Journal of

Personality Disorders, 9(3), 190-198,

1995

1995 The Guilford Press

A CONTROLLED TRIAL OF SHORT-TERM

GROUP TREATMENT FOR BORDERLINE

PERSONALITY DISORDER
Heather Munroe-Blum, PhD, and Elsa Marziali, PhD

A randomized, controlled trial

was

conducted

on

1 10

subjects

who scored positive on the Diagnostic Interview for Borderlines

to assess the merits of an experimental, time-limited group
treatment for borderline
son

personality

disorder (BPD) in compari

with the control condition, individual

dynamic psychother

apy. Seventy-nine subjects received treatment. Analyses at 12and 24-month follow-ups on 84% of the treated subjects (N
=

66), demonstrated no statistically significant differences in out

come on the
major dependent variables. Outpatient referrals to

study complied with the treatments at twice the rate of in

patient referrals. The total study cohort showed significant im
provements on all major outcomes at follow-up. The cost
effectiveness of the group approach, in tandem with its poten
tial for application in a range of community services by multidisciplinary practitioners, speaks to the promise of this
treatment as an innovative service approach for BPD.
the

There

is

well-documented

high prevalence

of borderline

personality

disorder (BPD) in

psychiatry outpatient and inpatient settings (Kass, Skodol, Charles, Spitzer, & Williams, 1985; Munroe-Blum & Marziali, 1988;
Piersma, 1987) and over the past two decades considerable effort has been
expended toward the development of new treatment approaches. Despite
innovations

the treatment of BPD has

frustrations and

challenges

for both

generally been characterized by

patients and therapists, and the merits

of traditional treatments have been

questioned (Akiskal, 1992; Bellak,

1980; Vaillant, 1992). Treatment problems include patient refusal of treat
ments offered, premature termination of therapy, poor patient outcomes,
therapist dissatisfaction, and high cost, among others (Gunderson, 1984;
Waldinger & Gunderson, 1987). Treatment progress has been thwarted by
Faculty of Social Work. Department of Psychiatry (E. M.), and Departments of Medicine
Psychiatry (H. M. B.).
Address correspondence to Heather Munroe-Blum,
University of Toronto, Simcoe Hall, 27
King's College Circle. Toronto. Ontario M5S 1A1. Canada.
The study was supported by the Ontario Mental Health Foundation,
grant 988-87-89, and
the National Health Research and Development Program, grants 6606-4232-MH and 66064232-64. The authors acknowledge the important contributions made to the
project by Toni
Newman. Mary Wilson, and Lynn McCIeary.
From

and

190

191

SHORT-TERM BROUP TREATMENT FOR BPD

empirical data in support of effective interventions

for treating this population, problems with the classification of the disorder,
and a lack of innovation in developing models of treatment that respond
directly to the specific nature of the disorder (Gunderson, 1984; Munroethree factors:

lack of

Blum & Marziali, 1988).

Practice has continued to be dominated

(long-term, psychodynamically

treatment outcomes has been limited

sizes

by a unitary treatment approach

psychotherapy) and research of
by weak methodologies (small sample

oriented

and/or retrospective, uncontrolled studies). Nonetheless some pro

recent years, attempts have been made to assess

gress has been made. In

the effects of

number of different treatments for BPD from multimodal

approaches (Waldinger & Gunderson, 1987) to psychopharmacological

interventions (Soloff, George, Schulz, Ulrich, & Perel, 1986) using rigorous
research strategies that increase confidence in study findings. For the first
time, randomized, clinical trials of psychological treatments for BPD are
being conducted through the research programs of Linehan (Linehan,
Armstrong, Suarez, Allman, & Heard, 1991) and that of the authors as
reported here. Similarly, although there is room to improve upon the
classification of BPD with respect to clinical subtypes (Marziali, Munroemeasures of BPD exist (Gunderson,
Kolb, & Austin, 1981; Loranger, Susman, Oldham, & Russakoff, 1985;
Spitzer, Williams, & Gibbon, 1987) and are increasingly used in the

Blum &Links, 1994), reliable and valid

classification of the disorder for clinical and research purposes.

