Brief Dialectical Behavior
Therapy (DBT-B) for
Suicidal Behavior and
Non-Suicidal Self Injury

Barbara Stanley, Beth Brodsky, Joshua D. Nelson,
and Rebecca Dulit

The purpose of this study is to evaluate the effectiveness of a shorter course of
Dialectical Behavior Therapy (DBT) in enhancing treatment retention and reducing:
urges to engage in non-suicidal self injury (NSSI), NSSI, suicide ideation, and sub-
jective distress in borderline personality disorder (BPD). Twenty patients with BPD
received a six-month course of Dialectical Behavior Therapy (DBT-B). DBT-B was
delivered in the standard manner except for the shortened duration from one-year
minimum to six months. All variables were measured at baseline, and at six
months. Data were analyzed using paired t-tests. Treatment retention rate was
95%. Significant reductions were found in NSSI urges, NSSI, suicide ideation, sub-
jective distress, depression, and hopelessness between baseline and six months. These
results support the use of DBT-B in a six-month format when NSSI and suicidal
behavior and ideation are the targeted behaviors. Target behaviors were reduced sig-
nificantly and retention was extremely high in comparison to other interventions for
this population. A large scale randomized controlled trial investigating its efficacy is
warranted to determine if the results can be replicated and if improvement can be
sustained.

Keywords

borderline personality disorder, dialectical behavior therapy, non-suicidal self injury,

suicide

Suicide is a major cause of death among
patients with borderline personality dis-
order (Pompili, Girardi, Ruberto et al.,
2005), while deliberate non-suicidal self
injurious behavior (NSSI) is a cause of sig-
nificant amount of morbidity (Gunderson,
2001; Linehan, 1993). Individuals with
BPD commit suicide more frequently than
the general population and many other psy-
chiatric

populations

(Pompili,

Girardi,

Ruberto et al., 2005). In addition, it is

estimated that as many as 75% of indivi-
duals with borderline personality disorder
engage in some form of NSSI, and=or sui-
cidal behavior (self destructive behavior
with an intent to die) (Gunderson, 2001;
Linehan, 1993), a rate much higher than
that of groups in the general population
(Gratz, 2001; Ross and Heath, 2002).
Clearly, the treatment of suicidal behavior
and NSSI among individuals with BPD is
an area of critical importance. However,

Archives of Suicide Research, 11:337–341, 2007
Copyright # International Academy for Suicide Research
ISSN: 1381-1118 print/1543-6136 online
DOI: 10.1080/13811110701542069

337

few established treatments are available. As
Binks, Fenton, McCarthy et al. (2006) note
‘‘. . . some of the problems frequently
encountered by people with borderline per-
sonality disorder may be amenable to talk-
ing=behavioral treatments but all therapies
remain experimental and the studies are
too few and small to inspire full confidence
in their results’’ (p. 21).

Dialectical Behavior Therapy (DBT)

has been shown to be effective in treating
Borderline Personality Disorder (BPD) by
significantly reducing suicide attempts and
NSSI (Linehan, Comtois, Murray et al.,
2006; Linehan, Heard, & Armstrong,
1993; Linehan, Tutek, Heard et al., 1994).
However, studies have traditionally utilized
one-year trials of DBT, with improvement
ratings occurring both during the treatment
(Linehan, Tutek, Heard et al., 1994), as well
as during a one-year follow-up period
(Linehan, Heard, & Armstrong, 1993).
Recently, Linehan, Comtois, Murray et al.
(2006) found that, among patients with this
disorder, DBT was significantly more
effective than Community Treatment by
Experts in reducing suicide attempts, and,
thus, concluded that this effectiveness
results from

unique psychotherapeutic

mechanisms that cannot be accounted for
by general factors of expert psychotherapy.

While DBT is recommended as a year-

long treatment for the initial stage of skill
development and gaining control of suicidal
behavior and NSSI, the greatest treatment
effects occur during the initial four months
of treatment. The subsequent eight months
have been viewed as a period of skills con-
solidation

(Linehan,

Armstrong,

Suarez

et al., 1991). A shorter treatment length was
supported by one small pilot project that
found DBT could be successfully applied in
a six-month model (Koons, Robins, Tweed
et al., 2001). The question of the necessity
of this longer treatment length has not been
examined. DBT is a labor intensive and costly
treatment that may ultimately be a necessary
one, considering the extent of the problems

that BPD patients experience. Yet, it may
be possible that a shorter model, which
would maximize resources and result in a
cost savings, could yield faster overall skills
acquisition, especially of the basic coping
techniques and abilities, that help one to stay
alive and refrain from NSSI and suicidal
behavior. Furthermore, enhanced treatment
compliance and fewer difficulties with treat-
ment termination may be found because
patients may focus more on the skills to be
acquired rather than the therapeutic relation-
ship and therapist. The current pilot study
investigates these questions.

