931164ANP ANZJP ArticlesWalton et al. Research Australian & New Zealand Journal of Psychiatry 2020, Vol. 54(10) 1020 –1034 A randomised trial of dialectical https://doi.org/10.1177/0004867420931164DOI: 10.1177/0004867420931164 © The Royal Australian and behaviour therapy and the New Zealand College of Psychiatrists 2020 Article reuse guidelines: conversational model for the treatment sagepub.com/journals-permissions of borderline personality disorder with journals.sagepub.com/home/anp recent suicidal and/or non-suicidal self-injury: An effectiveness study in an Australian public mental health service Carla J Walton1,2,3 , Nick Bendit1,2,3, Amanda L Baker3, Gregory L Carter2,3,4 and Terry J Lewin2,3 Abstract Objectives: Borderline personality disorder is a complex mental disorder that is associated with a high degree of suffer- ing for the individual. Dialectical behaviour therapy has been studied in the largest number of controlled trials for treat- ment of individuals with borderline personality disorder. The conversational model is a psychodynamic treatment also developed specifically for treatment of borderline personality disorder. We report on the outcomes of a randomised trial comparing dialectical behaviour therapy and conversational model for treatment of borderline personality disorder in a routine clinical setting. Method: Participants had a diagnosis of borderline personality disorder and a minimum of three suicidal and/or non-sui- cidal self-injurious episodes in the previous 12 months. Consenting individuals were randomised to either dialectical behav- iour therapy or conversational model and contracted for 14 months of treatment (n = 162 commenced therapy). Dialectical behaviour therapy involved participants attending weekly individual therapy, weekly group skills training and having access to after-hours phone coaching. Conversational model involved twice weekly individual therapy. Assessments occurred at baseline, mid-treatment (7 months) and post-treatment (14 months). Assessments were conducted by a research assistant blind to treatment condition. Primary outcomes were change in suicidal and non-suicidal self-injurious episodes and severity of depression. We hypothesised that dialectical behaviour therapy would be more effective in reducing suicidal and non- suicidal self-injurious behaviour and that conversational model would be more effective in reducing depression. Results: Both treatments showed significant improvement over time across the 14 months duration of therapy in suicidal and non-suicidal self-injury and depression scores. There were no significant differences between treatment models in reduction of suicidal and non-suicidal self-injury. However, dialectical behaviour therapy was associated with significantly greater reductions in depression scores compared to conversational model. Conclusion: This research adds to the accumulating body of knowledge of psychotherapeutic treatment of borderline personality disorder and supports the use of both dialectical behaviour therapy and conversational model as effective treatments in routine clinical settings, with some additional benefits for dialectical behaviour therapy for persons with co-morbid depression. 1 Centre for Psychotherapy, Hunter New England Mental Health Service, Corresponding author: Newcastle, NSW, Australia Carla J Walton, Centre for Psychotherapy, Hunter New England Mental 2Priority Research Centre for Brain and Mental Health Research, The Health Service, PO Box 833, Newcastle, NSW 2300, Australia. University of Newcastle, Callaghan, NSW, Australia Email: [email protected] 3School of Medicine and Public Health, The University of Newcastle, Callaghan, NSW, Australia 4 Consultation Liaison Psychiatry, Calvary Mater Hospital, Waratah, NSW, Australia Australian & New Zealand Journal of Psychiatry, 54(10) Walton et al. 1021 Keywords Borderline personality disorder, randomised controlled trial, psychotherapy, dialectical behaviour therapy, conversational model, effectiveness, depression, suicidal behaviour, non-suicidal self-injurious behaviour Borderline personality disorder (BPD) is associated with a There are two studies, adequately powered by large high degree of suffering, high rates of suicide attempts (Lieb sample sizes and where DBT was delivered with fidelity, et al., 2004) and a lifetime suicide mortality rate of approxi- which have compared DBT with another ‘active’ treatment. mately 10% (Black et al., 2004). Beyond high levels of Linehan et al. (2006a) compared DBT with ‘treatment by symptomatic impairment, large-scale studies have shown experts’ that included clinicians in the community with pervasive social and functional impairment (Gunderson expertise in treating BPD using non-DBT treatments. DBT et al., 