Article

Evaluating Three Treatments for Borderline Personality

Disorder: A Multiwave Study
John F. Clarkin, Ph.D.
Kenneth N. Levy, Ph.D.
Mark F. Lenzenweger, Ph.D.
Otto F. Kernberg, M.D.

Objective: The authors examined three

yearlong outpatient treatments for borderline personality disorder: dialectical
behavior therapy, transference-focused
psychotherapy, and a dynamic supportive
treatment.
Method: Ninety patients who were diagnosed with borderline personality disorder were randomly assigned to transference-focused psychotherapy, dialectical
behavior therapy, or supportive treatment and received medication when indicated. Prior to treatment and at 4-month
intervals during a 1-year period, blind raters assessed the domains of suicidal behavior, aggression, impulsivity, anxiety,
depression, and social adjustment in a
multiwave study design.
Results: Individual growth curve analysis revealed that patients in all three
treatment groups showed significant positive change in depression, anxiety, global
functioning, and social adjustment across
1 year of treatment. Both transferencefocused psychotherapy and dialectical

behavior therapy were significantly associated with improvement in suicidality.

Only transference-focused psychotherapy
and supportive treatment were associated with improvement in anger. Transference-focused psychotherapy and supportive treatment were each associated
with improvement in facets of impulsivity. Only transference-focused psychotherapy was significantly predictive of
change in irritability and verbal and direct assault.
Conclusions: Patients with borderline
personality disorder respond to structured treatments in an outpatient setting
with change in multiple domains of outcome. A structured dynamic treatment,
transference-focused psychotherapy was
associated with change in multiple constructs across six domains; dialectical behavior therapy and supportive treatment
were associated with fewer changes. Future research is needed to examine the
specific mechanisms of change in these
treatments beyond common structures.
(Am J Psychiatry 2007; 164:922928)

mpulsivity, diminished nonaffective constraint, negative affectivity, and emotional dysregulation are core characteristics of borderline personality disorder (13). The
prevalence of borderline personality disorder in the community is approximately 1.3% to 1.4% (4, 5). This chronic
and debilitating syndrome is associated with high rates of
medical and psychiatric utilization of services (6, 7). Psychopharmacology notwithstanding, psychotherapy represents the recommended primary technique for treating
borderline personality disorder (8). Dialectical behavior
therapy (9) has demonstrated superiority over treatment
as usual (10) and therapy by community experts (11).
Other therapeutic approaches, such as psychodynamic
treatments, continue to be prominent in the treatment of
borderline personality disorder, as supported by the APA
Practice Guideline (8) and prior research (12). A promising psychodynamic treatment approach is an object relations approach called transference-focused psychotherapy (13). Transference-focused psychotherapy is an
effective treatment using patients as their own compari-

sons (14) and has demonstrated superiority over treatment as usual (unpublished data by KN Levy et al. available from the authors).
A necessary and first step in illuminating effective treatments for borderline personality disorder is to show that a
given treatment is associated with significant improvement in the disorderimprovement in relevant dimensions of pathology beyond self-damaging behaviors. Empirical evidence should show that candidate treatments,
such as dialectical behavior therapy and psychodynamic
approaches, are systematically related to change in a
number of substantive domains of clinical significance. A
recent influential review reported that existing therapies
for borderline personality disorder remain experimental,
and more real-world studies are necessary (15).
We examined patients who were taken from the community and reliably diagnosed with borderline personality
disorder. Patients were randomly assigned to transferencefocused psychotherapy, dialectical behavior therapy, or
supportive treatment for 1 year. Our study has characteris-

This article is featured in this months AJP Audio, is the subject of a CME course, and is discussed in an editorial by Dr. Gabbard on p. 853.

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Am J Psychiatry 164:6, June 2007

CLARKIN, LEVY, LENZENWEGER, ET AL.

tics of both efficacy and effectiveness studies. Similar to an

efficacy study, we used random assignment to treatments,
manualized treatments, blind raters, therapists blind to all
baseline assessments, and specific and reliably measured
outcome variables. Similar to an effectiveness study, however, we included a range of borderline personality disorder patients. Therapists provided treatment in their private
offices in the community rather than in a university or hospital setting. Medication treatment was decided on an individual basis so that the use or nonuse of medication and
medication type and amount were not standardized.

