Copyright © The British Psychological Society

Reproduction in any form (including the internet) is prohibited without prior permission from the Society

Stages of change in dialectical behaviour therapy
for borderline personality disorder

Joaquim Soler

1

*, Joan Trujols

1

, Juan Carlos Pascual

1

,

Maria J. Portella

1

, Judith Barrachina

1

, Josefa Campins

1

,

Rosa Tejedor

2

, Enrique Alvarez

1

and Victor Pe´rez

1

1

Servei de Psiquiatria, Hospital de la Santa Creu i Sant Pau, Universitat Auto`noma de
Barcelona, Barcelona, Spain

2

Divisio´ Salut Mental, Althaia, Xarxa Assistencial de Manresa, Manresa, Spain

Objectives.

The study aims at evaluating the suitability of applying the

transtheoretical model (TTM) stage-of-change construct to the treatment with
dialectical behaviour therapy (DBT) of borderline personality disorder (BPD).

Design.

Stages of change were assessed by means of the University of Rhode Island

Change Assessment (URICA) scale prior to and after 3 months DBT skills group
psychotherapy.

Method.

The sample was comprised of 79 people with BPD (86% of females) at pre-

treatment, and 42 patients (80% of females) at post-treatment. All patients were referred
from clinical services and diagnosed by means of two semi-structured interviews.

Results.

In pre-treatment assessment, precontemplation scores correlated signifi-

cantly and negatively with the other subscales (contemplation, action, and maintenance)
and these three subscales also correlated significantly and positively with each other.
The precontemplation stage was directly related to drop-out from the DBT group. The
action subscale and the committed action (CA) composite score were significantly higher
by the end of the DBT group treatment. However, with the absence of a control group it
cannot be assured that these increases were directly related to DBT intervention.

Conclusions.

In this observational design the stages of change of TTM seemed

applicable to the DBT conceptualization of BPD and could further our understanding of
the process of change in people with BPD treated with DBT.

The transtheoretical model ( TTM; Prochaska & DiClemente, 1983; Prochaska,
DiClemente, & Norcross, 1992) is a framework which was developed to describe,
explain, and predict the process of intentional change of any behaviour problem.

* Correspondence should be addressed to Joaquim Soler, Department of Psychiatry, Hospital de la Santa Creu i Sant Pau,

Barcelona, 08025, Spain (e-mail: [e-mail]).

The
British
Psychological
Society

417

British Journal of Clinical Psychology (2008), 47, 417–426

q

2008 The British Psychological Society

www.bpsjournals.co.uk

DOI:10.1348/014466508X314882

Copyright © The British Psychological Society

Reproduction in any form (including the internet) is prohibited without prior permission from the Society

It has been applied successfully to a broad range of mental health disorders, for

example, drug dependence (DiClemente, 2003). However, other studies (Brug et al.,
2005) have noted some potential limitations with the TTM.

The TTM core variable is the stage of change. According to this model, there are five

stages in the process of change of a behaviour: precontemplation, that is no current
intention to take action to deal with a problem; contemplation, actively considering
taking action on a problem, but ambivalent; preparation, commitment to change; action,
commitment to change and actively applying change strategies towards this end; and
maintenance, having changed and working on preventing relapse. Classifying individuals
according to the stage of change offers a useful perspective for treatment match
(DiClemente, Schlundt, & Gemmell, 2004) and is one of the best predictors of outcome
during the treatment and post-treatment periods in several behavioural disorders
(Carbonari & DiClemente, 2000; Petry, 2005).

In borderline personality disorder ( BPD) treatment, there is an increasing evidence

to support the efficacy of both psychoanalytic therapy and dialectical behaviour therapy
(DBT; American Psychiatric Association, 2001; Bender & Oldham, 2005; Linehan et al.,
2006; Oldham, 2005; Robins & Chapman, 2004). The standard DBT procedure includes
four types of intervention: group psychotherapy; individual psychotherapy; phone calls;
and a consultation group, over a 1-year treatment period. Several authors have modified
the original application design in attempt to shorten the duration of therapy, to lower
economic costs, or to apply it to other settings or patients (Bohus et al., 2004; Evans
et al., 1999).