This paper presents the 12 month (end of treatment) and 24 month

findings
respond

of

time-limited group treatment for BPD that was designed to

implications of these findings for

to the nature of the disorder. The

treatment of BPD

are

discussed.

METHODOLOGY
A randomized controlled trial of
treatment

study,

110

as

usual"

was

"time-limited group treatment" versus "individual

Over the 6 years of the

conducted from 1986 to 1992.

eligible subjects were recruited from the in

teaching hospitals of a large Canadian

units of the

inclusion characteristics
at least

experienced
Diagnostic

the

one

were

outpatient psychiatry
university. Subject

males and females,

18-65 years of age, who had

contact, and who met criteria for BPD on

prior psychiatric
(DIB

Interview for Borderlines

7+). Exclusion characteristics

and

urban

Gunderson et al., 1981) (cutoff score

language difficulty, neurological impairment

or mental retardation, a primary diagnosis of alcohol or
drug addiction, and physical
disorders of a known psychiatric consequence. All eligible subjects were randomized
to outpatient individual or group treatment, and signed, informed consent was
=

were:

obtained prior to both screening procedures and treatment assignment.

The 1 10 subjects were randomly allocated to the two treatment cells over 5

waves

of treatment assignment. Sample size reflects the N deemed necessary to test the
hypothesized differences based on sample size calculations with a power estimate

Randomized Clinical Trial of Relationship Management Time-Limited Group Treatment of

Borderline Patients, funded by Ontario Mental Health Foundation and the National Health
and Research Development Program.

MUNROE-BLUM AND

192

MARZIALI

study and at 6-. 12-, 18- and

demographic, and symptom charac
teristics; and on behavioral indicators of functioning. Only the 12- and 24-month
follow-up results are reported. Of the 1 10 subjects who were randomly allocated to
41 for individual treatment
treatment, 79 accepted the treatment assignment (N
and n
38 for group); 31 withdrew from the study at the point of randomization [N
10 for individual treatment and 21 for group). There were no statistically
of .80.

Subjects

24-month

assessed at inclusion into the

were

follow-up

on

measures

of social,

significant

differences

treatments

or

The

major

between

on

clinical and

sociodemographic factors between the two

in the study and those who withdrew.

patients who remained

study included behaviors related

symptom status. Social dysfunction

outcome variables of interest in the

social

to social

and

performance,
dysfunction,
by the Objective Behaviors Index (OBI Munroe-Blum & Marziali,
1986) developed by the investigators for use in this study. The OBI is an interviewformat measure wherein the clinician elicits patient reports on eight types of
behaviors that reflect levels of dysfunction (hospitalizations, suicide attempts,
problems with the law, substance abuse, impulse control, house moves, psycho
therapy, and use of mental health/social services). The total OBI score reflects the
number of items endorsed as well as frequency and intensity of occurence. The
was

measured

accumulative

score

range is 0 (no items endorsed) to 1 12 (all 8 items endorsed at

the

highest level of dysfunction). General social performance was measured on the

Social Adjustment Scale (SAS Weissman & Bothwell, 1976). Clinical symptomatic
status was measured on the Beck Depression Inventory (BDI
Beck, Ward, Men
delsohn, Mock, & Erbaugh, 1961) and the Hopkins Symptom Checklist (HSCL-90
Deragotis, Lipman, & Covi, 1973).
The major hypothesis in this study was: BPD patients treated with the experi
mental treatment, interpersonal group psychotherapy (IGP), would make greater
improvements than the comparison individual treatment as usual (individual

dynamic psychotherapy IDP) on behavioral dysfunction as measured by the OBI,

general social performance as measured by the SAS, and symptoms as measured
by the HSCL-90 and the BDI. Secondary objectives of the study concerned the
longitudinal analysis of the total study cohort.

