Personality and Mental Health
(2014)
Published online in Wiley Online Library
(wileyonlinelibrary.com) DOI 10.1002/pmh.1264
Are recommendations for psychological
treatment of borderline personality disorder
in current UK guidelines justiﬁed? Systematic
review and subgroup analysis
HUSSEIN OMAR1, MARIA TEJERINA-ARREAL2 AND MIKE J. CRAWFORD3, 1Central and
North West London NHS Foundation Trust, London, UK; 2Facultad de Psicología, Universidad
de Murcia, Mucia, Spain; 3Centre for Mental Health, Imperial College London, London, UK
ABSTRACT
Current UK guidelines on the management of borderline personality disorder include speciﬁc recommendations
about the duration of therapy and number of sessions per week that patients should be offered. However, very
little research has been conducted to examine the impact of these aspects of treatment process on patient
outcomes. We therefore undertook a systematic review to examine the impact of treatment duration, number
of sessions per week and access group-based therapy on general mental health, depression, social functioning
and deliberate self-harm. We identiﬁed 25 randomized trials for possible inclusion in the review. However,
differences in outcome measures used meant that only 12 studies could be included in the analysis.
Statistically signiﬁcant reductions in self-harm and depression and improvement in social functioning were found
for treatments that include more than one session per week and those that included group-based sessions but were
not found for those that deliver in individual sessions or one or fewer sessions per week. Longer term outcomes of
short-term interventions have not been examined. Further research is needed to examine the impact of shorter
term interventions and to compare the effects of group-based versus individual therapies for people with borderline
personality disorder. Copyright © 2014 John Wiley & Sons, Ltd.
Introduction
Over the last 30 years, a range of psychological
treatments have been developed for the treatment
of people with borderline personality disorder
(BPD). Many of these appear to beneﬁt patients,
and national treatment guidelines in several countries have promoted their wider use (American Psychiatric Association, 2001; NICE, 2009; National
Health and Medical Research Council, 2012).
Copyright © 2014 John Wiley & Sons, Ltd.
There has been much debate about whether
beneﬁts associated with psychological treatments
for BPD are the result of speciﬁc ‘active ingredients’
of different treatment approaches or the result of
general factors such as providing people with
structured and coordinated care (de Groot,
Verheul, & Trijsburg, 2008; Livesley, 2004). In
2009, the National Institute for Health and Care
Excellence (NICE) highlighted features of psychological treatments that may be most helpful for
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Omar et al.
people with BPD (NICE, 2009). Based on the
observation that studies of relatively long-term
multi-modal interventions such as dialectical
behaviour therapy and mentalization-based
treatment were associated with positive outcomes,
this group recommended that short-term therapies
(of less than 3-month duration) should be avoided
and that twice-weekly therapy should be considered. These recommendations were based on the
views of an expert panel of researchers, clinicians
and patients; evidence from clinical trials of
psychological therapies for people with BPD was
not provided in support of these recommendations
(Levy, Yeomans, Denning, & Fertuck, 2010; Tyrer
& Haigh, 2010). It is therefore unclear whether
variation in outcomes associated with different
psychological treatments for people with BDP is
the result of differences in the length, number of
sessions per week or type of treatment that is
offered.
Subgroup analysis has been recommended as a
means of examining heterogeneity in the results
of clinical trials (Oxman & Guyatt, 1992; Yusuf
et al., 1991). By comparing treatment outcomes
among subgroups of patients or groups of people
offered different types of therapy, subgroup
analysis can be used to test whether positive outcomes are more likely among some types of people
or among those offered particular kinds of
treatment (Oxman & Guyatt, 1992; Yusuf et al.,
1991). Secondary analysis of data from clinical
trials has also been used to examine the impact
of treatment process on outcomes of psychological
therapies for other mental disorders: Churchill,
Hunot and Corney (2001) reported that groupbased treatments may be less effective than
individual therapy for people with depression.
However, to date, this approach has not been used
to examine the relationship between process and
outcomes of psychological treatments for people
with BPD.
In summary, treatment guidelines for people
with BPD have attempted to deﬁne aspects of
the organization and delivery of therapy that are
associated with better patient outcomes; however,
Copyright © 2014 John Wiley & Sons, Ltd.
to date, these have been based on expert opinion
and narrative reviews of available evidence. Better
evidence about the ‘active ingredients’ of psychological treatments for BPD could help ensure that
health care professionals and patients make
informed choices about the types of psychological
therapy that they should use; it also has the
potential to inform modiﬁcations to existing
treatment approaches and research into new
treatments that may help people with this
condition. We therefore set out to conduct a
systematic search of published trials of the effects
of psychological treatments for people with BPD
and to examine the impact that three process
factors highlighted in previous treatment guidelines (duration of treatment, number of sessions
per week and access to group sessions) had on
the effectiveness of psychological therapies for
people with BPD.