Method
Participants
The patients were men and women between the ages of 18 and
50 (mean age: 30.9 [SD=7.85] years) who met DSM-IV criteria (16)
for borderline personality disorder. Individuals with comorbid psychotic disorders, bipolar I disorder, delusional disorder, delirium,
dementia, and/or amnestic as well as other cognitive disorders
were excluded. Those with active substance dependence were also
excluded, although patients with past substance dependence and
past and current substance abuse were included. Patients were recruited from New York City and the adjacent tri-state area.

Assessments and Procedures

Patients were screened for age and location in telephone interviews. Suitable individuals were assessed in face-to-face evaluations by trained evaluators prior to their assignment to treatment.
Each participant received a diagnosis of borderline personality
disorder based on DSM-IV criteria as assessed by the International Personality Disorders Examination (17). High levels of reliability were obtained for the number of DSM-IV borderline personality disorder criteria met by each subject (single rater
intraclass correlation coefficient [1, 1]=0.83). An acceptable level
of reliability for borderline personality disorder diagnosis was obtained (kappa=0.64). Exclusion diagnoses were based on the
Structured Clinical Interview for DSM-IV (SCID) (18).
Domains of outcome. A priori, we chose suicidality, aggression, and impulsivity as primary outcome domains and anxiety,
depression, and social adjustment as secondary outcome domains. The variables of interest were assessed at baseline and at 4,
8, and 12 months (termination of treatment). Thus, each study
participant was measured on the same variables at approximately
the same intervals at four points in time; however, the assessment
intervals varied slightly. Measures and outcome domains are provided in Table 1.
Treatment and therapists. After initial assessments, patients
were randomly assigned to one of the three outpatient treatment
conditions for 1 year. Additionally, all patients were evaluated for
pharmacotherapy at entry into the study by one of three study
psychiatrists who were blind to psychotherapy assignment. A
medication algorithm (19) was used to guide the pharmacological
treatment.
The three psychotherapies were delivered with attention to
preserving their integrity and ecological validity (20). Therefore,
dialectical behavior therapy consisted of a weekly individual
and group session and available telephone consultation. Transference-focused psychotherapy consisted of two individual
weekly sessions, and supportive treatment consisted of one
weekly session, which could be supplemented with additional
sessions as needed.
The primary focus of transference-focused psychotherapy is on
the dominant affect-laden themes that emerge in the relationship
Am J Psychiatry 164:6, June 2007

between patient and therapist. It has been hypothesized that dialectical behavior therapy operates through the learning of emotion regulation skills in the validating environment provided by
the treatment (9). Supportive treatment (21) provides emotional
supportadvice on the daily problems facing the patient with
borderline personality disorder. The therapist follows and manages the transference but explicitly does not use interpretations.
In the present study, each of the three psychotherapies was administered and supervised by a treatment condition leader. Dialectical behavior therapy was supervised by Barbara Stanley,
Ph.D., transference-focused psychotherapy by Frank Yeomans,
M.D., and supportive treatment by Ann Appelbaum, M.D., all of
whom are acknowledged experts. A total of 19 therapists were selected by the treatment condition leaders based on prior demonstration of competence in their respective modality. All therapists
had advanced degrees in social work, psychology, or psychiatry,
with at least 2 years of prior experience treating patients with borderline personality disorder. All therapists were monitored and
supervised weekly by treatment condition leaders who were
available to observe videotaped sessions, provide feedback, and
rate therapists for adherence and competence.

