Hunter DBT project: randomized controlled

trial of dialectical behaviour therapy in

women with borderline personality disorder
Gregory L. Carter, Christopher H. Willcox, Terry J. Lewin,
Agatha M. Conrad, Nick Bendit

Objective: Deliberate self-harm (DSH), general hospital admission and psychiatric hospital
admission are common in women meeting criteria for borderline personality disorder (BPD).
Dialectical behaviour therapy (DBT) has been reported to be effective in reducing DSH
and hospitalization.
Method: A randomized controlled trial of 73 female subjects meeting criteria for BPD was
carried out with intention-to-treat analyses and per-protocol analyses. The intervention was
DBT and the control condition was treatment as usual plus waiting list for DBT (TAUWL),
with outcomes measured after 6 months. Primary outcomes were differences in proportions
and event rates of: any DSH; general hospital admission for DSH and any psychiatric
admission; and mean difference in length of stay for any hospitalization. Secondary
outcomes were disability and quality of life measures.
Results: Both groups showed a reduction in DSH and hospitalizations, but there were no
significant differences in DSH, hospital admissions or length of stay in hospital between
groups. Disability (days spent in bed) and quality of life (Physical, Psychological and
Environmental domains) were significantly improved for the DBT group.
Conclusion: DBT produced non-significant reductions in DSH and hospitalization when
compared to the TAUWL control, due in part to the lower than expected rates of
hospitalization in the control condition. Nevertheless, DBT showed significant benefits for
the secondary outcomes of improved disability and quality of life scores, a clinically useful
result that is also in keeping with the theoretical constructs of the benefits of DBT.
Key words: borderline personality disorder, deliberate self-harm, disability, quality of life,
randomized controlled trial.

Australian and New Zealand Journal of Psychiatry 2010; 44:162–173

Borderline personality disorder (BPD) is one of only accompaniment to this disorder. It has also been found,
two conditions that includes suicide attempts as a crite- however, that the least prevalent and most changeable
rion for diagnosis in the DSM-IV classification system criteria for BPD are self-injury and behaviours defending
[1], indicating that suicidal behaviour is a common against abandonment [2]. A review suggested that people

Gregory L. Carter, Conjoint Professor and Principal Researcher
Centre for Brain and Mental Health Research, University of
Newcastle, Newcastle, New South Wales, Australia. (Correspondence)
Dept. Consultation-Liaison Psychiatry, Locked Bag 7, Hunter
Region Mail Centre, NSW 2310, Australia. Email: gregory.carter@
newcastle.edu.au
Christopher H. Willcox, Conjoint Senior Lecturer and Senior Clinical Psy-
chologist
School of Psychology, University of Newcastle, Newcastle, New South
Wales, Australia; Centre For Psychotherapy, Hunter New England
Mental Health Services, Newcastle, New South Wales, Australia.
Terry J. Lewin, Research Manager; Agatha M. Conrad, Research
Development Officer
Centre for Brain and Mental Health Research, University of Newcastle,
Newcastle, New South Wales, Australia; Hunter New England Mental
Health Services, Newcastle, New South Wales, Australia.
Nick Bendit, Staff Specialist Psychiatrist, and Conjoint Lecturer
Centre for Brain and Mental Health Research, University of Newcastle,
Newcastle, New South Wales, Australia; Centre For Psychotherapy, Hunter
New England Mental Health Services, Newcastle, New South Wales,
Australia
Received 17 March 2009; accepted 24 June 2009.