Treatments utilizing a time-limited group format may be particularly promising in this

regard, as they may be less expensive than individual therapies and may give the chance
to reach a larger number of clients. However, there is only preliminary support for the
usefulness of time-limited group interventions in the treatment of BPD ( Blum, Pfohl,
St. John, Monahan, & Black, 2002; Grantz & Gunderson, 2006; Monroe-Blum & Marziali,
1995; Soler et al., 2005).

From a search of the databases PsycINFO and MEDLINE (until May 2007), the

suitability of stage-of-change construct to BPD has not empirically been addressed,
although some authors ( Freeman, 2004; Livesley, 2003, 2005; Miller & Kraus, 2007 )
have suggested the possible usefulness of the TTM in the treatment of personality
disorders. The aim of the present study was to evaluate the suitability of TTM stage-of-
change construct to BPD treatment by (a) exploring the pattern of the University of
Rhode Island Change Assessment (URICA) subscales’ inter-correlations, ( b) examining
whether stage-of-change is a useful predictor of DBT drop-out, and (c) analysing possible
differences between pre- and post-treatment URICA subscales within participants that
completed the DBT group intervention.

Method

Participants
From a total sample of 86 screened subjects, 79 met inclusion criteria and they filled
out at least the pre-intervention URICA questionnaire. From these, 60 began a DBT
3-month group treatment, 51 patients completed the intervention and 42 out of these
filled out correctly the pre-treatment and post-treatment URICA. The sample was
referred from clinical services of Barcelona, Spain (out-patients and psychiatric
emergency services). Inclusion criteria were: (1) DSM-IV diagnostic criteria for BPD as

418

Joaquim Soler et al.

Copyright © The British Psychological Society

Reproduction in any form (including the internet) is prohibited without prior permission from the Society

assessed by two semi-structured diagnostic interviews: the Structured Clinical
Interview for DSM-IV Axis II Disorders (SCID-II) and the Revised Diagnostic Interview
for Borderlines (DIB-R); (2) age between 18 and 45 years; (3) no comorbidity with
schizophrenia, drug-induced psychosis, organic brain syndrome, current alcohol or
other psychoactive drug dependence, bipolar disorder, mental retardation, or major
depressive episode in course; (4) Clinical Global Impression of Severity (CGI-S) scores
$ 4; (5) no current psychotherapy.

Study variable

University of Rhode Island Change Assessment (URICA) scale
The instrument used to assess the stages of change was the URICA (McConnaughy,
DiClemente, Prochaska, & Velicer, 1989; McConnaughy, Prochaska, & Velicer, 1983).
This self-reported questionnaire consists of 32 items, 8 for each of the following stages
of change or subscales: precontemplation (P); contemplation (C); action (A); and
maintenance (M).

The version used in the present study employs the generic ‘problem’ frame for

the items and it does not focus on a specific behaviour associated with BPD. This
generic format has allowed the URICA to be used with a variety of disorders or
problematic behaviours, by instructing the participants that ‘for all statements that
refer to your “problem”, answer in terms of problems related to “xxxxxxx” (in this
study, “your personality”)’. Each item is rated on a 5-point Likert scale that ranges
from strongly disagree to strongly agree. Subscores are averaged, and thus the scores
range from 1 to 5.

The four URICA subscales can be combined arithmetically (C þ A þ M

2 P) to

form a second order factor used to assess readiness to change (RC; Diclemente &
Prochaska, 1998): the RC composite score that can range from

2 2 to þ 14, with

higher scores indicating greater RC. DiClemente et al. (2004) have proposed an
algorithm for assigning a stage-of-change status to individuals using the following cut-
off points of the RC: scores below 8 correspond to precontemplation; scores
between 8 and 12, contemplation; and scores above 12, preparation/action (P/A).
We also used a second composite score developed by Pantalon, Nich, Frankforter,
and Carroll (2002): committed action (CA). It consists of A score minus C score.
This composite score is considered appropriate to assess motivation for change in
treatment-seeking samples since they usually score low in subscales P and M. CA
scores range from

2 32 to þ 32 since this composite score is calculated from the raw

subscales scores ( Pantalon et al., 2002).

