L. M., Rosenberg, S. E., Baer, B. A., Ureno, G., & Villasenor, V. S. (1988). Inventory of interpersonal problems: Psychometric properties and clinical applications. Journal of Consulting and Clinical Psychology, 56, 885–892.CrossRefPubMedGoogle Scholar
  29. IBM Corp. (2013). IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY: IBM Corp.Google Scholar
  30. Jacobson, N. S., & Truax, P. (1991). Clinical significance: A statistical approach to defining meaningful change in psychotherapy research. Journal of Consulting and Clinical Psychology, 59, 12–19.CrossRefPubMedGoogle Scholar
  31. Kazdin, A. (2015). Evidence-based psychotherapies II: Changes in models of treatment and treatment delivery. South African Journal of Psychology, 45, 3–21.CrossRefGoogle Scholar
  32. Kjaer, J. N., Biskin, R., Vestergaard, C., Gustafsson, L. N., & Munk-Jorgensen, P. (2016). The clinical trajectory of patients with borderline personality disorder. Personality and Mental Health, 10, 181–190.CrossRefPubMedGoogle Scholar
  33. Krawitz, R., & Miga, E. M. (2019). Cost-effectiveness of dialectical behaviour therapy for borderline personality disorder. In M. A. Swales (Ed.), The Oxford handbook of dialectical behaviour therapy (pp. 497–514). Oxford: Oxford University Press.Google Scholar
  34. Lai, C. M., Leung, F., You, J., & Cheung, F. (2012). Are DSM-IV-TR borderline personality disorder, ICD-10 emotionally unstable personality disorder, and CCMD-III impulsive personality disorder analogous diagnostic categories across psychiatric nomenclatures? Journal of Personality Disorders, 26, 551–567.CrossRefPubMedGoogle Scholar
  35. Linehan, M. M. (1993). Cognitive-behavioural treatment of borderline personality disorder. London: Guilford Press.Google Scholar
  36. Linehan, M. M. (2015). DBT skills training manual (2nd ed.). London: Guilford Press.Google Scholar
  37. Linehan, M. M., Korslund, K. E., Harned, M. E., Gallop, R. J., Lungu, A., Neacsiu, A. D., et al. (2015). Dialectical behaviour therapy for high suicide risk in individuals with borderline personality disorder: A randomised controlled trial and component analysis. Journal of the American Medical Association Psychiatry, 72, 475–482.PubMedGoogle Scholar
  38. Lynch, T. R., Chapman, A. L., Rosenthal, M. Z., Kuo, J. R., & Linehan, M. M. (2006). Mechanisms of change in dialectical behaviour therapy: Theoretical and empirical observations. Journal of Clinical Psychology, 62, 459–480.CrossRefPubMedGoogle Scholar
  39. McMain, S. F., Guimond, T., Barnhart, R., Habinski, L., & Streiner, D. L. (2016). A randomised trial of brief dialectical behaviour therapy skills training in suicidal patients suffering from borderline personality disorder. Acta Psychiatrica Scandinavica, 135, 138–148.CrossRefPubMedGoogle Scholar
  40. Miga, E. M., Neacsiu, A. D., Lungu, A., Heard, H. L., & Dimeff, L. A. (2019). Dialectical behaviour therapy from 1991-2015: What do we know about clinical efficacy and research quality? In M. A. Swales (Ed.), The Oxford handbook of dialectical behaviour therapy (pp. 415–466). Oxford: Oxford University Press.Google Scholar
  41. Morley, S., & Dowzer, C. N. (2014). Manual for the Leeds Reliable Change Indicator: Simple Excel ® applications for the analysis of individual patient and group data. Leeds: University of Leeds.Google Scholar
  42. Neacsiu, A. D., Rizvi, S. L., & Linehan, M. M. (2010). Dialectical behaviour therapy skills use as a mediator of treatment for borderline personality disorder. Behaviour Research and Therapy, 48, 832–839.CrossRefPubMedPubMedCentralGoogle Scholar
  43. Priebe, S., Bhatti, N., Barnicot, K., Bremner, S., Gaglia, A., Katsakou, C., et al. (2012). Effectiveness and cost-effectiveness of dialectical behaviour for self-harming patients with personality disorder: a pragmatic randomised controlled trial. Psychotherapy & Psychosomatics, 81, 356–365.CrossRefGoogle Scholar
  44. Prinz, U., Nutzinger, D. O., Schulz, H., Petermann, F., Braukhaus, C., & Andreas, S. (2013). Comparative psychometric analyses of the SCL-90-R and its short versions in patients with affective disorders. BMS Psychiatry, 13, 104.CrossRefGoogle Scholar
  45. Richter, C., Bruno, S., zum Eschenhoff, A., & Bermpohl, F. (2016). Psychotherapy of borderline personality disorder: Can the supply meet the demand? A german nationwide study in DBT inpatient ad day clinical treatment facilities. Community Mental Health Journal, 52, 212–215.CrossRefPubMedGoogle Scholar