© 2010 The Royal Australian and New Zealand College of Psychiatrists

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 G.L. CARTER, C.H. WILLCOX, T.J. LEWIN, A.M. CONRAD, N. BENDIT
with BPD improve over the long term, decreasing in sui-
cidality, self-destructiveness and interpersonal malad-
justment, if survival is effectively managed during the
turbulent years of youth [3]. Nevertheless, a recent review
suggested that suicidal behaviour is a common complica-
tion, and continues to be a chief concern in the clinical
management of BPD [4].
Better treatments for BPD and particularly for the
suicidal behaviour and suicide deaths experienced by
these patients have been sought for some time. It has been
estimated that although 10% will eventually complete
suicide, this outcome is not readily predictable, and hos-
pitalization is of unproven value for suicide prevention,
possibly producing negative effects [5].
There have been few effective interventions tested in
randomized controlled trials (RCTs) to reduce rates of sui-
cide attempt, parasuicide or deliberate self-harm (DSH) in
BPD. For outpatients, a day hospital programme with a
psychoanalytic treatment component [6] and for female
subjects with multiple parasuicidal behaviours, dialectical
behaviour therapy (DBT) have been shown to be effective
[7]. Both of these therapies have also demonstrated long-
term reduction in suicidal behaviour after the cessation of
therapy [8–10]. DBT is a team-based treatment combining
cognitive, behavioural and mindfulness techniques, deliv-
ered in individual therapy, group-based skills training, out-
of-hours telephone contact with individual therapist
modalities and a therapist consultation group [7].
There have been other trials of DBT with a reduction in
suicidal behaviours as the primary outcome, replicated out-
side of the University of Washington: RCT in the Nether-
lands [11], a study with inpatients in Germany in a
non-controlled design [12], and a three-arm RCT in New
York [13]. There have also been adaptations of the duration
or ‘dose’ of DBT into a 12 week programme for adoles-
cents [14], 6 months for female veterans [15], 6 months for
female subjects with active suicidal ideation [16], 28 weeks
skills training for depressed women aged >60 years [17]
and 20 weeks for bulimic behaviour [18]. DBT has also
been applied in other female BPD populations: drug depen-
dence [19], veterans [15], opioid dependence [20] with
bulimic behaviour [18] and in depressed elderly [17].
DBT has been demonstrated to be effective in RCTs for
other outcomes including retention in treatment [7,19],
fewer inpatient hospital days [7], social and global adjust-
ment [19] and reduction in substance use [19,20]. Never-
theless, there have been some reservations expressed about
the limited research base and methodological limitations
of the published studies for DBT, especially in the light of
the enthusiastic take up of DBT as a treatment [21].
There are no RCTs from Australia addressing suicidal
behaviour in BPD, but a non-controlled study of 30 sub-
jects using a self-psychology intervention (Hobson’s
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163
conversational model) delivered by trainee psychiatrists
showed improvement for the year of treatment, which was
sustained at follow up 12 months later. Improvements
were shown in frequency of use of drugs (both prescribed
and illegal), number of visits to medical professionals,
number of episodes of violence and self-harm, time away
from work, number of hospital admissions, time spent as
an inpatient and a score on a self-report index of symptoms
[22]. This group was later followed up for a period of
5 years and was compared to a cohort (non-randomized)
of waiting list (WL) patients. The primary outcome was
improvement in DSM total criteria scores [23]. In a dif-
ferent Australian study, a retrospective examination of two
different treatment conditions for BPD patients showed
that those who received a special treatment contract had a
significantly higher total number of admissions but not
more presentations to the emergency department than the
standard treatment group [24].
Aims
The purpose of the present study was to compare DBT
and the control condition of treatment as usual plus WL
for DBT (TAUWL) for the primary outcomes (differ-
ences in proportions and event rates) of any DSH event;
general hospital admission for DSH and psychiatric
admission for any reason; and mean difference in length
of stay for any hospitalization. Secondary outcomes were
disability and quality of life measures.
Methods
Setting
The Hunter DBT project was undertaken in Newcastle, Australia at
the Centre for Psychotherapy, a clinical outpatient unit of the Hunter
New England Mental Health Service. Individual DBT therapists and
skills trainers were psychiatrists, social workers, clinical psychologists,
psychologists, occupational therapists or nurses by training.
Training
DBT training for therapists was initially undertaken with a self-
directed reading programme using the DBT skills manual [25] and
other materials suggested by the honorary consultants to the study. An
initial introductory programme was conducted and later extended with
DBT consultation sessions conducted in Newcastle. Four members of
the Hunter DBT treatment team attended a 2 week intensive training
in DBT in New Zealand after the project had commenced.
Study design
The Hunter DBT project was an RCT of modified DBT. The inter-
vention condition was based on the comprehensive DBT model, a
164 HUNTER DBT PROJECT
team-based approach including individual therapy, group-based skills
training, telephone access to an individual therapist and therapist
supervision groups following the model of treatment developed by
Linehan et al. [7]. The main change to the Linehan et al. model was
the telephone access to individual therapists. In the present study tele-
phone access was delivered using a group roster of DBT individual
therapists (not contact with each participant’s individual therapist)
between 8:30 a.m. and 10 p.m., and telephone contact with the local
psychiatric hospital between 10 p.m. and 8:30 a.m.
The control condition was a 6 month WL for DBT while receiving
TAU (TAUWL). Subjects, both in the initial DBT group and in the
TAUWL group who came to DBT after 6 months were offered
12 months DBT treatment, although the comparison between groups
was restricted to the first 6 months of DBT versus TAUWL. This
design was also different to the original Linehan et al. study, which
used TAU as the control condition and comparison of groups after
4 months, 8 months and 12 months of DBT therapy.
Randomization
Randomization was carried out by the research staff and participants
were allocated by selection of sealed opaque envelopes. Randomization
was undertaken after consent to participate and completion of all the
baseline measures and eligibility interview.
Treatment procedures
Treatment (DBT) participants were assigned to the next available
individual therapist. Treatment subjects were also assigned to the rel-
evant skills training group, meeting weekly with the modules running
in the following order: Interpersonal Effectiveness, Emotion Regula-
tion and Distress Tolerance. Each module ran for 8 weeks. Groups had
a minimum of four members before commencement and a maximum
of eight members. Entry to the skills group occurred only at the com-
mencement of the next skills module.
Participants
The flow of participants through the study is shown in the CON-
SORT diagram (Figure 1). Of the 112 participants referred for partici-
pation in the trial, 16 did not attend the assessment, while 16 were
excluded because they did not meet the criteria for BPD and one was
of no fixed address (NFA). Of the 79 participants eligible for the pro-
gramme, three did not complete initial baseline assessments and were
therefore excluded from the study, two withdrew consent after assess-
ments and treatment were completed and one died by suicide following
the baseline assessment period. Additionally, three completed baseline
assessments but due to a technical error some of their demographic and
diagnostic data were not recorded and were missing in those analyses.
Participants were female, aged 18–65 years, meeting criteria for BPD
determined by clinical interview by a psychiatrist using DSM-IV
criteria [1] and having a history of multiple episodes of deliberate
self-harm, at least three self-reported episodes in the preceding
12 months. The psychiatrist assessor had the option of determining if
any potential subjects were unsuitable for inclusion in therapy or unmo-
tivated to participate, although there were no specific criteria for this
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exclusion. Exclusion criteria were presence of a disabling organic con-
dition, schizophrenia, bipolar affective disorder, psychotic depression,
florid antisocial behaviour, or developmental disability. Recruitment
commenced in February 2000 and the last participant finished baseline
assessment in July 2003.
Participants were referred from treating general practitioners, treat-
ing psychiatrists or public mental health services (any units of Hunter
Mental Health Services); this process was coordinated by one of the
investigators (CW). Referring clinicians were advised of the need for
subjects to meet inclusion criteria and the need to maintain current
therapy with the subjects until randomization was complete for the
DBT group and during the 6 month wait time for the TAUWL group.
Upon commencement of DBT, participants were asked to discontinue
psychological therapy of any sort for at least the 12 month duration
of DBT.
Assessments and measures
Baseline assessment included parts of the computerized interview
used in the Australian National Survey of Mental Health and Wellbeing
[26]: demographics; Composite International Diagnostic Interview
(CIDI; selected modules): anxiety, depression, bipolar disorders, alco-
hol abuse and dependence, substance abuse and dependence, Interna-
tional Personality Disorder Examination Questionnaire (IPDEQ) [27];
and the Brief Disability Questionnaire (BDQ) [28]. Other assessment
instruments included Lifetime Parasuicide Count–2 [29]; Parasuicide
History Interview–3 month period (PHI-2) [30] and the World Health
Organization (WHO) Quality of Life–BREF version (WHOQOL-
BREF) [31]. Two additional questions were asked at the end of the
BDQ: (i) during the last month, how many days in total were you
unable to carry out your usual daily activities fully; and (ii) during the
last 1 month, how many days in total did you stay in bed all or most
of the day because of illness or injury.
Assessments repeated 3 months and 6 months after allocation to
DBT or TAU  WL included BDQ, PHI-2 and WHOQOL-BREF.
Outcomes and blindness of raters
Baseline characteristics were determined by research staff before
randomization occurred and hence allocation was blind.
Outcomes were determined for the intention-to-treat analyses by
assessors blinded to allocation, extracting information from psychiatric
hospital and general hospital records either by direct examination of
the clinical records or by extraction electronically from the Hunter Area
Toxicology Service database at Newcastle Mater Hospital [32]. Pri-
mary outcomes for the intention-to-treat analyses were the proportion
of participants with any hospital admission for DSH and the proportion
with any psychiatric hospitalization for any reason; the number of gen-
eral hospital admissions for DSH and the number of psychiatric hospi-
tal admissions for any reason; the length of stay for hospital admissions
for DSH and for psychiatric hospital admissions for any reason.
General hospital admission for DSH included any episode according
to the following definition originally developed for ‘attempted suicide’:
‘any intentional self-injury or the deliberate ingestion of more than the
prescribed amount of therapeutic substances, or deliberate ingestion of
substances never intended for human consumption’ [33]. Secondary
 G.L. CARTER, C.H. WILLCOX, T.J. LEWIN, A.M. CONRAD, N. BENDIT 165