Screening measures

Diagnostic Interview for Borderlines-Revised (DIB-R; Barrachina et al., 2004; Zanarini, Gunderson,
Frankenburg, & Chauncey, 1989)
This semi-structured diagnostic interview for BPD is composed of 125 items from
which 22 summarized statements (SS) are derived. These SS in-turn produce the 4 area
scores (AS): cognition; affect; impulse action patterns; and interpersonal relationships.
The AS determine the overall score on a scale from 0 to 10, where scores equal to or
above 6 are rendered compatible with the diagnosis of BPD.

Stages of change in BPD

419

Copyright © The British Psychological Society

Reproduction in any form (including the internet) is prohibited without prior permission from the Society

Structured Clinical Interview for DSM-III-R Personality Disorders (SCID-II; Go´mez-Beneyto et al.,
1994; Spitzer & Williams, 1990)
This semi-structured diagnostic interview is oriented to the diagnosis of personality in
general and it allows 11 possible axis II diagnoses.

Clinical Global Impression of Severity Scale (CGI-S; Guy, 1976)
The CGI-S evaluates the severity of the disorder assessing the present severity of the
patient’s symptoms.

Procedure
Screening measures were completed by a psychiatrist ( JCP) trained in their
administration. The length of the study was 3 months, during which time patients
were included in DBT group therapy. Participants were visited every 2 weeks by an
experienced psychiatrist for a clinical consultation and medication adjustment and
they participated in weekly group psychotherapy sessions. Thirteen psychotherapy
sessions of 150 minutes were conducted with 8–10 members in each group.
An adaptation of the standard version of the DBT format was used (Linehan, 1993a,
1993b), applying 2 of the 4 types of intervention: skills training and phone calls.
Skills training covered all of the original modules and instructed participants in the
following skills: mindfulness; distress tolerance; interpersonal skills; and emotional
regulation skills. Psychotherapeutic interventions were led by two cognitive
behavioural psychotherapists with prior experience in-group therapy in BPD and
trained in DBT in courses organized by the ‘Behavioural Technology Transfer Group’.
The URICA was administered prior to and at the end of the 3 months DBT group
treatment, by one of the psychotherapists.

Data analysis
Pearson correlations were used to express the relationships between URICA
subscales themselves, as well as between the subscales and the composite scores.
This test was also used to establish relationships between URICA subscales and
scores of the CGI-S. A set of pairwise t tests was conducted to test the differences on
URICA subscales and composite scores between pre- and post-treatment. To avoid
type I error inflation, a Bonferroni correction was used, and significance level was
set at .008. A chi-squared analysis was employed to test the relation between stage-
of-change and drop-outs. Tests of significance were always two-tailed. All analyses
were performed using the SPSS 15.0 statistical package.

Results

The demographics of the sample are shown in Table 1. The mean age was 27.4 years
(range 19–43, SD ¼ 5

:66). Clinically, the sample was composed of people with moderate-

severe BPD (DIB – R mean ¼ 7

:36; SD ¼ 1:38; range 6–9 and CGI–S mean ¼ 5:14;

SD ¼ 0

:86; range 4–7) and 73.5% of them met also diagnostic criteria for one or more

additional personality disorders in SCID-II.

The associations between URICA subscales and between the URICA subscales and

composite scores are shown in Table 2. The P subscale showed a significant negative
relation with the other three subscales (C, A, and M). These three subscales also showed
significant positive correlations with each other. The RC composite score showed a

420

Joaquim Soler et al.