METHOD

Twenty patients with a diagnosis of DSM-IV
(American Psychiatric Association, 1994)
Borderline Personality Disorder partici-
pated in the study. Participants from major
metropolitan areas who were part of a
larger research project investigating the
biological and clinical factors associated
with suicidal behavior were offered open
treatment. The Institutional Review Board
approved the study, received psycho-tropic
medication as needed, and all participants
provided written consent. All participants
were outpatients and had active suicidal idea-
tion at baseline. Exclusion criteria were psy-
chotic disorders, mental retardation, history
of severe head trauma, or other cognitive
impairment that might interfere with the
accuracy of the assessments or competency
to give informed consent. The sample ranged
in age from 18 to 49, and had a mean age of
32.2 8.7 and was 85% female. The partici-
pants were predominantly Caucasian (85%).

Diagnoses were determined using the

Structured Clinical Interview from DSM-IIIR=
DSM-IV, Patient Edition (SCID-I, Spitzer,
Williams, Gibbon et al., 1990) and the
Structured Clinical Interview for DSM-IV
Axis II Personality Disorders (SCID-II,
First, Spitzer, Gibbon et al., 1996). All
interviews were conducted by doctoral

Brief DBT for Suicidal Behavior and Self-Injury

338

VOLUME 11 NUMBER 4 2007

level

clinicians

who

were

specifically

trained in the use of SCID instruments.
Urges to self injure, self-injury episodes,
suicide ideation, and subjective distress
were assessed on diary cards, as part of
the treatment, at baseline and after a six-
month course of DBT. NSSI was assessed
using a count of episodes for the prior
week. Urges to self injure, suicide ideation
and subjective distress were assessed as self
report measures on a scale of 1–5 for the
prior week. Other clinical ratings were
conducted independently by a rater not
involved

in

the

patient’s

treatment.

Response to treatment was determined by
paired t-tests with an alpha-level set at
p < .01. Beck Hopelessness Scale, Beck
Depression Inventory, and the Hamilton
Depression Rating Scale (Ham-D) were
used to assess hopelessness and depression.

RESULTS

All variables except the Ham-D, decreased
significantly during the six-month treatment
period, with the rates at six months lower
than the rates at three months and baseline
(Table 1). Paired t-tests found significant
decreases, from baseline to six months in
NSSI urges, NSSI episodes, suicide ideation
(t ¼ 7.18, p < .001), and subjective distress

(t ¼ 5.24, p < .001). Also, Beck Hopeless-
ness Scale (BHS) and Beck Depression
Inventory (BDI) scores declined significantly
(BHS: Baseline Mean ¼ 12.3 5.0, 6 mo.
Mean ¼5.0 2.6; t ¼ 2.59, p < .05; BDI
Baseline Mean ¼ 23.5 8.1, 6 mo. Mean
9.0 4.0,

t ¼ 2.84,

p < .05).

Hamilton

Depression Rating Scale scores did not show
a significant decline. During the course of
treatment, two low lethality (neither requiring
medical

intervention)

suicide

attempts

occurred, both in patients with a history of
multiple suicide attempts. One of these
patients was subsequently hospitalized.

The dropout rate was only 5% (1=20

patients).

This

patient

left

treatment

because she found that she could not toler-
ate participating in the group portion of
this treatment, that is, skills training. This
withdrawal occurred during the commit-
ment phase within the first month.

DISCUSSION

This analysis examined the effectiveness
of a brief, targeted DBT intervention for
individuals with BPD. We found that a
six-month intervention lead to significant
decreases in subjective distress, self-rated
depression, urges to self injure, NSSI,
suicide ideation and hopelessness. In

TABLE 1.