Potential participants n = 112 Exclusion n = 33

Referred from clinical services 16 Did not attend, 1 NFA
to Hunter DBT Project 16 Did not satisfy DSM criteria

Eligible participants n = 79
DSM –IV BPD Exclusion n = 3
Recent self-injurious behaviour 3 Did not complete baseline
Female assessment
18 years old

Exclusion n = 3
Randomized
1 Died
76 2 Withdrew consent later

Allocated DBT Allocated TAU+WL

n = 38 n = 35

Per Protocol Per Protocol

n = 26 completed n = 29 completed
3 months treatment 3 months waitlist and
and self-report self-report

Per Protocol Per Protocol

Intent to treat Intent to treat
n = 20 completed n = 31 completed
n = 38: Hospital data n = 35: Hospital data
6 months treatment 6 months waitlist and
for outcomes for outcomes
and self-report self-report

Figure 1. CONSORT Diagram of participant flow. BPD, borderline personality disorder; DBT, dialectical behaviour
therapy; NFA, no fixed address; TAUWL, treatment as usual  waitlist.

outcomes included any presentation without admission for general Analyses

hospital-treated DSH and any presentation without admission to a
psychiatric hospital for any reason.
For participants who received treatment and completed the
self-report instruments at 3 months and 6 months after allocation,
per-protocol analyses were conducted. All reasonable attempts were
made to maintain blindness to allocation status for these raters, but this
could not achieve perfect blindness. Primary outcomes for the
per-protocol analyses were undertaken for the proportion of subjects
with any episode of DSH (called parasuicide in the rating scales) and
the number of DSH events. Secondary outcomes were disability scores
and quality of life scores: days out of role in the past month and days
spent in bed in the last month; and WHOQOL-BREF scores for all four
domains (Physical, Psychological, Social and Environmental). The two
items thought to be most relevant to disability for this patient popula-
tion were chosen a priori for analysis, from the questions following on
from the BDQ: days spent in bed and days out of role.
Differences in proportions were tested using χ2 test. Event or count
data were predominately analysed using either Poisson regression or
negative binomial regression when appropriate. Negative binomial
regression was used when the distribution showed overdispersion (vari-
ance much greater than the mean in Poisson distribution) or the good-
ness of fit for a Poisson regression showed large χ2 values or the
likelihood ratio test of alpha was significantly different from zero. Zero
inflated models were used when there was an excess of zero counts in
the data and the Vuong test was significant. Results were expressed as
incidence rate ratios with 95% confidence intervals (IRR: 95%CI). A
post-hoc descriptive graphical analysis of the number of general
hospital admissions for DSH and the number of psychiatric admissions
for any reason for the period of 12 months (in 6 month blocks) before
and after baseline was done to contextualize the pattern of psychiatric
hospitalizations and general hospital admission for DSH over