2011). Depression commonly co-occurs with BPD was found to be superior on outcomes of suicide attempts, (Beatson and Rao, 2013). Within mental health settings, treatment retention and service utilisation. McMain et al. approximately 10% of all psychiatric outpatients and (2009, 2012) compared DBT with general psychiatric man- between 15% and 25% of psychiatric inpatients meet crite- agement (GPM), a psychodynamic therapy with a medica- ria for BPD (Leichsenring et al., 2011). During the past tion algorithm and found both treatments demonstrated 30 years, there has been considerable progress in treatments significant reductions in suicidal behaviour and NSSI developed and evaluated for BPD. Psychiatric medication between pre-treatment and post-treatment, as well as on a is not a recommended first-line treatment as it does not alter range of other clinically relevant measures. the course of the disorder and psychotherapy is the indi- There is no direct evidence from comparisons of active cated treatment for BPD (National Collaborating Centre for models developed specifically for the treatment of BPD Mental Health (NCCMH), 2009; National Health and that any one form of psychotherapy is superior to any other Medical Research Council (NHMRC), 2012). model. In the most recent Cochrane review of BPD (Stoffers A number of cognitive behavioural therapies have been et al., 2012), the authors outlined several limitations of developed or adapted specifically for the treatment of BPD studies of outpatient psychotherapeutic treatment for BPD. with varying degrees of evidence from randomised trials Many have small sample sizes (range, n = 47–180). Apart (Stoffers et al., 2012). Dialectical behaviour therapy (DBT) from DBT, most treatments have only been evaluated in is one of these therapies and targets skill development to one or two studies (Stoffers et al., 2012) and the majority of build a ‘life worth living’ (Linehan and Wilks, 2015). DBT studies have been conducted by investigators who devel- has been the focus of more clinical trials than any other psy- oped the treatment or who have a strong allegiance to one chotherapy for BPD (Cristea et al., 2017). Across these trials, particular model (Bateman and Fonagy, 2009; Giesen-Bloo results generally show a reduction in suicidal and non- et al., 2006; Levy et al., 2006; Linehan and Wilks, 2015). suicidal self-injurious (NSSI) episodes and psychiatric hos- Among psychotherapy studies in which all investigators pital admissions. Beyond cognitive behavioural therapies, have allegiance to one particular model, outcomes have been there is evidence from randomised trials for numerous psy- consistently in support of that treatment model (Luborsky chodynamic therapies developed specifically for the treat- et al., 1999). Researcher allegiance is now well recognised as ment of BPD (Bateman and Fonagy, 1999, 2009; Clarkin affecting results (Leichsenring et al., 2017). Hence, replica- et al., 2007; Gunderson and Links, 2014). Conversational tions are needed, particularly by independent researchers not model (CM) was originally developed by Hobson and involved in treatment development. Furthermore, most have Meares and then further developed by Meares as a specific been conducted in university settings by highly trained ther- model to treat BPD, targeting the development of a healthy apists; consequently, it is unclear how well effects would sense of self (Meares, 2004, 2012). It focuses heavily on the generalise to real-world clinical settings (Roy-Byrne et al., therapeutic relationship as a template for other relationships 2003). and aims to help individuals increase their capacity to build a The aims of this study were (1) to evaluate DBT in a reflective awareness of inner events (Meares, 2012: 20). CM routine clinical setting and compare it against an active has been evaluated for BPD in a published study (Stevenson treatment and (2) to compare CM against another therapy and Meares, 1992), utilising a pre-post design, with a replica- for BPD with an established evidence base. CM was tion study (Korner et al., 2006), using a treatment as usual selected as the active treatment for this study based on the waiting list control, but has not yet been tested in a ran- promising evidence and because it is one of few treatments domised trial. Both CM studies showed significant reduction specifically designed for treatment of BPD that is taught in suicidal behaviour and NSSI, and hospital admissions and used in Australia (Korner and McLean, 2017). This after 1 year of therapy, with gains maintained at 5-year fol- study attempted to address some of the limitations identi- low-up (Stevenson et al., 2005). fied above. Australian & New Zealand Journal of Psychiatry, 54(10) 1022 ANZJP Articles