Comparison of Baseline, 3 month and 6 month Assessments for DBT Patients

Measure

Baseline

assessment

Mean SD

3 month

assessment

Mean SD

6 month

assessment

Mean SD

t-test baseline

vs. 6 mos.þ

NSSI episodesþ

1.76 1.79

1.09 1.48

0.73 1.10

3.26

NSSI urgesþ

2.84 2.01

2.14 1.93

1.33 1.59

5.07

Hamilton Depression Rating Scale

19.67 6.72

15.25 11.87

NA

< 1

Beck Hopelessness Scale

12.26 4.95

5.00 2.65

NA

2.59

Beck Depression Inventory

23.47 8.06

9.00 4.00

NA

2.84

Suicide ideationþ

3.52 1.31

2.14 1.49

1.27 1.28

7.18

Subjective distressþ

4.43 .734

3.48 .68

3.00 1.13

5.24

þ3 month comparison because 6 mos. was not available.

p < .05.

p < .01.

B. Stanley et al.

ARCHIVES OF SUICIDE RESEARCH

339

addition, retention was extremely high
especially considering the typically high
treatment drop-out rate of this population.
Overall, these results provide support that
DBT may be effective in briefer format that
is typically recommended and used in clinical
trials (Linehan, Armstrong, Suarez et al.,
1991; Linehan, Heard, & Armstrong, 1993).
This finding is particularly noteworthy
because it may mean that the subsequent
treatment consolidation period is less neces-
sary than previously believed if the primary
treatment goal is the reduction of suicidal
and non-suicidal urges and behaviors. How-
ever, it must be noted that this study could
not address this question directly because it
did not have a follow up period.

The survival analysis by Linehan,

Comtois, Murray et al. (2006) demonstrates
that DBT is significantly more effective
than community treatment by expert clini-
cians at increasing the time until first suicide
attempt, over a two-year period (one year of
treatment, one year of follow up). This
study indicates that, among participants
who received DBT, the vast majority of sui-
cide attempts occurred during the first six
months of treatment. Similarly, in the initial
study of DBT by Linehan, Armstrong,
Suarez et al. (1991), significant reductions
in suicide attempts and NSSI occurred dur-
ing the first four months of treatment that
were not further decreased in the following
eight months. The rationale for the
additional

months

of

treatment

was

described to be for ‘‘consolidation of gains’’
(Linehan et al., 1991). While the argument
can be made that relapse may be greater
without the longer treatment length, this is
an untested hypothesis. Other psychosocial
interventions in this population (Davidson,
Norrie, Tyrer et al. 2006; Gratz & Gunder-
son, 2006) recommend fewer sessions when
the reduction of NSSI and suicidal behavior
are the focus of treatment, such as the
Davidson, Norrie, Tyrer et al. (2006) adap-
tation of CBT for BPD. It is possible that
shorter treatment duration enables both

patients and therapists to focus on the
problem behaviors and skills deficits and
less on fear of losing the relationship since
both parties know in advance that the treat-
ment will end in six months. In other
words, therapeutic relationships may be less
tumultuous and strained and patients more
quickly focused on skills acquisition and
building. Perhaps because of the treat-
ment’s brevity, patients would be more
likely to remain in treatment for the dur-
ation and be more motivated to achieve
the treatment’s initial, tangible benefits.
Furthermore, being able to complete a recom-
mended course of therapy increases hope for
patients who have had numerous experiences
of dropping out or being terminated from
treatments. Patients can then continue in
treatment if desired, based on mutual agree-
ment of the patient and therapist.

These preliminary findings are limited

because they include neither a follow-up
nor a comparison group. It is also important
to note that the target behaviors of this analy-
sis, while important, are narrow in focus and
not designed to address the emotion dysregu-
lation and impulsivity frequently found in
BPD. Instead, it presents a brief version of
DBT, DBT-B, focused on helping indivi-
duals with BPD develop skills and means
of coping to enable them to stay alive and
unharmed during acute periods of distress.
Future studies should determine whether
the goals achieved in this time frame can be
maintained either without further treatment
for these behaviors, with a limited ‘‘booster’’
session approach, or whether a minimum
year long treatment is necessary. Randomized
controlled trials are required to make this
determination. If DBT-B is shown to be
effective, the treatment will be more cost
effective and accessible to more patients.

AUTHOR NOTE

This work was funded in part by grants
MH061017 and MH062665 from the

Brief DBT for Suicidal Behavior and Self-Injury

340

VOLUME 11 NUMBER 4 2007

National Institute of Mental Health and
P20 AA015630 from NIAAA.