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166 HUNTER DBT PROJECT
a longer time frame than the 6 month comparison of treatment
effects.
Analysis of variance (ANOVA) was used for between-group mean
differences in age, number of BPD criteria, IPDEQ score and mean
number of reported lifetime episodes of self-harm. Mann–Whitney
U-test was used for lifetime median number of DSH episodes (due to
non-normally distributed data). A repeated-measures analysis of vari-
ance (rANOVA) was used for the mean number of DSH events over
three 3 month time periods, covering the period of 3 months before
baseline until 6 month follow up.
A rANOVA was also used for the secondary outcomes: BDQ days out
of role in the past month and days spent in bed in the last month; and
WHOQOL-BREF scores for all four domains (Physical, Psychological,
Social and Environmental) over the same three time periods. Because
these per-protocol analyses are subject to potential attrition bias and
hence a threat to internal validity, we also conducted confirmatory linear
mixed effect model analyses for any result showing a significant benefit
of group (DBT vs TAUWL) or the interaction of group (DBT vs
TAUWL) × time for the secondary outcomes of disability and quality
of life. These confirmatory procedures used intention-to-treat analyses
based on randomization status for all subjects who had baseline data
available (disability, n  70; quality of life, n  73), using fixed effects
for group (two levels), time (three levels) and group × time (six levels)
predictor variables. Results are reported as F (derived by taking the ratio
of the appropriate sums of squares) and p for each significant predictor
variable. These analyses were conducted using the MIXED procedure in
SPSS version 15 (SPSS, Chicago, IL, USA). All other analyses were
conducted using SPSS version 14 or STATA SE version 10 (StataCorp
LP, College Station, TX, USA).
Results
Table 1 lists the demographic characteristics and Table 2 the clinical
characteristics of the participants at baseline. There were no significant
imbalances of any of the a priori selected demographic or clinical vari-
ables at baseline.
The participants were young women, usually single, not in the labour
force (home duties, pensioner or student), with nearly 40% having
some post-schooling qualification. There was considerable exposure to
traumatic events of sexual, physical and potentially life-threatening
types. The participants showed substantial psychopathology with high
rates of BPD criteria, IPDEQ scores and Axis 1 comorbidity. They had
a substantial previous history of self-harm events, with external damage
to skin (usually by cutting) and self-poisoning being the most common
forms.
Table 3 lists the principal outcomes for the intention-to-treat analyses
and the per-protocol analyses. For the intention-to-treat analyses, there
were no significant differences in proportions for general hospital admis-
sion for DSH or for any psychiatric admission. There were no significant
differences for the mean number of admissions of either type. Figure 2
also indicates that admissions of both types were rising in the time before
the baseline of the study, falling for the 6 months of the study and con-
tinuing to fall for the 6 months following the study (when the TAUWL
control group had begun DBT) for both groups.
The length of stay overall, or the length of stay for those with either
type of admission was not significantly different, although the DBT
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group tended to have shorter lengths of stay. For the 6 months of the
study, the mean length of stay overall was as follows: psychiatric hos-
pital for any reason, total  7.19  27.53 days, con-
trol  9.48  33.63 days, DBT  5.10  20.62 days (F(1,69)  0.14);
and general hospital for DSH, total  0.88  2.65 days, con-
trol  1.25  3.54 days, DBT  0.53  1.38 days (F(1,69)  0.90).
When the analyses were restricted to those who had any hospital admis-
sion the mean length of stay was as follows: psychiatric hospital for
any reason, total  37.53  54.5 days, control  47.43  65.6 days,
DBT  27.64  43.5 days (F(1,10)  0.69); and general hospital for
DSH, total  3.79  4.47 days, control  4.88  5.78 days,
DBT  2.56  2.06 days (F(1,13)  0.17). For the per-protocol analy-
ses, there were no significant differences for the proportion of patients
with any DSH episode in 6 months, or for the number of self-harm
episodes for the baseline–3 months and 3–6 months periods. There was
a significant effect (linear and quadratic) for time in the rANOVA for
the number of DSH episodes over the three time periods, but no sig-
nificant effect for group status.
Table 4 lists the per-protocol results for the secondary outcomes, dis-
ability and quality of life. There was no significant effect for group or
time in the rANOVA for days spent in bed in the previous month or for
days out of role in the previous month. There was a significant beneficial
effect for group × time (linear), in favour of DBT for days spent in bed
but no significant effect for days out of role. Similarly, for days spent in
bed, there was also a significant effect for group (F(1,64.9) = 5.42, p 
0.05) in favour of DBT in the confirmatory mixed-effects analysis.
There was a significant beneficial effect for time (linear) and
group × time (linear), in favour of DBT, for three of the four domains
of quality of life: Physical, Psychological and Environmental. Similarly
there was a significant effect for time (F(2,57.2)  7.56, p  0.01) and
group (F(1,75.6)  4.58, p  0.05) for Physical Domain; time
(F(2,55.4)  26.68, p  0.001) and group × time (F(2,55.4)  3.28,
p  0.05) for Psychological Domain; but only for time (F(2,56.4)  8.06,
p  0.01) for Environmental Domain in the confirmatory analyses.
There was a significant beneficial effect for time (linear) in the Social
Domain but no significant effect for group. Similarly, there was a
significant effect only for time (F(2,57.1)  11.71, p  0.001) for the
Social Domain in the confirmatory analyses.
Discussion
Strengths and weaknesses of the study
This was RCT, using opaque envelope technique,
with the main primary outcomes determined by
assessors blind to allocation status. These primary out-
comes for the intention-to-treat analyses were deter-
mined from hospital records and not participant
self-report, eliminating the potential for a differential
response bias. Participants knew their allocation status
but were not told specifically of the outcomes of interest.
There were no significant imbalances for the a priori
selected demographic or clinical variables at baseline,
indicating a successful randomization procedure. The
post-hoc pattern of hospitalizations seen in Figure 2,
 G.L. CARTER, C.H. WILLCOX, T.J. LEWIN, A.M. CONRAD, N. BENDIT 167

Table 1. Demographic characteristics of the sample

Groups

Overall (n = 70) TAUWL (n = 33) DBT (n = 37)