Methods
As a systematic review had been completed by the
National Institute for Health and Care Excellence
of all randomized trials of psychological therapies
for people with BPD up until April 2008, we built
on this and searched for new trials published from
then until the end of June 2011. This involved
searching the same four bibliographic databases
(MEDLINE, Excerpta Medica database, PsychINFO
and Cumulative Index to Nursing and Allied
Health Literature) using terms related to psychological therapies (psychological therapy, psychotherapy,
talking therapy, cognitive behavioural therapy
(CBT), dialectical behavioural therapy (DBT),
cognitive analytic therapy (CAT), cognitive
therapy (CT), client-centred therapy (CCT),
dynamic deconstructive therapy (DDT), schemafocused therapy (SFT), mentalization-based
therapy (MBT) and interpersonal therapy), BPD
(borderline, borderline state, borderline personality, cluster b, emotional instability, emotionally
unstable, emotional dysfunction, personality disorder and multiple personality) and those related to
clinical trials (clinical trials, controlled clinical
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Impact of treatment process on outcomes of BPD
trials, crossover procedure/design/studies, double
blind procedure/study/design, random allocation,
random sampling, random assignment, randomization, random sample and randomized controlled
trials). We searched the reference list of all new
studies and approached experts in the ﬁeld at a
national conference (in March 2011) in an attempt
to identify any recent unpublished trials.
Inclusion and exclusion criteria
Studies were eligible for inclusion if they were the
following: randomized controlled trials, involved
patients who have a formal diagnosis of BPD
according to DSM criteria or ICD criteria for
emotionally unstable personality disorder using
either clinical judgement or a structured interview
assessment, written in English, examined outcomes
using validated outcome measures and compared a
psychological treatment with a control condition.
Studies that compared two or more active
treatments without a control group were not
included in the subgroup analysis. Trials for people
with other types of personality disorder or other
mental health problems (such as deliberate selfharm) were included only if they reported separate
data on subgroups of patients with a formal diagnosis of BPD.
Participants were adults aged 18 or over from
any treatment setting (outpatient, inpatient and
primary care). Trials of participants with co-morbid
alcohol use or dependence were included, but those
that focussed exclusively on people with dependence on other substances were excluded.
Process factors and outcome measures
We examine the impact of three process factors on
study outcomes: (1) number of sessions per week
(deﬁned dichotomously according to NICE
guidelines into those delivered more than once a
week and those delivered once a week or less
often); (2) duration of treatment (deﬁned dichotomously according to NICE guidelines into those
of more and those of less than 3 months); and
Copyright © 2014 John Wiley & Sons, Ltd.
(3) whether or not a treatment included groupbased sessions.
Trials of psychological treatments for people
with a BPD use a large range of different
outcome measures. For the purpose of this
review, we decided to focus on the four outcome
measures that have been most widely reported in
such trials: general mental health, depression,
social functioning and whether study participants self-harmed during the follow-up period.
Trials also reported outcomes over a broad range
of different time periods. The most frequently
reported time point for study outcomes was
12 months after randomization, and we therefore
selected outcomes at 1 year. When a study did
not report 12-month outcomes but did provide
data 4 months either side of this date (i.e. 8
and 16 months), we included these in the subgroup analysis.
Data extraction and analysis
Two independent reviewers (HO and MTA)
inspected electronic copies of all papers that were
considered for possible inclusion in the review.
Where disagreement occurred about whether a trial
met the study inclusion criteria, this was resolved on
a discussion with a third reviewer (MC). HO and
MTA then independently extracted data from
selected trials using a pre-prepared data extraction
form. This included information on the speciﬁc
psychological interventions, its comparator, process
factors (as described in the previous texts) and
demographic data on study participants. Each study
was assigned a quality rating using the rating system
developed by the Scottish Intercollegiate Guidelines Network (SIGN, 2002). This system is based
on a checklist of 10 aspects of study design. Trials
are categorized as high quality if the majority of
the criteria are met and there is little or no risk of
bias, acceptable if most criteria are met but there
are some ﬂaws and an associated risk of bias and
low quality if either most criteria are not met or
there are signiﬁcant ﬂaws relating to key aspects of
study design.
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Omar et al.
We used the Comprehensive Meta-analysis
software (DerSimonian & Laird, 1986) to analyse
the data. We made the assumption that there
would be heterogeneity across studies and therefore used a random effects model to calculate the
standardized mean difference (SMD) with 95%
conﬁdence intervals for the impact of different
types of psychological treatments on each of the
pre-deﬁned outcomes.