Copyright © The British Psychological Society

Reproduction in any form (including the internet) is prohibited without prior permission from the Society

significantly positive correlation with C, A, and M subscales, and a negative correlation
with the P subscale. The CA composite score only correlated significantly with the C
(moderate and negative correlation) and with the A (moderate–high and positive
correlation) subscales. It has to be stated that these correlations were not unexpected
given that composite scores are made up of the subscales. Regarding the association
between URICA subscales and their derived composite scores with the severity of BPD
(CGI-S), the M subscale showed a significant correlation (r ¼

:333, p ¼ :004), whereas

the remaining correlations were not significant (p .

:05).

Table 1. Sociodemographic variables

Variables

Initial sample (N ¼ 79)

Patients completing the DBT group

intervention (N ¼ 42)

N/percentage (%)

N/percentage (%)

Sex

Male

11/14

8 / 20

Female

68 / 86

34 / 80

Marital status

Married/stable couple

20 /25

13 / 31

Single

44 / 56

23 / 55

Separated/divorced

15 /19

6/14

Education

First level

20 / 25

9 / 22

High school

36 / 44

22 / 52

University

25 / 31

11/26

Employment

Working

49 / 62

20 / 48

Not working

30 / 38

22 / 52

Note. DBT, Dialectical behavioural therapy; First level, schooling until 14 years old; High school, studies
beyond 14 years old, pre-university studies and professional qualifications; University, University studies
(completed and uncompleted university studies); Working, currently in paid-employment (either full-
time or part-time); Not working, any other condition (e.g. temporary or permanent sick leave;
unemployment; volunteering).

Table 2. Correlations between the University of Rhode Island Change Assessment (URICA) subscales
themselves, as well as between the subscales and the composite scores

URICA subscale or composite score P

C

A

M

RC

CA

Precontemplation (P)

2 .620**

2 .288*

2 .338**

2 .741**

.213

Contemplation (C)

.443**

.392**

.811**

2 .365**

Action (A)

.415**

.752**

.673**

Maintenance (M)

.689**

.107

Readiness to change (RC)

.111

Committed action (CA)

Note. Readiness to change ¼ ðContemplation þ Action þ MaintenanceÞ 2 Precontemplation; Committed
action ¼ Action 2 Contemplation.
*p ,

:05; **p , :01.

Stages of change in BPD

421

Copyright © The British Psychological Society

Reproduction in any form (including the internet) is prohibited without prior permission from the Society

No statistically significant differences were found between either the clinical or

demographic baseline characteristics of those that dropped out of treatment compared
to those that completed the DBT group sessions. In terms of categorical assignment to a
particular stage-of-change ( DiClemente et al., 2004), only 9 of the 43 patients in stage C
(21%) and 1 of the 11 patients in stage P/A (9%) dropped out before completing all DBT
group sessions compared to four of the six patients in stage P (67%). This difference was
statistically significant,

x

2

ð2

; N ¼ 60Þ ¼ 7:68, exact p value ¼ :02. The individuals

assigned to the P stage were more likely to drop-out than other participants,
x

2

ð1

; N ¼ 60Þ ¼ 7:00, exact p value ¼ :023.

In the comparison between pre-intervention scores and post-intervention scores, the

A subscale (tð41Þ ¼ 23

:434, p ¼ :001) and the CA composite score (tð41Þ ¼ 23:484,

p ¼

:001) showed statistically significant differences with greater values at post-

intervention (see Table 3).

Discussion

Some authors ( Freeman, 2004; Livesley, 2003, 2005; Miller & Kraus, 2007 ) have

suggested the possible usefulness of the TTM in the treatment of personality disorders.

Therefore, the stages-of-change have been used as a framework to conceptualize both

the phases of treatment and the process of change in psychotherapies for personality

disorders. It may also act as a guide for sequencing and selecting appropriate

interventions. The present study provides the first empirical insight into the suitability

of TTM stage-of-change construct to BPD treatment.