Statistical Analysis of Change

We used individual growth curve analysis to investigate change
in the dimensions of symptoms and functioning over time (22
26). The individual growth curve approach hypothesizes that, for
each individual, the continuous outcome variable is a specified
function of time called the individual growth trajectory, plus error.
This trajectory is specified as a simple linear function of time containing two important unknown individual growth parameters
an intercept and a slopethat determine the shape of individual
true growth over time. The individual intercept parameter represents the net elevation of the trajectory over time. The individual
slope parameter represents the rate of change over time and in this
study is the within-person rate of change in the dependent variable over time. Individual growth trajectories are specified at level
1 and capture individual change over time. A level 2 model is then
used to investigate the way that the individual growth parameters
at level 1 are related to between-subjects factors.
The hypothesized level 1 and level 2 statistical models were fitted simultaneously using hierarchical linear modeling (full maximum likelihood) (27). First, we conducted a set of unconditional
growth analyses (24, 26), in which we posited a linear individualchange trajectory at level 1. Such unconditional analyses partition
the outcome variation into variance components that describe the
net variation in slope and intercept across individuals.
We fitted two sets of conditional (level 2) analyses that examined systematic interindividual differences in the intercept and
slope values from level 1. The first set of level 2 conditional analyses examined whether age at entry into the study predicted
change. The second set of conditional analyses represented the
central analyses for the study, namely the use of the between-subjects factor of the treatment group (transference-focused psychotherapy, supportive treatment, dialectical behavior therapy) to
explain differences in level 1 intercept and slope values. Importantly, the conditional model for these analyses deleted the intercepts in each of the two level 2 equations. Deletion of the intercepts from the level 2 equations allows for easy inspection of the
fixed effects associated with each treatment. It also allows for
straightforward evaluation of the null hypothesis that membership in a given treatment group is not associated with an intercept
or slope that differs from zero. The level 2 models yield fixed effects in the prediction of the slope and intercept values at level 1.
Additionally, level 2 models yield estimates of residual variance
that describe remaining interindividual variability in the individual slopes and intercepts after accounting for the fixed effects
(available upon request from the authors).
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EVALUATING THREE TREATMENTS FOR BORDERLINE PERSONALITY DISORDER

TABLE 1. Measures and Related Outcome Domains

TABLE 2. Patient Characteristics

Measure
Overt Aggression Scale-Modified (34)
Anger, Irritability, and Assault Questionnaire (35)
Barratt Impulsiveness Scale-II (29)
Brief Symptom Inventory (36)
Beck Depression Inventory (37)
Global Assessment of Functioning Scale (18)
Social Adjustment Scale (38)

Characteristic
Gender
Women
Men
Marital status
Married
Divorced
Living with partner
In relationship
Education
Less than high school
High school graduate
Some college
Associates degree
College degree
Graduate training
Employment
Full-time
Part-time
Ethnicity
Caucasian
African American
Hispanic
Asian
Other
Lifetime axis I disorders
Any mood disorder
Any anxiety spectrum disorder
Any eating disorder
Drug/alcohol abuse/dependence
Suicidal behavior
Prior suicidal behavior
Prior parasuicidal behavior
No history of suicidal/parasuicidal
behavior

Outcome Domain
Suicidality
Aggression
Impulsivity
Anxiety
Depression
Social Adjustment
Social Adjustment

Using each subjects date of birth and exact assessment dates,

the time between assessments for each participant was calculated in months and then centered on age at entry into the study
for each participant. Centering the assessment intervals on age at
entry and including age at entry as a predictor at level 2 account
for each participants unique chronological age when he or she
began the study and cause the individual level 1 intercepts to represent the true value of the first (time 1) assessments as the participants initial status. Individual growth curves were derived only
for those participants who had completed three or four assessment waves.

Results
Patient Characteristics
Between 1998 and 2003, 336 patients were referred to
our project. Of the 336 referrals, 129 either did not meet
criteria or decided not to schedule an intake interview. We
interviewed 207 individuals for at least one evaluation session; of these, 109 were eligible for randomization. Exclusions were because of the following reasons: did not meet
criteria for borderline personality disorder (N=34), age (N=
30), current substance dependence (N=9), psychotic disorder (N=8), bipolar I disorder (N=6), IQ below 80 (N=2),
scheduling conflict (N=1), and dropouts (N=8). Of the 109
participants eligible for randomization, 90 were randomized to treatment. There were no differences in terms of
demographics, diagnostic data, or severity of psychopathology between those who were randomized to treatment
and those who were not. Patient characteristics are provided in Table 2 (number of lifetime axis II disorders:
mean=2.49 [SD=1.13]). More detail regarding participant
referral and selection, rater and participant characteristics, and assessment of reliability is available elsewhere
(28). The present analyses are based on the patients for
whom we obtained three or more data points, which included 23 transference-focused psychotherapy patients,
17 dialectical behavior therapy patients, and 22 supportive
treatment patients, indicating continuation into the 9- to
12-month period.