Results
Six trials identiﬁed in the NICE review met our
inclusion criteria. Our search for new trials yielded
1 554 titles of which 6 were randomized trials that
met our inclusion criteria and contained data on
one of the four outcome measures (refer to ﬂow
chart in Figure 1). Therefore, the total number
of studies included in the meta-analysis was 12.
Details of these 12 trials are presented in Table 1.
All 12 studies were rated as ‘acceptable’ or higher
according to SIGN criteria; four (33.3%) were
rated ‘high quality’ (refer to Table 2).
Results of subgroup analysis
The impact of treatment duration on study
outcomes could not be explored as only two studies
examined interventions of less than 3-month
duration (Weinberg, Gunderson, Hennen, &
Figure 1: Preferred Reporting Items for Systematic Reviews and Meta-Analyses ﬂow chart
Copyright © 2014 John Wiley & Sons, Ltd.
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Copyright © 2014 John Wiley & Sons, Ltd.
124 people with BPD
based on DSM-IV
79 people with BPD based
on DSM-IV
Blum et al. (2008)
Bos, van Wel,
Appelo and
Verbraak (2010)
Davidson et al. (2006)
Linehan et al. (1991)
Gregory et al. (2008)
Farrell, Shaw and
Webber (2009)
Doering et al. (2010)
134 people with BPD
based on DSM-IV
Bateman and
Fonagy (2009)
30 people aged
18–45 years with
DSM-IV BPD and
alcohol misuse
63 patients aged
18–45 years with
DSM-III BPD and
ecent self-harm
84 female patients aged
18–45 with BPD based
on DSM-IV
106 people with DSM-IV
BPD and recent selfharm
38 people with DSM-III-R
BPD
Participants
Bateman and
Fonagy (1999)
Study
Dialectical behaviour
therapy versus
individual
psychotherapy
Transference-focused
psychotherapy versus
treatment by
psychotherapists
Group-based schema
focused therapy versus
weekly supportive
psychotherapy
Dynamic psychotherapy
versus therapy and
mental health care
Group-based STEPPS
therapy versus
medication and case
management
Weekly skills training
versus monthly mental
health follow-up
Individual CBT versus
treatment as usual
Day treatment with MBT
versus psychiatric
review
MBT versus structured
clinical management
Experimental and
control treatment
Table 1: Studies included in the subgroup analysis with quality rating
Yes
Yes
Yes
Yes
No
No
Yes
No
Yes
>1
>1
1 or less
>1
1 or less
>1
>1
1 or less
>1
18 months
18 months
20 weeks
18 weeks
12 months
12 months
8 months
12 months
12 months
Included
groups
Sessions
per week
Duration of
treatment
Deliberate self-harm
Social functioning
Depression
Deliberate self-harm
Social functioning
Depression
Deliberate self-harm
Social functioning
General mental health
Depression
Deliberate self-harm
Social functioning
General mental health
Social functioning
General mental health
Deliberate self-harm
General mental health
Depression
Deliberate self-harm
General mental health
Depression
Deliberate self-harm
Social functioning
General mental health
Depression
Social functioning
Outcomes included
in the review
(Continues)
Acceptable
Acceptable
High quality
High quality
High quality
Acceptable
Acceptable
High quality
Acceptable
Study quality
SIGN system
Impact of treatment process on outcomes of BPD
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High quality
Deliberate self-harm
>1
12 months
Yes
Acceptable
Depression
Deliberate self-harm
General mental health
>1
12 months
Dialectical behaviour
therapy versus general
psychiatric
management
Dialectical behaviour
therapy versus followup from mental health
services
Yes
High quality
Depression
Yes
>1
12 months
Dialectical behaviour
therapy versus
community treatment
by experts
Copyright © 2014 John Wiley & Sons, Ltd.
Verheul et al. (2003)
McMain et al. (2009)
Linehan et al. (2006)
101 women aged
18–45 years with
DSM-IV BPD and at
least two suicidal
attempts.
180 patients aged
18–60 years with
DSM-IV BPD and
self harm
58 women with DSM-IV
diagnosis of BPD
aged 18–70
Sessions
per week
Duration of
treatment
Study
Table 1: (continued)
Participants
Experimental and
control treatment
Included
groups
Outcomes included
in the review
Study quality
SIGN system
Omar et al.