Demographic Mean  (SD) Mean  (SD) Mean  (SD) Statistics

Age (years) 24.5  (6.10) 24.7  (6.15) 24.5  (6.12) F(1,68)  0.065
Marital status % % %
Married 25.7 33.3 18.9
Divorced 18.6 21.2 16.2 χ2(2)  2.82
Single 55.7 45.5 64.9
Employment
Employed 18.6 12.1 24.3
Unemployed 5.7 9.1 2.1 χ2(2)  2.72
Not in labour force 75.7 78.8 73.0
Education status
Still at school 4.3 6.1 2.7
Did not complete secondary education 34.3 39.4 29.7
Completed secondary education 22.9 15.2 29.7 χ2(3)  2.56
Post-school qualification 38.6 39.4 37.8
Mean ⴞ (SD) Range Mean ⴞ (SD) Range Mean ⴞ (SD) Range
No. children 0.56  (1.21) 0–5 0.52  (1.12) 0–5 0.59  (1.30) 0–5 IRR 1.44 (0.67–3.08)
Significance levels: ∗p  0.05, ∗∗p  0.01, ∗∗∗p  0.001.

however, suggests a possible imbalance based on gen-
eral and psychiatric hospitalizations at baseline. Princi-
pal analyses were done on an intention-to-treat basis,
based on randomization status, with three subjects
removed from the TAUWL group, one because of
death soon after randomization and two because of with-
drawal of consent after completion of treatment. The
statistical techniques used were appropriate to the data
analysed [34], in particular the use of either Poisson
regression or negative binomial regression when appro-
priate to analyse event (count) data, which has been only
infrequently used before in repetition of DSH studies
[35,36]. In the present study the secondary outcomes
(disability and quality of life) were determined by par-
ticipant self-report on various measures and so the losses
of participants, particularly from the DBT treatment
group in the per-protocol analyses, may limit the internal
validity of these secondary outcome results. We also
used an alternative analytic model, linear mixed-effect
models for repeated measures data, as confirmatory
analyses for the secondary outcomes, which strengthens
the validity of these results [37].
The current study was powered on the basis of a previ-
ously published study [7], which used the repetition of
self-reported ‘parasuicide’ as the outcome of interest (DBT
26% vs TAU 60%), which had demonstrated a powerful
benefit of 33% absolute risk reduction, 56% relative risk
reduction and a number needed to treat of only three (cal-
culated by GC). In the present study two different primary
outcomes were used that approximated the self-reported
parasuicide outcome in that original study: general hospital
admission for DSH, which proved to be relatively infre-
quent in both the DBT (21%) and TAUWL (26%)
groups; and self-reported DSH, which proved to be rela-
tively frequent in both the DBT (75%) and TAUWL
(67%) groups. We did not have sufficient data from
participants to determine whether there was equivalence of
treatment hours in the two groups, and so reported benefits
in secondary outcomes may be due to differences in ther-
apy hours rather than the specific effects of treatment. The
external validity of the study is not known and so gener-
alization from these results to any other populations should
be done with caution.
Primary outcomes: DSH and hospitalization
The current study failed to replicate some of the impor-
tant findings (significant reduction in DSH and reduction
in psychiatric hospitalization) from other studies [7,10].
Although there was improvement in both groups over
time, there was no significant differential reduction in
general hospital-treated DSH, psychiatric hospitalization
or self-reported DSH, for either the binary outcome or
event rates.
There are several possible explanations as to why
DBT was not effective in this study: regression to back-
ground (pre-baseline) levels, the Hawthorne effect
whereby both groups improved because of the effect of
being in a study, the potentially powerful effect of being
in a 6 month TAUWL group for DBT for the control
condition, beneficial effects of the TAU condition avail-
able in the Hunter region, modifications to standard

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 168

Table 2. Clinical characteristics of the sample

Groups
Statistical
Clinical characteristics Overall (n = 70) TAUⴙWL (n = 33) DBT (n = 37) analyses

% Mean ± (SD) % Mean ± (SD) % Mean ± (SD)

DSM-IV personality disorder criteria
No. BPD Criteria 7.21  (1.02) 7.10  (0.95) F(1,65)  0.28
Abandonment (PD criteria) 83.6 7.15  (0.98) 81.8 83.6 χ2(1)  0.14
Unstable relationships (PD criteria) 94.0 97.0 91.2 χ2(1)  1.10
Unstable self-image (PD criteria) 83.6 81.8 85.3 χ2(1)  0.15
Impulsivity (PD criteria) 52.5 48.5 55.9 χ2(1)  0.36
Suicide and self-harm (PD criteria) 100 100 100 n.a.
Instability of mood (PD criteria) 98.5 97.0 100 χ2(1)  1.04
Chronic emptiness (PD criteria) 61.2 57.6 64.7 χ2(1)  0.35
Inappropriate anger (PD criteria) 86.6 90.9 82.4 χ2(1)  1.05
Dissociation and psychotic (PD criteria) 55.2 66.7 44.1 χ2(1)  3.44
IPDEQ score 0.58  (0.23) 0.56  (0.23) 0.61  (0.23) F(1,68)  1.72
Traumatic events
Ever raped 60.0 63.6 56.8 χ2(1)  0.34
Ever Sexually molested 65.7 63.6 67.6 χ2(1)  0.12
Physically assaulted 47.1 45.5 48.6 χ2(1)  0.07
HUNTER DBT PROJECT

Threatened with a weapon 40.0 45.5 35.1 χ2(1)  0.77

DSM-IV comorbidity (CIDI)
Any substance use disorder 68.6 66.7 70.3 χ2(1)  0.10
Any affective disorder 73.0 75.8 70.3 χ2(1)  0.26
Any anxiety disorder 88.6 87.9 89.2 χ2(1)  0.03
Lifetime self-harm

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Mean lifetime self-harm episodes 96.3  (109.70) 89.7  (103.72) 102.4  (115.98) F(1,71)  0.23
Median lifetime self-harm episodes 53.0 41.0 55.5 91.5
Proportion with any self-harm episode in 67.3 62.1 73.1 χ2(1)  0.75
6 months before baseline
Most recent self-harm episode
Damage to skin or tissue (external) 60.3 60.0 60.5
Self-poisoning 26.0 31.4 21.1 χ2(2)  2.04
Other- hanging, jumping or stabbing 13.7 8.6 18.4
Significance levels: ∗p  0.05, ∗∗p  0.01, ∗∗∗p  0.001.
 Table 3. Principal outcomes
Groups