Medication Treatment
At treatment onset, 70% of dialectical behavior therapy,
65% of supportive treatment, and 52% of transference-focused psychotherapy patients were placed on medication.
The percentage of patients receiving medication remained relatively constant throughout the 1-year treatment period. Any difference in the percentage of patients
receiving medication in the three treatment cells cannot

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83
7

92.2
7.8

7
40
11
21

7.7
44.4
12.2
23.3

3
7
28
6
29
17

3.3
7.8
31.1
6.7
32.2
18.9

30
23

33.3
25.6

61
9
8
5
7

67.8
10.0
8.9
5.6
7.8

69
43
30
34

76.7
47.8
33.3
37.8

51
56

56.7
62.2

15

16.7

be attributed to symptom severity, since there were no significant differences between the three groups of patients
at time 1 on the domain measures.

Individual Growth Curve Analyses

An unconditional growth model was fitted for all domains, providing estimates of the average elevation and
rate of change parameters and their natural variation
across all participants at entry into the study. The estimated average elevation of the individual growth trajectories at entry into the study (intercepts) differed significantly from zero for all domain dimensions (all p<0.001).
These results were expected, since the borderline personality disorder patients were relatively impaired. Notably,
the estimated average rates of change (i.e., slopes) also differed significantly from zero for all of the domain dimensions, except for the Barratt Factor 3 impulsivity and anxiety dimensions (29), indicating that much change over
time was evident in the data (all p=0.05).
The first set of level 2 conditional analyses examined
whether the age at which a participant entered the study
was related to change on the various domain variables, irrespective of treatment group. Statistically, age at entry
into the study was not significantly related to intercept
(level) values for any of the domain dimensions. Age at entry into the study was also essentially unrelated to the
slope (rate of change) values for the domain dimensions,
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CLARKIN, LEVY, LENZENWEGER, ET AL.

TABLE 3. Predicting Interindividual Differences in Change of Borderline Personality Disorder Patients Across Three Treatments in Multiwave Perspectivea
Rate of Change (Slope) of Individual
Trajectory (B1i)

Elevation (Intercept) of Individual

Trajectory (B0i)
Measure and Treatment Type
Depression (Beck Depression Inventory [37])
Transference-focused psychotherapy
Dialectical behavior therapy
Supportive treatment
Anxiety (Brief Symptom Inventory [36])
Transference-focused psychotherapy
Dialectical behavior therapy
Supportive treatment
Functioning (Global Assessment of Functioning
Scale [18])
Transference-focused psychotherapy
Dialectical behavior therapy
Supportive treatment
Suicidality (Overt Aggression Scale-Modified [34])
Transference-focused psychotherapy
Dialectical behavior therapy
Supportive treatment
Social adjustment (Social Adjustment Scale [38])
Transference-focused psychotherapy
Dialectical behavior therapy
Supportive treatment
Barratt Factor 1
Transference-focused psychotherapy
Dialectical behavior therapy
Supportive treatment
Barratt Factor 2
Transference-focused psychotherapy
Dialectical behavior therapy
Supportive treatment
Barratt Factor 3
Transference-focused psychotherapy
Dialectical behavior therapy
Supportive treatment
Irritability
Transference-focused psychotherapy
Dialectical behavior therapy
Supportive treatment
Anger
Transference-focused psychotherapy
Dialectical behavior therapy
Supportive treatment
Verbal assault
Transference-focused psychotherapy
Dialectical behavior therapy
Supportive treatment
Direct assault
Transference-focused psychotherapy
Dialectical behavior therapy
Supportive treatment