The significant correlation found between the severity of BPD and the M subscale is

consistent with the common association between the severity of an egodystonic disorder
and the effort to maintain the desired changes. According to the TTM, the correlations
between the URICA subscales were congruent with the relationships found in previous
research on this measure in a psychotherapy intervention context (Greenstein, Franklin,
& McGuffin, 1999; McConnaughy et al., 1983, 1989; Pantalon et al., 2002). P scores were

Table 3. Pre- and post-DBT treatment comparison on the University of Rhode Island Change
Assessment (URICA) and composite scores

N ¼ 42

URICA subscale or

Pre-DBT treatment

Post-DBT treatment

Results

composite score

Mean

SD

Mean

SD

t

p

URICA subscale

Precontemplation

1.783

0.576

1.649

0.494

1.784

.082

Contemplation

4.312

0.550

4.327

0.372

2 0.153

.879

Action

3.750

0.703

4.164

0.543

2 3.434

.001

Maintenance

4.021

0.542

4.069

0.656

2 0.519

.607

Composite score

Readiness to change

10.301

1.706

10.911

1.460

2 2.188

.034

Committed action

2 4.500

5.658

2 1.309

4.003

2 3.484

.001

Note. DBT, Dialectical behavioural therapy. Readiness to change ¼ ðContemplation þ Actionþ
MaintenanceÞ 2 Precontemplation. Committed action ¼ Action 2 Contemplation. Significance level
was set at p ¼

:008 after Bonferroni correction.

422

Joaquim Soler et al.

Copyright © The British Psychological Society

Reproduction in any form (including the internet) is prohibited without prior permission from the Society

significantly and negatively correlated with the other three subscales, whereas
correlations between C, A, and M were all significantly positive. These last three
subscales correspond, in different degrees, to a readiness-to-change attitude, so it is
reasonable that the P subscale goes in the opposite direction to these subscales.
As several other studies have found (Greenstein et al., 1999; McConnaughy et al., 1983,
1989; Pantalon et al., 2002), we also observed that the URICA subscales corresponding
to adjacent stages, correlated with each other more than the nonadjacent stages did. It is
relevant to point out that the composite scores RC and CA were not significantly
correlated, supporting the suggestion that these scores measure independent constructs
(Pantalon et al., 2002).

We observed that the stage-of-change was significantly related to dropping out from

DBT group treatment. Patients in the P stage were prone to drop-out before completing
all DBT group sessions. This finding is theoretically congruent with the TTM and
consistent with the results of several studies that have found similar relationships in
substance abuse treatment (Callaghan et al., 2005) and psychotherapy samples ( Brogan,
Prochaska, & Prochaska, 1999; Dozois, Westra, Collins, Fung, & Garry, 2004). This
association, however, has not been found by all researchers (Derisley & Reynolds, 2000).
Further studies must establish possible relationships between stages-of-change of
people with BPD and other clinical outcome measures.

In the pre- and post-psychotherapy comparison, we found statistically significant

differences in the A subscale and the CA composite score. In both variables the scores
were higher after DBT group intervention. These changes can be interpreted as an
increased self-reported behavioural effort or attitude, by people with BPD, in dealing
with their problem. A DBT group psychotherapy, as other cognitive-behavioural
therapies, oriented to acquire, strengthen and generalize a wide set of skills, probably
has a larger influence on action-stage oriented variables (i.e. A subscale and CA
composite score) than on pre-action ones (i.e. P and C subscales). The results of the A
subscale are comparable to those reported by Treasure et al. (1999) who found a
statistically significant increase in the A subscale after a cognitive behavioural therapy in
a bulimia nervosa sample. Although A subscale scores were statistically higher after DBT
treatment, further research is required to demonstrate that these differences are
clinically meaningful and related to actual behavioural change.

The absence of change observed in the M subscale could be explained in terms that

the majority of the abilities taught in the skills group during the first phase of DBT
intervention, aiming at establishing behavioural control, were primarily focused on
action-related processes of change. Nevertheless, the lack of increases on the M subscale
scores could be seen as a good outcome because this subscale, as has been described by
Carbonari and DiClemente (2000) and DiClemente et al. (2004), actually measures the
striving to maintain the change (i.e. the difficulty and struggle that one has or expects to
have when trying to sustain a given change of a behaviour).