Principal outcomes: intent to treat Overall (n  73) TAUWL (n  35) DBT (n  38) Statistical analyses

Proportion with at least one hospital admission % % %

Psychiatric hospital 19.2 20.0 18.4 χ2(1)  0.03
General hospital: DSH 23.3 25.7 21.1 χ2(1)  0.22
Hospital admissions Mean  (SD) Mean  (SD) Mean  (SD)
No. admissions to a psychiatric hospital 0.75  (2.40) 0.91  (2.64) 0.61  (2.18) IRR: 0.66 (0.14–3.10)
No. admissions to a general hospital: DSH 0.93  (3.29) 1.40  (4.47) 0.50  (1.54) IRR: 0.36 (0.09–1.43)
No. admissions: Total 1.68  (5.43) 2.31  (6.88) 1.11  (3.64) IRR: 0.48 (0.13–1.73)
Hospital presentations without admission
Psychiatric hospital 0.20  (0.55) 0.26  (0.66) 0.16  (0.44) IRR: 0.61 (0.22–1.73)
General hospital: DSH 0.12  (0.55) 0.06  (0.24) 0.18  (0.73) IRR: 3.22 (0.67–15.52)
No. presentations: Total 0.33  (0.88) 0.31  (0.83) 0.34  (0.94) IRR: 1.09 (0.49–2.43)
Principal outcomes: per-protocol
Proportion with any self-harm episode % % %
Baseline–6 months (n  51) 70.6 67.0 75.0 χ2(1)  0.31
No. self-harm episodes Mean  (SD) Mean  (SD) Mean  (SD)
Baseline–3 months (n  55) 6.95  (12.80) 7.59  (14.50) 6.23  (10.83) IRR 0.82 (95%CI  0.34–1.99)
3–6 months (n  51) 7.16  (21.42) 8.42  (26.92) 5.20  (7.47) IRR 0.62 (95%CI  0.23–1.65)
No. self-harm episodes in previous 3 months (n  41) (n  23 ) (n  18 )

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Baseline 19.80  (35.51) 18.08  (40.67) 22.00  (28.60) Group F(1,39)  0.00
3 months 5.95  (11.32) 6.13  (11.41) 5.72  (11.53) Time (Linear) F(1,39)  14.00∗∗
G.L. CARTER, C.H. WILLCOX, T.J. LEWIN, A.M. CONRAD, N. BENDIT

6 months 7.48  (23.80) 9.21  (31.22) 5.27  (7.87) Time (Quadratic) F(1,39)  4.93∗
Group  Time (Linear) F(1,39)  1.31
Group  Time (Quadratic) F(1,39)  0.003
Significance levels: ∗p  0.05, ∗∗p  0.01,∗∗∗p  0.001.
169
170
Admissions Type
2 Psychiatric – TAU+WL
Mean Number of Admissions
1.5
1 reporting significantly reduced number of suicide
0.5
0
(−12 to −6m) (−6 to −0m)
Time period
Figure 2. Psychiatric and general hospital admissions
during the 12 months before and after study recruitment:
( ) psychiatric (treatment as usual waitlist (TAUWL));
( ) psychiatric (Dialectical Behaviour Therapy (DBT);
(°) general (TAUWL); (•) general (DBT).
DBT (including the 6 month duration of DBT, after-
hours telephone contact by roster of individual thera-
pists), the possible inferiority of training of DBT
therapists to that of those in other studies or inferior
adherence to the DBT methods despite adequate train-
ing, and methodological differences (e.g. the use of
hospital-treated DSH measured by hospital records as a
primary outcome or possible differences in the popula-
tion used in the study).
In the present study the duration for comparison was
only 6 months, while the original Linehan et al. study
was of 12 months duration [7], and the original Bate-
man and Fonagy study was of 18 months duration [6],
so it could be argued that the current study was too
brief in duration of treatment comparisons to demon-
strate benefits in terms of DSH or hospitalization for
BPD patients. We were aware of this argument during
the planning of the current study but believed that a
close examination of these previous studies indicated
that improvement occurred before 6 months of treat-
ment had elapsed. Linehan et al. examined both num-
ber of parasuicidal acts and proportion of subjects with
any episode of parasuicide in three time periods:
0–4 months, 4–8 months and 8–12 months, reporting
significant differences in favour of DBT for all three
time periods for reduction in the number of parasui-
cidal acts, and for two time periods (0–4 months and
8–12 months) for the proportion of subjects with at
HUNTER DBT PROJECT
least one parasuicidal act in the period. Linehan et al.
and Group
also examined median psychiatric inpatient days for
the same three time periods, reporting significant ben-
Psychiatric – DBT
General – TAU+WL efits in favour of DBT only for the 0–4 month and
General – DBT 8–12 month periods, but showing no difference in the
proportion with at least one admission in the full
12 month period. [7]. Similarly, Bateman and Fonagy
also examined two primary outcomes for three time
periods: 0–6 months, 6–12 months and 12–18 months,
attempts for all three time periods and reduced self-
mutilating behaviours for two time periods
(6–12 months and 12–18 months) [6]. In the present
study, after 6 months the proportions of patients with
any episode of DSH were already high in both groups
and so a further period of study would have been very
unlikely to result in a significant difference being
(0 to +6m) (+6 to +12m) found in favour of DBT or TAUWL. The mean num-
ber of DSH events, however, was non-significantly
lower in the DBT group for both the 0–3 month and
3–6 month periods, and so it may have been possible
that the 6 month duration of comparison may have
been too short to observe an emerging difference in
favour of the DBT group. Similarly, hospitalization by
proportions and by event rates were also non-signifi-
cantly in favour of DBT, so the 6 month duration of
comparison may have missed emerging differences in
favour of DBT.
In considering other studies, a reduction in parasui-
cide and suicide attempt has been reported in two studies
using DBT at the University of Washington [7,10], while
another team at the University of Amsterdam reported
reduction in self-mutilation but not suicidal behaviour
[11]. One underpowered study from Duke University
reported significant decreases in suicidal ideation, but
no significant reduction in number of parasuicide acts or
number of hospitalizations [15]. Two other small-sample-
size studies from the University of Washington on drug-
dependent women with BPD [19] and opioid-dependent
women, showed no difference in parasuicide [20].
The current study found that the 6 month rate of hospi-
tal-treated DSH in the DBT group (21%) was very simi-
lar to the 12 month (26%) and 24 month (23%) rates for
self-report of parasuicide in the USA [7,10]. The 6 month
rate of self-reported DSH in the present study (DBT 75%,
TAUWL 67%), however, was much higher than the
equivalent parasuicide rates (DBT 26%, TAU 60% [7] and
DBT 21%, expert control 46% [10]). Later studies separated
suicidal behaviours into two outcomes, suicide attempts
and non-suicidal self-injury [10] or suicidal behaviours
and self-mutilation [11], making direct comparison with
the current study difficult. The second Linehan et al. study
(DBT vs treatment by expert control) showed a significant
reduction in suicide attempts in favour of DBT, while both
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 G.L. CARTER, C.H. WILLCOX, T.J. LEWIN, A.M. CONRAD, N. BENDIT 171