Fixed-Effect
Coefficient

Effect Size r

Fixed-Effect
Coefficient

33.41
35.91
34.91

0.001
0.001
0.001

0.93
0.91
0.93

0.55
0.59
0.69

0.001
0.003
0.001

0.50
0.38
0.49

50.03
53.23
49.16

0.001
0.001
0.001

0.98
0.97
0.98

0.34
0.57
0.40

0.004
0.001
0.001

0.37
0.50
0.48

52.84
52.21
50.22

0.001
0.001
0.001

0.95
0.96
0.96

0.59
0.67
0.62

0.001
0.004
0.001

0.44
0.36
0.43

1.20
2.17
0.84

0.001
0.001
0.001

0.57
0.59
0.44

0.05
0.09
0.03

0.01
0.01

0.33
0.34
0.18

4.47
4.75
5.04

0.001
0.001
0.001

0.92
0.92
0.98

0.04
0.09
0.09

0.03
0.001
0.001

0.28
0.44
0.59

29.90
31.92
29.87

0.001
0.001
0.001

0.97
0.97
0.93

0.01
0.17
0.09

13.41
13.73
13.32

0.001
0.001
0.001

0.96
0.91
0.96

0.09
0.05
0.03

21.02
19.62
20.55

0.001
0.001
0.001

0.96
0.93
0.97

0.06
0.02
0.10

1.92
1.61
1.63

0.001
0.001
0.001

0.94
0.89
0.86

0.03
0.01
0.02

0.01

0.33
0.11
0.16

1.74
1.52
1.34

0.001
0.001
0.001

0.87
0.80
0.82

0.06
0.03
0.03

0.001

0.44
0.25
0.28

1.80
1.55
1.49

0.001
0.001
0.001

0.94
0.87
0.88

0.04
0.02
0.02

0.001

0.43
0.21
0.19

0.82
0.73
0.72

0.001
0.001
0.001

0.72
0.56
0.64

0.02
0.002
0.001

0.05

0.26
0.01
0.01

b
b
b

0.005
b
b
b
b

0.02
b
b

0.05
b
b

b
b

Effect Size r

0.01
0.18
0.17
0.36
0.14
0.12
0.16
0.05
0.31

Level 2 analysis detected variability in change across individuals and determined the relationship between predictors and the elevation (intercept) and rate-of-change (slope) components of each patients individual growth trajectory from the level 1 analysis. All components of the
level 1 and 2 models were estimated simultaneously. Treatment types were coded as yes=1 and no=0. Intercepts were deleted from the level
2 equations to enable entry of each treatment type without dummy coding. Barratt Factor 2 and 3 dimensions were scored so that increases
in scores over time reflect decreasing impulsivity. Values represent the final estimates of the fixed effects with robust standard errors. Fixed
effects were tested to determine whether they differ from zero. Effect size was interpreted as 0.10=small; 0.24=medium; and 0.37=large (30).
b Not significant (p<0.05).

except for global functioning (p<0.02), suicidality (past

week) (p<0.05), and Barratt Factor 1 impulsivity (p<0.02).
Thus, differing developmental levels reflected, albeit
crudely, through chronological age were not related to elevation and rate of change in the domain dimensions.
Therefore, age at entry was not included in the second set
of level 2 conditional analyses. Additionally, age at entry
Am J Psychiatry 164:6, June 2007

did not differ significantly across the three treatment

groups (F=1.26, df=2, 59, p=0.30).
The second set of level 2 conditional analyses investigated the impact of the three treatments on the level and
rate of change (slope) in the participants. As noted previously, the intercept was deleted from each of the two level
2 equations in order to facilitate direct examination of the
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effect of each treatment group on the level and rate of

change. In these analyses, we determined whether the
level and rate of change observed for any of the treatment
groups differed significantly from zero. With respect to the
rate of change (or slope), the null hypothesis would be that
a treatment has no impact on change, and therefore it
should not be statistically related to change (or growth)
over time. Table 3 contains the fixed effects and variance
components associated with each level 2 predictor (i.e.,
treatment group), the approximate p value for testing that
these effects are zero in the population, and an estimate of
the effect size r (30).
With respect to elevation, each of the three treatment
groups was a statistically significant predictor of individual elevation parameters in the domain variables (all
p<0.001, large effect sizes). Given that the cohort consisted of subjects diagnosed with borderline personality
disorder, it was expected that the elevations would all differ from zero.
The critical growth parameter for this study is the individual slope parameter as it directly indexes the rate and
direction of individual change over time. The prediction of
slope (change) at level 2 by each of the three treatments
was significant for depression, anxiety, global functioning,
and social adjustment (all p<0.05); the direction of effects
was toward symptom improvement. Both transference-focused psychotherapy and dialectical behavior therapy
were significantly associated with improvement in suicidality over time, and both transference-focused psychotherapy and supportive treatment were significantly associated
with improvement in anger over time. Only transferencefocused psychotherapy was significantly predictive of
symptom improvement in Barratt Factor 2 impulsivity, irritability, verbal assault, and direct assault. Supportive treatment alone was predictive of improvement in Barratt Factor 3 impulsivity. None of the three treatments was
associated with improvement in Barratt Factor 1 impulsivity. Thus, transference-focused psychotherapy predicted
significant improvement in 10 of the 12 variables, dialectical behavior therapy in five of the 12 variables, and supportive treatment in six of the 12 variables.
We also refit the level 2 models examining treatment effects for the global functioning, suicidality, and Barratt
Factor 1 domains, including both the treatment group and
age at entry variables. For both the global functioning and
suicidality domains, inclusion of the age at entry variable
made the significant associations between the three treatment types and improvement in these domains stronger.
Inclusion of age at entry for Barratt Factor 1 did not alter
the nonsignificant relationships between the treatment
types and this variable as found in the initial conditional
analyses (Table 2).
The hierarchical linear model approach allows for hypothesis testing using the method of contrast analysis. We
conducted one contrast analysis for each domain of analysis based on theoretical predictions contained in the