Cutter, 2006; Zanarini & Frankenburg, 2008) and
neither measured outcomes between 8 and
16 months. SMDs for the number of sessions per
week and type of treatment are presented in
Table 2. Interventions delivered twice weekly or
more were associated with statistically signiﬁcant
improvements in all outcome measures apart from
general mental health; those delivering treatments
less often were not. Interventions that included
group therapy were associated with statistically
signiﬁcant improvements in all outcomes; those
that did not were not.
Discussion
The results of this review conﬁrm that a variety of
psychological interventions for people with BPD
are associated with small to medium-sized
improvements in a broad range of outcomes.
However, our ability to combine data from studies
for the subgroup analysis was limited by marked
differences in both the content and timing of
outcome assessments used in different trials. This
was especially true for trials of short interventions,
and we were unable to compare the results of these
therapies with those of longer duration. However,
we were able to conduct a subgroup analysis of
interventions of differing numbers of sessions per
week and those that did or did not include
group-based therapy. These showed that treatments that were offered twice weekly or more
and those that included group sessions led to
clinically and statistically signiﬁcant improvements in general mental health, depression and
social functioning and reduction in the likelihood
of deliberate self-harm. These results support one
of the two conclusions of NICE recommendations
for psychological treatment for people with BPD
that interventions that are delivered at an intensity of more than one session per week should be
considered in preference to those that deliver less
often (NICE, 2009). However, all but one of these
treatments also include a group-based component,
and effect sizes associated with interventions that
included access to group therapy had effect sizes
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Impact of treatment process on outcomes of BPD
Table 2: Standardized mean differences (SMDs) associated with different types of psychological treatment for people with
borderline personality disorder
Number of sessions per week
Outcome measure
General mental health
Less than two
per week
N
SMD (95% CI)
p-value
Two or more
sessions per week
N
SMD (95% CI)
p-value
N=1
N = 6*
Group-based component
Does not
include group
N
SMD (95% CI)
p-value
Includes group
N
SMD (95% CI)
p-value
N=2
0.052 (0.337 to
0.233) 0.720
N=5
0.425 ( 0.805 to
0.044) 0.029
Depression
N=3
0.193 ( 0.437
to 0.051) 0.121
N=5
0.265 ( 0.457
to 0.073) 0.007
N=3
0.166 ( 0.431
to 0.100) 0.221
N=5
0.269 ( 0.447 to
0.09) 0.003
Deliberate self-harm
N=2
0.186 ( 0.602
to 0.231) 0.383
N=5
0.402 ( 0.753
to 0.052) 0.024
N=3
0.035 ( 0.345
to 0.275) 0.825
N=4
0.558 ( 0.847
to 0.270) <0.001
Social functioning
N=3
0.768 ( 2.317
to 0.780) 0.331
N=4
0.969 ( 1.736
to 0.202) 0.013
N=3
0.137 ( 0.402
to 0.128) 0.311
N=4
1.527 ( 2.669 to
0.355) 0.011
*Subgroup analysis not conducted as insufﬁcient studies in each group.
as or greater than those associated with treatments
of higher intensity. Clear positive outcomes found
in a trial of a low-intensity group-based intervention Systems Training for Emotional Predictability
and Problem Solving (‘STEPPS’) (Blum et al.,
2008) provide additional support for the hypothesis that it is the exposure to group-based treatment
rather than the intensity of treatment that
contributes to the beneﬁts of interventions for
people with BPD.
This is the ﬁrst study to our knowledge that has
attempted to systematically study the impact of the
process of delivering psychological therapies on
outcomes of treatment for people with BPD. This
was achieved through a subgroup analysis using
potential moderators that had been highlighted in
previous reports. We used a comprehensive search
strategy to build on a previous high-quality review
to ensure that all studies that met our inclusion
criteria were included in the review. Previous
studies based on subgroup analysis have been
Copyright © 2014 John Wiley & Sons, Ltd.
criticized for not stating a priori hypotheses that
increases the potential to generate type I error
(Sun et al., 2012). One of the strengths of this
study was that process variables and outcome measures were selected before any analysis of outcomes
was undertaken. Process variables were selected on
the basis of factors identiﬁed as important by experts working on national guidance for BPD, and
outcome variables were selected according to how
often they had been used in previous trials.
However, the study has a number of important
limitations, notably the small number of trials that
we were able to be included in the subgroup
analysis. While over 30 trials of psychological
treatments for people with BPD had been
published up until June 2011, most of these had
to be excluded, either because they did not
include a control condition or because they did
not report one of the outcome measures that we
focussed on between 6 and 18 months after
randomization. As a result, of the small number
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Omar et al.
of trials that we were able to include, conﬁdence
limits around SMDs were wide resulting in a lack
of precision in the estimate of true effect sizes associated with different types of treatment. Differences in trial design, choice of outcome measures
and study quality are likely to have had a bearing
on differences in effect sizes across trials. The
content of control treatments also varied considerably between studies. In some, this consisted of
occasional reviews from a mental health professional, while in others, it involved more intensive
and structured support. We cannot rule out the
possibility that some of the differences seen in
the subgroup analysis are the result of differences
in control treatment rather than the active treatments that were studied. We also found differences in study quality, and these could have had
an impact on study ﬁndings. However, all studies
were randomized and were of sufﬁcient quality to
be included in the subgroup analysis.