Post-intervention scores in the P subscale tended to be lower than pre-intervention

scores. To obtain greater improvements in the P subscale an individual DBT mode may
be necessary. We should point out that our application was only partial (without an
individual mode) and brief (only 3 months) and the evidence of short group DBT
interventions is preliminary and limited (Blum et al., 2002; Grantz & Gunderson, 2006;
Monroe-Blum & Marziali, 1995; Soler et al., 2005).

Given that in this study no specific behaviour is the focus of the URICA this may

represent a limitation. However, it is likely that people with BPD have answered the
URICA in terms of their own most severe symptoms.

Stages of change in BPD

423

Copyright © The British Psychological Society

Reproduction in any form (including the internet) is prohibited without prior permission from the Society

Other study limitations were the reduced sample size and the consecutive

recruitment of participants. Also, due to our study design (absence of control group) we
cannot reject the possibility that the same pattern of changes seen in URICA subscales
would be found with some other non-DBT intervention or even without any
intervention. Another limitation could be that the validity of our results relies on self-
reported data (URICA scale), so the potential influence of factors such as optimism in
self-assessed RC cannot be completely ruled out (Brug et al., 2005). Use of an adequate
control group in future research would help to address this question.

It has to be emphasized that in this work we used URICA to assess a general

motivation to change in a disorder with a wide range of behavioural targets. Motivation
to change some of these (e.g. self-harm) could be quite different to that of other
behaviours (e.g. substance use) (Trujols, Luquero, Tejero, & Pe

´rez de los Cobos, 2004).

Further studies are warranted to test this hypothesis and to assess the motivation to
change with regard to each of these problem behaviours separately.

In spite of these limitations, the results of this preliminary study using URICA for BPD

suggest that conceptualizing motivation or patient readiness-to-change in terms of the
TTM stages-of-change can enrich and further our understanding of the process of change
in people with BPD treated with DBT.

Acknowledgements

Study supported by grants from the Fondo de Investigacio

´n Sanitaria (REF 03/434) and by the

Spanish Ministry of Health, Instituto de Salud Carlos III, CIBERSAM. Dr. Portella is funded by the
Spanish Ministry of Education and Science through a "Juan de la Cierva" postdoctoral contract.

References

American Psychiatric Association (2001). Practice guidelines: Practice guideline for the treatment

of patients with borderline personality disorder. American Journal of Psychiatry, 158, 1–52.

Barrachina, J., Soler, J., Campins, M. J., Tejero, A., Pascual, J. C., Alvarez, E., et al. (2004). Validacio

´n

de la versio

´n espan

˜ola de la Diagnostic Interview for Borderlines Revised (DIB-R). Actas

Espan

˜olas de Psiquiatrı´a, 32, 293–298.

Bender, D. S., & Oldham, J. M. (2005). Psychotherapies for borderline personality disorder.

In J. G. Gunderson & P. D. Hoffman (Eds.), Understanding and treating borderline personality
disorder: A guide for professionals and families (pp. 21–41). Arlington, VA: American
Psychiatric Publishing.

Blum, N., Pfohl, B., St. John, D., Monahan, P., & Black, D. W. (2002). STEPPS: A cognitive-behavioral

system-based group treatment for outpatients with borderline personality disorder:
A preliminary report. Comprehensive Psychiatry, 43, 301–310.

Bohus, M., Haaf, B., Simms, T., Limberger, M. F., Schmahl, C., Unckel, C., et al. (2004). Effectiveness

of inpatient dialectical behavioral therapy for borderline personality disorder: A controlled
trial. Behaviour Research and Therapy, 42, 487–499.

Brogan, M. M., Prochaska, J. O., & Prochaska, J. M. (1999). Predicting termination and continuation

status in psychotherapy using the transtheoretical model. Psychotherapy, 36, 105–113.