Barbara Stanley, Department of Molecular

Imaging and Neuropathology, New York
State Psychiatric Institute, Department of
Psychiatry, Columbia University College
of Physicians & Surgeons and Department
of Psychology, City University of New
York-John Jay College, New York.

Beth Brodsky, Department of Molecular

Imaging and Neuropathology, New York
State Psychiatric Institute and Department
of Psychiatry, Columbia University College
of Physicians & Surgeons.

Joshua D. Nelson, Department of

Molecular Imaging and Neuropathology,
New York State Psychiatric Institute,
New York, New York.

Rebecca Dulit, Weill Medical College,

Cornell University, New York, New York.

Correspondence regarding this article

should be addressed to Barbara Stanley,
Ph.D., Unit 42, Department of Molecular
Imaging and Neuropathology, New York
State Psychiatric Institute, Unit 42, 1051
Riverside Drive, New York, New York
10032. E-mail: [e-mail]

REFERENCES

American Psychiatric Association. (1994). Diagnostic and

statistical manual of mental disorders (4th ed.)

. Washington,

DC: American Psychiatric Association.

Binks, C. A., Fenton, M., McCarthy, L. et al. (2006).

Psychological therapies for people with borderline
personality disorder. Cochrane Database Systematic
Review

, Jan 25(1), CD005652.

Davidson, K., Norrie, J., Tyrer, P. et al. (2006). The

effectiveness of cognitive behavior therapy for
borderline personality disorder: Results from the
borderline personality disorder study of cognitive
therapy (BOSCOT) trial. Journal of Personality Disor-
ders

, 20(5), 450–465.

First, M. B., Spitzer, R. L., Gibbon, M. et al. (1996).

Structured clinical interview for the DSM-IV axis I
personality disorders

. New York: New York State

Psychiatric Institute.

Gratz, K. L. (2001). Measurement of deliberate

self-harm: Preliminary data on the Deliberate
Self-Harm Inventory. Journal of Psychopathology and
Behavioral Assessment

, 23, 253–263.

Gratz, 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. Beha-
vioral Therapy

, 37(1), 25–35.

Gunderson, J. G. (2001). Borderline personality disorder:

A clinical guide

. Washington, DC: American Psychi-

atric Publishing.

Koons, C. R., Robins, C. J., Tweed, J. L. et al. (2001).

Efficacy of dialectical behavior therapy in women
veterans with borderline personality disorder.
Behavioral Therapy

, 32(2), 371–390.

Linehan, M. (1993). Cognitive behavioral treatment of bor-

derline personality disorder

. New York: Guilford

Press.

Linehan M. M., Armstrong, H. E., Suarez, A. et al.

(1991). Cognitive-behavioral treatment of chroni-
cally parasuicidal borderline patients. Archives of
General Psychiatry

, 48, 1060–1064.

Linehan, M. M, Comtois, K. A., Murray, A. M. et al.

(2006). Two-year randomized controlled trial and
follow-up of dialectical behavior therapy vs. ther-
apy by experts for suicidal behaviors and border-
line personality disorder. Archives of General
Psychiatry

, 63(7), 757–766.

Linehan, M. M., Heard, H. L., & Armstrong, H. E.

(1993). Naturalistic follow-up of a behavioral treat-
ment for chronically parasuicidal borderline patients.
Archives of General Psychiatry

, 50(12), 971–974.

Linehan, M. M., Tutek, D. A., Heard, H. L. et al.

(1994). Interpersonal outcome of cognitive beha-
vioral treatment for chronically suicidal borderline
patients. American Journal of Psychiatry, 151(12),
1771–1776.

Pompili, M., Girardi, P., Ruberto, A. et al. (2005).

Suicide in borderline personality disorder: A
meta-analysis. Norwegian Journal of Psychiatry, 59,
319–324.

Ross, S. & Heath, N. (2002). A study of the fre-

quency of self-mutilation in a community sample
of adolescents. Journal of Youth and Adolescence, 31,
67–77.

Spitzer, R. L., Williams, J. B. W., Gibbon, M. et al.

(1990). Structured clinical interview for the DSM-IIII-R=
DSM-IV–patient edition

. New York: New York

State Psychiatric Institute.

B. Stanley et al.

ARCHIVES OF SUICIDE RESEARCH

341