Finally, ﬁndings from subgroup analyses are
observational in nature and are not based on
randomized comparisons. The differences that we
found should not be considered as evidence of
their effect but only as a basis for generating
hypotheses for future research.
Major variation in both the type and timing of
outcomes that were assessed limited the number of
trials that we could include in the subgroup
analysis. There does not appear to be an empirical
basis for these differences. While there is a
tendency to assess only short-term outcomes of
brief psychological interventions, BPD is a longterm disorder and information about outcomes
over months rather than weeks are needed to
properly examine the impact of interventions.
Previous research has shown that there is a good
deal of agreement among patients, clinicians and
researchers about the most important outcomes
to use when examining the impact of treatment
for personality disorder (Crawford et al., 2008).
Future trials should focus on measuring these key
elements of mental health, quality of life, social
functioning and risk of harm to self and others.
This would make comparisons between trials
Copyright © 2014 John Wiley & Sons, Ltd.
easier to make and help build the evidence of
which aspects of treatment process are most likely
to bring about positive change for people with
BPD.
While we were not able to do a subgroup
analysis comparing the impact of short treatments
delivered over less than 12 weeks with longer
interventions, it is noteworthy that the two trials
of short-term interventions that have been published both reported positive effects. Weinberg
et al. (2006) examine the impact of adding six sessions of manual-assisted cognitive therapy to treatment as usual and reduced the incidence of
deliberate self-harm (but not the proportion of
those that self-harmed—hence, it has been excluded from the subgroup analysis). Zanarini and
colleagues examined the impact of adding a single
session of psychoeducation to the treatment of
people with BPD and reported greater reductions
in general impulsivity and relationship problems
3 months later. People with BPD have a fear of
abandonment and often ﬁnd treatment endings
difﬁcult (Lieb et al., 2004). While this may have
led some to be cautious about the use of short-term
treatments, it is possible that if clear information is
given about the length and scope of psychological
treatment, it may be possible to minimize these
problems. At present, treatments for BPD last far
longer than those for other mental disorders, and
while these may be associated reductions in the
overall costs of care, the development of effective
shorter term interventions for people with BPD
may help ensure that psychological treatments became more widely available.
The results of this subgroup analysis lend support to NICE recommendations that people with
BPD are offered multi-modal interventions. It is
difﬁcult to disentangle which process element(s)
of these interventions gives rise to positive outcomes. Both MBT and DBT include more than
one session per week and combine individual with
group-based sessions. The results of this study provide as much support for the notion that these
treatments are effective because they provide opportunities for supporting and being supported by
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Impact of treatment process on outcomes of BPD
peers as they do for the recommendation that people with BPD should receive interventions based
on more than one session a week. Further evidence to support the value of group-based therapy
for people with BPD comes from the study by
Blum and colleagues that tested group-based cognitive therapy and delivered less than two sessions
per week. Weekly group-based therapy may also
help improve mental health and social functioning of people with other forms of personality disorder (Huband et al., 2007). Qualitative data
collected from people with PD in receipt of psychosocial interventions also highlight the importance placed on group-based treatment (Price
et al., 2009). This ﬁnding contrasts with those
from studies examining individual versus groupbased treatments for other types of mental disorder
in which generally either no difference or that individual therapy is more effective (Churchill et al.,
2001; McRoberts, Burlingame, & Hoag, 1998;
Selwood, Johnston, Katona, Paton, & Livingston,
2005). Problems with interpersonal functioning
are central to personality disorder, and it may be
that group-based therapy offers opportunities for
improving interpersonal functioning that individual therapy may not provide.
Future research is needed to better understand
the active ingredients of complex interventions
for people with BPD; the results of this study highlight the need to standardize outcome measures in
such studies, to examine the impact of short-term
treatments and to compare the effects of groupbased versus individual therapies.
Conﬂict of interest
The authors have declared no conﬂicts of interest.
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Address correspondence to: Mike Crawford, Professor in Mental Health Research, Centre for
Mental Health, Imperial College London,
Claybrook Centre, 37 Claybrook Road, London
W6 8LN, UK. Email: [email protected]
(2014)
DOI: 10.1002/pmh