Table 4. Secondary outcomes: disability and quality of life

Group
Overall TAUⴙWL DBT
Variables n ⴝ 48 n ⴝ 28 n ⴝ 20 Statistical analyses
Days in bed (last month) BDQ Group F(1,46)  2.00
Mean  (SD) Mean  (SD) Mean  (SD)
Baseline 4.38  (6.97) 3.96  (7.02) 4.95  (7.05) Time (Linear) F(1,46)  0.18
3 months 4.76  (6.91) 6.02  (8.00) 3.00  (4.65) Time (Quadratic) F(1,46)  0.07
6 months 5.38  (7.24) 7.29  (8.33) 2.70  (4.28) Group × Time (Linear) F(1,46)  4.94∗
Group × Time (Quadratic) F(1,46)  0.51
Days out of role (last month) BDQ
Baseline 12.52  (12.26) 12.46  (12.5) 12.60  (12.23) Group F(1,46)  0.82
3 months 10.24  (10.74) 11.36  (11.42) 8.68  (9.79) Time (Linear) F(1,46)  0.94
6 months 11.02  (11.68) 13.07  (11.59) 8.15  (11.48) Time (Quadratic) F(1,46)  1.61
Group × Time (Linear) F(1,46)  1.63
Group × Time (Quadratic) F(1,46)  0.01
Physical Domain (0–100) WHOQOL-BREF
n  51 n  31 n  20
Mean  (SD) Mean  (SD) Mean  (SD)
Baseline 41.11  (19.95) 40.70  (22.35) 41.61  (16.06) Group F(1,49) 1.91
3 months 48.86  (20.59) 46.29  (21.17) 52.85  (19.52) Time (Linear) F(1,49)  10.04∗∗
6 months 47.83  (21.02) 42.39  (21.46) 56.25  (17.68) Time (Quadratic) F(1,49)  5.40∗
Group × Time (Linear) F(1,49)  6.45∗
Group × Time (Quadratic) F(1,49)  0.04
Psychological Domain (0–100) WHOQOL-BREF
Baseline 18.16  (14.04) 19.41  (13.96) 16.25  (14.30) Group F(1,49)  0.62
3 months 30.23  (21.98) 29.72  (22.77) 31.04  (21.26) Time (Linear) F(1,49)  50.91∗∗∗
6 months 35.13  (19.96) 30.24  (19.68) 42.71  (18.38) Time (Quadratic) F(1,49)  2.27
Group × Time (Linear) F(1,49)  8.94∗∗
Group × Time (Quadratic) F(1,49)  0.60
Social Domain (0–100) WHOQOL-BREF
Baseline 32.02  (22.38) 36.55  (23.73) 25.00  (18.53) Group F(1,49)  0.75
3 months 42.89  (24.59) 43.82  (27.40) 41.45  (20.07) Time (Linear) F(1,49)  20.73∗∗∗
6 months 49.34  (26.29) 49.73  (30.23) 48.75  (19.36) Time (Quadratic) F(1,49)  1.12
Group × Time (Linear) F(1,49)  1.70
Group × Time (Quadratic) F(1,49)  0.62
Environmental Domain (0–100) WHOQOL-BREF
Baseline 49.65  (16.11) 51.15  (15.61) 47.34  (17.00) Group F(1,49) 0.13
3 months 56.89  (17.27) 56.30  (16.43) 57.81  (13.69) Time (Linear) F(1,49)  14.64∗∗∗
6 months 57.27  (16.35) 54.57  (18.16) 61.45  (12.36) Time (Quadratic) F(1,49)  6.69∗
Group × Time (Linear) F(1,49)  5.43∗
Group × Time (Quadratic) F(1,49)  0.00
Significance levels: ∗p  0.05, ∗∗p  0.01,∗∗∗p  0.001.