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treatment manuals (15, 27) and the results of prior research. In short, to conserve space, we found that only one
contrast was close to statistically reliable, namely a contrast of slope coefficients that posited that transferencefocused psychotherapy and dialectical behavior therapy
should show stronger relationships with decreases in suicidal behavior than supportive treatment (and transference-focused psychotherapy and dialectical behavior
therapy should not differ [i.e., transference-focused psychotherapy=dialectical behavior therapy>supportive
treatment]). This contrast of slope coefficients approached significance (2=2.17, df=1, p<0.07; one-tailed).
We also conducted an intent-to-treat analysis. Such an
analysis is used to determine whether those participants
dropping out of the various treatment cells have affected
the pattern of findings across the treatments compared
with when the analyses are restricted to only those completing the study. We carried forward the last known value
for a variable for any participant who was assessed once or
twice in the protocol. For those participants who dropped
out of the study, we assumed assessments at 4, 8, or 12
months as time intervals. Therefore, the intent-to-treat
analysis database contained all those participants analyzed in the completer analyses as well as those who had
data carried forward as described above. In the intent-totreat analysis, the same variables of interest were analyzed
using the identical hierarchical linear model procedure
described previously. The results for the intent-to-treat
analysis did not differ in terms of the pattern of findings
from those obtained through the completer analyses.
The p values attached to each of the significance tests for
the coefficients for the intercept and slope variables were,
as one would expect, higher, given the greater degrees of
freedom. These results suggest that participant attrition
did not substantially alter the findings obtained in the
completer analyses.
One must consider the possible impact of medication
on change, specifically whether medication interacted differentially with any of the three treatments to amplify
change for patients in one or more of the treatments. To
examine this possibility, we conducted a parallel set of
growth curve analyses on only those subjects who had
been medicated at the study entry and through at least the
third assessment. In short, the pattern of findings (direction of effects, effect sizes) across the 12 dependent variables for the three treatments in this restricted cohort
where medication was held constant was highly similar to
that reported in Table 3 for the entire cohort.

Discussion
The major finding of this randomized controlled trial
was that transference-focused psychotherapy, dialectical
behavior therapy, and supportive treatment showed some
significant relation to positive change in multiple domains
across 1 year of outpatient treatment. This pattern sugAm J Psychiatry 164:6, June 2007

CLARKIN, LEVY, LENZENWEGER, ET AL.

gests that these structured treatments for borderline personality disorder are generally equivalent with respect to
broad positive change in borderline personality disorder
(31). Nonetheless, some differences emerged across the
three treatments in relation to change. For the primary
outcome variables, both transference-focused psychotherapy and dialectical behavior therapy were significantly associated with improvement in suicidality,
whereas transference-focused psychotherapy and supportive treatment were associated with improvement in
anger. Only transference-focused psychotherapy was significantly predictive of symptom improvement in Barratt
Factor 2 impulsivity, irritability, verbal assault, and direct
assault. Supportive treatment alone was predictive of improvement in Barratt Factor 3 impulsivity. Regarding secondary outcome variables, each of the three treatments
was significantly predictive of the rate of change in a positive direction for depression, anxiety, global functioning,
and social adjustment. Overall, transference-focused psychotherapy was predictive of significant improvement in
10 of the 12 variables across the six domains, dialectical
behavior therapy in five of the 12, and supportive treatment in six of the 12.
Only one contrast analysis yielded a tendency toward
significance, which suggests that transference-focused
psychotherapy and dialectical behavior therapy, the two
treatments with a specific focus on the reduction of suicidal behaviors in borderline personality disorder patients,
were more effective than a general supportive treatment.
Four design issues in this study deserve comment. To
our knowledge, this is the first randomized controlled trial
design that examines three well-described (manualized)
treatments for borderline personality disorder, one of
which (dialectical behavior therapy) is considered by
many to be a standard treatment in the field, which represents a design of the highest level of control (32). Second,
although transference-focused psychotherapy and supportive treatment share many of the same basic techniques, they differ in a way that allows for a component of
therapeutic control (transference-focused psychotherapy
employs transference interpretation as a possible mechanism of change, whereas supportive treatment does not).
Third, our design combines features of both efficacy and
effectiveness studies. Patients from a large tri-state metropolitan area were referred to us, and inclusion/exclusion
criteria were based on criteria used in clinical practice. Patients were assessed at a community-serving, universityaffiliated hospital, and the treatments were delivered by
community practitioners in their private offices. One
might expect attenuated outcomes with the treatments
delivered in the community, without the structure and the
expectancies provided by a university setting in which
many randomized controlled studies of this kind are conducted. Finally, we report both completer and intent-totreat analyses and thus address both the internal and exAm J Psychiatry 164:6, June 2007