  46. Ritschel, L. A., Tone, E. B., Schoemann, A. M., & Lim, N. E. (2015). Psychometric properties of the difficulties in emotion regulation across demographic groups. Psychological Assessment, 27, 944–954.CrossRefPubMedGoogle Scholar
  47. Rizvi, S. L., Steffel, L. M., & Carson-Wong, A. (2013). An overview of dialectical behaviour therapy for professional psychologists. Professional Psychology: Research and Practice, 44, 73–80.CrossRefGoogle Scholar
  48. Schulz, S. C., Zanarini, M. C., Bateman, A., Bohus, M., Detke, H. C., Trzaskoma, Q., et al. (2008). Olanzapine for the treatment of borderline personality disorder: Variable dose 12-week randomised double-blind placebo-controlled study. The British Journal of Psychiatry, 193, 485–492.CrossRefPubMedGoogle Scholar
  49. Siqueland, L., Crits-Christoph, P., Barber, J. P., Butler, S. F., Thase, M., Najavits, L., et al. (2000). The role of therapist characteristics in training effects in cognitive, supportive-expressive, and drug counselling for cocaine dependence. Journal of Psychotherapy Practice and Research, 9, 123–230.PubMedGoogle Scholar
  50. Soler, J., Pascual, J. C., Tiana, T., Cebria, A., Barrachina, J., Campins, M. J., et al. (2009). Dialectical behaviour therapy skills training compared to standard group therapy in borderline personality disorder: A 3-month randomised controlled trial. Behaviour Research and Therapy, 47, 353–358.CrossRefPubMedGoogle Scholar
  51. Stoffers, J. M., Völlm, B. A., Rücker, G., Timmer, A., Huband, N., & Lieb, K. (2012). Psychological therapies for people with borderline personality disorder. Cochrane Database of Systematic Reviews. Scholar
  52. Swales, M. A., & Heard, H. L. (2017). Dialectical behaviour therapy: The CBT distinctive features series (2nd ed.). London: Routledge.Google Scholar
  53. Swenson, C. R., Torrey, W. C., & Koerner, K. (2002). Implementing dialectical behaviour therapy. Psychiatric Services, 53, 171–178.CrossRefPubMedGoogle Scholar
  54. Valentine, S. E., Bankoff, S. M., Poulin, R. M., Reidler, E. B., & Pantalone, D. W. (2015). The use of dialectical behaviour therapy skills training as a standalone treatment: A systematic review of the treatment outcome literature. Journal of Clinical Psychology, 71, 1–20.CrossRefPubMedGoogle Scholar
  55. Van Gelder, K. (2010). The Buddha and the borderline: My recovery from borderline personality disorder through dialectical behavior therapy, buddhism, and online dating. Oakland, CA: New Harbinger Publications.Google Scholar
  56. Verardi, S., Nicastro, R., McQuillan, A., Keizer, I., & Rossier, J. (2008). The personality profile of borderline personality disordered patients using the five-factor model of personality. International Journal of Clinical and Health Psychology, 8, 451–464.Google Scholar
  57. Vickers, J. (2016). Assessing a six-month dialectical behaviour therapy skills-only group. Mental Health Practice, 19, 26–30.CrossRefGoogle Scholar
  58. Wampold, B. E., & Imel, Z. E. (2015). The great psychotherapy debate (2nd ed.). London: Routledge.CrossRefGoogle Scholar
  59. WHO. (1992). The ICD-10 classification of mental and behavioural disorders: Clinical descriptions and diagnostic guidelines. Geneva: WHO.Google Scholar
  60. Wierzbicki, M., & Pekarik, G. (1993). A meta-analysis of psychotherapy dropout. Professional Psychology: Research and Practice, 24, 190–195.CrossRefGoogle Scholar
  61. Wilks, C. R., Korslund, K. E., Harned, M. S., & Linehan, M. M. (2016). Dialectical behaviour therapy and domains of functioning over two years. Behaviour Research and Therapy, 77, 162–169.CrossRefPubMedGoogle Scholar
  62. Zanarini, M. C., Frankenburg, F. R., Reich, D. B., Silk, K. R., Hudson, J., & McSweeney, L. B. (2007). The subsyndromal phenomenology of borderline personality disorder: A 10-year follow-up study. The American Journal of Psychiatry, 164, 929–935.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of PsychologyCluain Mhuire Community Mental Health ServicesBlackrock, Co. DublinIreland
  2. 2.School of PsychologyBangor UniversityBangorUK
  3. 3.Centre for Educational Development, Appraisal and ResearchUniversity of WarwickCoventryUK
  4. 4.South Eastern Health and Social Care TrustDundonaldUK
  5. 5.Department of PsychologySt Patrick’s University HospitalDublinIreland

Personalised recommendations