treatments were associated with a reduction in non-suicidal
self-injury, meaning no significant difference in non-sui-
cidal self-injury [10]. A 12 month RCT in Amsterdam com-
paring DBT to TAU found no difference in the frequency
of suicidal behaviours (threats, preparation for attempts
and attempts) nor the proportion with suicide attempt, but
did find a difference in self-mutilating behaviours for the
time × treatment condition and a reduction in the propor-
tion with any self-mutilating behaviour in the 6–12 month
period [11].
The present study found reductions in psychiatric
hospitalization for both groups over time but again no
significant benefit in favour of DBT for the binary out-
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come, the mean event rate or the mean length of stay
for those with an admission at the end-point of the trial.
In the original DBT trial there was a demonstrated ben-
efit for median days of psychiatric hospitalization after
12 months, but no difference in proportions for any psy-
chiatric admission or for median number of admission
per person [7]. In the later DBT trial, using a mixed-effect
ANOVA, significantly fewer DBT subjects had any
psychiatric admissions after the year 1 (DBT 20% vs
expert control 49%) and year 2 (DBT 23% vs expert
control 24%) outcomes were combined [10].
In the present study there was one death by suicide in
the TAUWL control group, while in studies from the
172
University of Washington there was one death by suicide
in the DBT group [7] and one death in the treatment by
expert control group not attributed to suicide but to ‘the
cumulative effects of previous suicide attempts’ [10].
Secondary outcomes: disability and quality of life
Life-threatening behaviours and therapy-interfering
behaviours are primary targets in DBT (stage 1 target: ‘out
of control behaviours’) followed by quality of life-interfer-
ing behaviours and increasing behavioural skills, which are
also stage 1 targets. Other quality of life and disability issues
may also be dealt with at a later stage of therapy (stage 2
target: reducing ‘quiet desperation’). Improvements in dis-
ability and quality of life, however, were found in the pres-
ent study even though there was no differential improvement
in DSH and psychiatric hospitalization.
Although there was no significant effect for one mea-
sure of overall disability (days out of role), there was a
significant benefit for DBT for the more specific disability
measure of days spent in bed, an absolute difference of
4 days per month per person, which we consider to be clin-
ically significant. With 81% of participants either not in the
labour force or unemployed, it may be difficult to interpret
the meaning of the ‘days out of role’ result derived from
the BDQ. Nonetheless, with an average of 11 days out of
role per month the overall level of disability was high,
which was not surprising for this clinical population.
Both groups had substantially lower scores on quality of
life measures than the Australian population norms: Physical
health domain  73.5  18.1, Psychological well-be-
ing  70.6  14.0, Social relationships  71.5  18.2 and
Environment domain  75.1  13.0 [38]. Three of the four
quality of life domains, however, showed significant
improvement over time for the DBT condition in the present
study (group × time interaction), while both groups improved
over time for the fourth domain (Social). The magnitude of
these improvements in quality of life was substantial and
considered to be clinically significant, although the final
scores for the Psychological domain still fell short of com-
munity population norms by more than one standard devia-
tion, suggesting considerable residual psychological distress
or dysfunction.
These improvements in disability and quality of life have
only rarely been demonstrated or evaluated in RCTs involv-
ing subjects with BPD, again making comparison with the
present study difficult. One study of drug-dependent women
with BPD showed overall improvement but no differences
in social or global adjustment during treatment or at 12 month
follow up, with a significantly lower score in the DBT group
at 16 month follow up [19]. A later study of opioid-depen-
dent women showed overall improvement but no benefit in
social or global adjustment at any time point [20].
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HUNTER DBT PROJECT
Conclusion
For the principal outcomes, the present study found no
differences in self-reported DSH, general hospital-treated
DSH, psychiatric hospitalization or length of stay in gen-
eral hospital or psychiatric hospital, although there was
considerable improvement in both the DBT and the
TAUWL control groups from baseline levels. Even
though the present study did not replicate the benefits of
reduction in DSH behaviour and hospital admissions
found in other studies [7,10], several secondary outcomes
(disability and quality of life) showed clinically significant
benefits in favour of DBT, in keeping with the theoretical
predictions for DBT. BPD is a common diagnosis in pub-
lic psychiatric services and the present study suggests that
using DBT in a team approach, very similar to the original
Linehan et al. treatment model, might produce meaningful
improvement in the lives of these patients.
Acknowledgements
Our thanks go to several people for their contributions to
the Hunter DBT Project: Dr Chris Hayes, University of
Newcastle and Ms Susan Burgoyne as investigators in the
initial project development; to Peter Sneesby as Masters of
Clinical Psychology student, University of Newcastle, assist-
ing with the initial phases of data collection; to Natalia Carter
and Gillian Maddock who helped with data extraction from
the clinical records; to Dr Kerrie Clover, University of New-
castle, for assistance with instrument scoring and data clean-
ing; and to Ben Britton who assisted with linear mixed effect
models. Our thanks also go to all the staff who contributed
clinical services: individual therapists Danielle Adams, Mar-
ianne Ayre, Dr Nick Bendit, Susan Burgoyne, Jennifer
Evans, Dr Howard Johnson, Jennifer Koorey, Natalie
McCall, Chris McCrory, Jane Taylor and Chris Willcox; and
skills trainers Marianne Ayre, Dr Nick Bendit, Linda Bragg,
Michael Currie, Annabel Kelly, Michelle Meyer, Ruth
Spence and Don Stewart; and also to Dr Neil Port and Dr
Howard Johnson, who undertook the baseline clinical inter-
views. We also appreciated the input from external honorary
consultants Dr Marsha Linehan and Dr Kelly Koerner, Uni-
versity of Washington, USA; and several episodes of supple-
mentary training of DBT therapists by Dr Kate Comtois and
Dr Kelly Koerner, University of Washington, USA. Finally,
without the support and clinical leadership of Dr Howard
Johnson, Director of the Centre for Psychotherapy, this study
would not have been possible.
Declaration of interest: The authors report no con-
flicts of interest. The authors alone are responsible for
the content and writing of the paper.
 G.L. CARTER, C.H. WILLCOX, T.J. LEWIN, A.M. CONRAD, N. BENDIT
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