ternal validity of the study. Completer analyses speak to

the issue of sufficient dose, whereas intent-to-treat analyses provide generalizability to the community.
There are three areas of limitation in the present study.
Similar to other statistical methods, statistical power in
multilevel modeling of growth curves is a function of four
factors: cohort size, variance in the cohort, size of the effect being studied, and the number of data waves available. Although reliable a priori effect sizes were not available for our three treatments and we did not wish to
constrain the patient characteristics in an artificial manner to reduce variability, we feel that a larger cohort and
more data waves might have yielded more significant results because of increased power. Ethical constraints did
not allow a no-treatment comparison group for self-destructive and highly suicidal borderline personality disorder patients. In a similar fashion, it was not possible to
standardize medications across these patients whose pathology called for individualized medication treatments.
However, we note that the pattern of results observed for
the medicated subgroup of patients was highly similar to
that observed for the full cohort.
The general equivalence of outcome across the three
treatments studied suggests that there may be different
routes to symptom change in patients with borderline
personality disorder. In contrast to dialectical behavior
therapy, which focuses directly on skills to help the patient
regulate emotion and reduce symptoms, transference-focused psychotherapy focuses on developing greater selfcontrol through the integration of representations of self
and other as they are activated in the relationship with the
therapists. In this study, transference-focused psychotherapy effects were observed across a broader range of outcome domains than dialectical behavior therapy and supportive treatment. Given the pervasiveness and chronicity
of borderline personality disorder, future research will
need to examine the maintenance of these symptom
changes and specification of the mechanisms through
which treatments relate to outcome (33).
Received June 19, 2006; revisions received Oct. 23 and Dec. 4, 2006;
accepted Dec. 12, 2006. From Weill Medical College of Cornell University, New York; Pennsylvania State University, University Park, Pa.; and
State University of New York at Binghamton, Binghamton, N.Y. Address correspondence and reprint requests to Dr. Clarkin, New York
Hospital-Cornell Medical Center, Westchester Division, 21 Bloomingdale Rd., White Plains, NY 10605; [email protected] (email).
Supported by the Borderline Personality Disorder Research Foundation.
The authors thank Marco Stoffel, Borderline Personality Disorder
Research Foundation Executive Officer, and the Foundations scientific board for their advice and encouragement. The authors also
thank John B. Willett, Ph.D. (Harvard University, Cambridge, Mass.) for
useful statistical consultations and Jill Delaney, Joel McClough, Simone Hoermann, Kenneth L. Critchfield, Pamela A. Foelsch, James
Hull, Catherine Eubanks Carter, and Mya Kushner for patient assessment and data collection.

ajp.psychiatryonline.org

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EVALUATING THREE TREATMENTS FOR BORDERLINE PERSONALITY DISORDER

CME DISCLOSURE
Drs. Levy, Lenzenweger, and Kernberg report no competing interests. Dr. Clarkin receives royalties from a book published by American Psychiatric Publishing.
APA policy requires disclosure by CME authors of unapproved or investigational use of products discussed in CME programs. Off-label
use of medications by individual physicians is permitted and common. Decisions about off-label use can be guided by scientific literature and clinical experience.

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