Brug, J., Conner, M., Harre

´, N., Kremers, S., McKellar, S., & Whitelaw, S. (2005). The

transtheoretical model and stages of change: A critique. Health Education Research: Theory
and Practice, 20, 244–258.

Callaghan, R. C., Hathaway, A., Cunningham, J. A., Vettese, L. C., Wyatt, S., & Taylor, L. (2005).

Does stage-of-change predict dropout in a culturally diverse sample of adolescents admitted to

424

Joaquim Soler et al.

Copyright © The British Psychological Society

Reproduction in any form (including the internet) is prohibited without prior permission from the Society

inpatient substance-abuse treatment? A test of the transtheoretical model. Addictive
Behaviors, 30, 1834–1847.

Carbonari, J. P., & DiClemente, C. C. (2000). Using transtheoretical model profiles to differentiate

levels of alcohol abstinence success. Journal of Consulting and Clinical Psychology, 68,
810–817.

Derisley, J., & Reynolds, S. (2000). The transtheoretical stages of change as predictor of premature

termination, attendance and alliance in psychotherapy. British Journal of Clinical Psychology,
39, 371–382.

DiClemente, C. C. (2003). Addiction and change: How addictions develop and addicted people

recover. New York: Guilford Press.

DiClemente, C. C., & Prochaska, J. O. (1998). Toward a comprehensive transtheoretical model of

change: Stages of change and addictive behaviors. In W. R. Miller & N. Heather (Eds.), Treating
addictive behaviors (2nd ed. pp. 3–24). New York: Plenum Press.

DiClemente, C. C., Schlundt, D., & Gemmell, L. (2004). Readiness and stages of change in

addiction treatment. American Journal on Addictions, 13, 103–119.

Dozois, D. J. A., Westra, H. A., Collins, K. A., Fung, T. S., & Garry, J. K. F. (2004). Stages of change in

anxiety: Psychometric properties of the University of Rhode Island Change Assessment
( URICA) scale. Behaviour Research and Therapy, 42, 711–729.

Evans, K., Tyrer, P., Catalan, J., Schmidt, U., Davidson, K., Dent, J., et al. (1999). Manual-assisted

cognitive-behaviour therapy ( MACT): A randomized controlled trial of a brief intervention
with bibliotherapy in the treatment of recurrent deliberate self-harm. Psychological Medicine,
29, 19–25.

Freeman, A. (2004, June). Treatment of personality disorders with cognitive-behavioural

psychotherapies. Paper presented at the VI ISSP European Congress on Personality Disorders,
Zaragoza, Spain.

Go

´mez-Beneyto, M., Villar, M., Renovell, M., Pe

´rez, F., Herna

´ndez, M., & Leal, C. (1994). The

diagnosis of personality disorder with a modified version of the SCID-II in a Spanish clinical
sample. Journal of Personality Disorders, 8, 104–110.

Grantz, K. L., & Gunderson, J. G. (2006). Preliminary data on an acceptance-based emotion

regulation group intervention for deliberate self-harm among women with borderline
personality disorder. Behavior Therapy, 37, 25–35.

Greenstein, D. K., Franklin, M. E., & McGuffin, P. (1999). Measuring motivation to change:

An examination of the University of Rhode Island Change Assessment Questionnaire (URICA)
in an adolescent sample. Psychotherapy: Theory, Research, and Practice, 36, 47–55.

Guy, W. (1976). Clinical global impressions. In W. Guy (Ed.), ECDEU assessment manual for

psychopharmacology, revised (pp. 217–222). Rockville, MD: National Institute of Mental
Health.

Linehan, M. M. (1993a). Cognitive-behavioral treatment of borderline personality disorder.

New York: Guilford Press.

Linehan, M. M. (1993b). Skills training manual for treating borderline personality disorder.

New York: Guilford Press.

Linehan, M. M., Comtois, K. A., Murray, A. M., Brown, M. Z., Gallop, R. J., Heard, H. L., et al. (2006).

Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy
by experts for suicidal behaviors and borderline personality disorder. Archives of General
Psychiatry, 63, 757–766.

Livesley, W. J. (2003). Practical management of personality disorder. New York: Guilford Press.
Livesley, W. J. (2005). Principles and strategies for treating personality disorder. Canadian Journal

of Psychiatry, 50, 442–450.

McConnaughy, E. A., DiClemente, C. C., Prochaska, J. O., & Velicer, W. F. (1989). Stages of change

in psychotherapy: A follow-up report. Psychotherapy, 26, 494–503.

McConnaughy, E. A., Prochaska, J. O., & Velicer, W. F. (1983). Stages of change in psychotherapy:

Measurement and sample profiles. Psychotherapy: Theory, Research, and Practice, 20,
368–375.

Stages of change in BPD

425

Copyright © The British Psychological Society

Reproduction in any form (including the internet) is prohibited without prior permission from the Society

Miller, T. W., & Kraus, R. F. (2007). Modified dialectical behavior therapy and problem solving for

obsessive–compulsive personality disorder. Journal of Contemporary Psychotherapy, 37,
79–85.

Monroe-Blum, H., & Marziali, E. (1995). A controlled trial of short-term group treatment for

borderline personality disorder. Journal of Personality Disorders, 9, 190–198.

Oldham, J. M. (2005). Guideline watch: Practice guideline for the treatment of patients with

borderline personality disorder. Arlington, VA: American Psychiatric Association.

Pantalon, M. V., Nich, C., Frankforter, T., & Carroll, K. M. (2002). The URICA as a measure of

motivation to change among treatment-seeking individuals with concurrent alcohol and
cocaine problems. Psychology of Addictive Behaviors, 16, 299–307.

Petry, N. M. (2005). Stages of change in treatment-seeking pathological gamblers. Journal of

Consulting and Clinical Psychology, 73, 312–322.

Prochaska, J. O., & DiClemente, C. C. (1983). Stages and processes of self-change of smoking:

Toward an integrative model of change. Journal of Consulting and Clinical Psychology, 51,
390–395.

Prochaska, J. O., DiClemente, C. C., & Norcross, J. C. (1992). In search of how people change:

Applications to addictive behaviors. American Psychologist, 47, 1102–1114.

Robins, C. J., & Chapman, A. L. (2004). Dialectical behavior therapy: Current status, recent

developments, and future directions. Journal of Personality Disorders, 18, 73–89.

Soler, J., Pascual, J. C., Campins, M. J., Barrachina, J., Alvarez, E., & Pe

´rez, V. (2005). A double-blind,

placebo-controlled study of borderline personality disorder: Olanzapine plus dialectical
behavior therapy. American Journal of Psychiatry, 162, 1221–1224.

Spitzer, R. L., & Williams, J. B. W. (1990). Structured clinical interview for DSM-III-R personality

disorders (SCID-II). New York: Biometrics Research Department, New York State Psychiatric
Institute.

Treasure, J. L., Katzman, M., Schmidt, U., Troop, N., Todd, G., & de Silva, P. (1999). Engagement

and outcome in the treatment of bulimia nervosa: First phase of a sequential design comparing
motivation enhancement therapy and cognitive behavioural therapy. Behaviour Research
and Therapy, 37, 405–418.

Trujols, J., Luquero, E., Tejero, A., & Pe

´rez de los Cobos, J. (2004). Estadios de cambio en

los trastornos de la conducta alimentaria: Consideraciones sobre su conceptualizacio

´n

y evaluacio

´n. Actas Espan

˜olas de Psiquiatrı´a, 32, 184–185.

Zanarini, M. C., Gunderson, J. G., Frankenburg, F. R., & Chauncey, D. L. (1989). The revised

diagnostic interview for borderlines: Discriminating borderline personality disorders from
other Axis II disorders. Journal of Personality Disorders, 3, 10–18.

Received 3 November 2006; revised version received 11 April 2008

426

Joaquim Soler et al.