TREATMENTS
EXPERIMENTAL TREATMENT MODEL

The

experimental treatment, interpersonal group psychotherapy was man

guided and consisted of 30 sessions of treatment (25 weekly sessions
followed by 5 biweekly sessions leading into termination), each session
scheduled for 1 1/2 hours. All study therapists were trained to use IGP in
formal training sessions based on a manualized
training procedure. To
ascertain the reliability of the application of the method to
treatment,
adherence-to-method ratings were performed independently
by members
of the research team and compared (Marziali, 1991). Off-model behaviors
were corrected in
ongoing supervision of the cotherapist pairs. A compre
hensive description of the model and its
development is given in the
accompanying paper by Marziali and Munroe-Blum (this issue). The IGP
strategies reflect an interpersonal group treatment approach geared to
ual

addressing

central feature of the borderline disorder, that is, a conflicted,

poorly defined self-system, which is inordinately dependent

unstable, and

upon here and

now

interpersonal

transactions for self-definition.

193

SHORT-TERM BROUP TREATMENT FOR BPD

COMPARISON TREATMENT MODEL

The comparison treatment model, individual dynamic psychotherapy con
sisted of open-ended, individual, dynamic psychotherapy. It is the typical

patients and is the model in which a

majority of therapists are trained (Kernberg, 1975). Although this is a
"treatment-as-usual" comparison, there were nonetheless several controls
on the IDP treatment including: (1) a multidisciplinary group of therapists

model of treatment offered to BPD

who

were

comparable

to the

therapists

in the

experimental

condition in

terms of

past training experience and specific experience treating BPD

patients, (2) individual sessions once or twice per week, (3) open-ended
contract, (4) responsibility for the treatment placed entirely on the therapist
and (5) treatments conducted from a psychodynamic perspective. Audio-

taped recordings of all individual sessions were maintained. Subsequent

analyses showed that the individual therapists used the traditional psy
chodynamic psychotherapy strategies of interpretation, confrontation, and
exploration, among others (Marziali, 1991).

STUDY SAMPLE

The 110

study subjects were primarily

female (81%) and

ranged

in

age from

18 to 52 years. Most were currently unmarried though many had had a

prior marriage or live-in relationship. Over half the patients had children,
who often

were

member, friend,
school and had

residing with them. The majority lived with a family

acquaintance. Most of the patients had completed high

not
or

history of some form of employment albeit intermittent.

study the patients experienced significant behavioral
and social dysfunction in the 6-month period prior to the index treatments.
On the OBI over one third of the sample had been hospitalized, and more
than one third had made one or more suicide attempts; about one half had
reported problems with the law and an equivalent number reported sub
stance abuse; 85% reported problems with impulse control; and all subjects
a

At inclusion into the

had used mental health and/or social services. On the measure of social
adjustment (SAS), the mean score at inclusion was comparable to the

reported

mean score

for

fell into the "case" range

tology on the HSCL-90.

general psychiatric outpatients. The modal subject

on the BDI and
experienced moderate symptomo-

The
to

majority (75%) of the sample scored in the upper DIB score range (8
10). Although this scoring range would be comparable to the DIB-R

(Zanarini, Gunderson, Frankenberg, & Chauncey, 1989), which has raised

score to eight, 25% of the
patients were included with the cut off

the cutoff
of 7

the DIB. Of note is the fact that

although the DIB 7 group now

by the DIB-R interview schedule, 50% of the DIB 7 group
qualified for a diagnosis of BPD on the Personality Disorder Exam (Loranger
et al., 1985), which is a DSM-III-R based diagnostic schedule. To the extent
score

on

would be excluded

that the DIB

score

an index of
severity of the disorder
1994) 75% of this sample were in the

range represents

(Marziali, Munroe-Blum 6k Links,

severe category of BPD.

MUNROE-BLUM AND MARZIALI

194

OUTCOME
TREATMENT-OUTCOME FINDINGS
In terms of

from refusers

on

not differ

patients who accepted treatment did

any of the pretreatment assessment measures
the

compliance

or

on

diagnosis or comorbid conditions. DIB scores in the 8 to 10 range and

comorbidity with either Axis I or other Axis II disorders were the norm in
both groups. Outpatient referrals complied with the treatments at twice the
rate of inpatient referrals. In order to maximize the number of subjects
available for
in three
to

analysis,

or more

missing data

subject

on

N for the

compliance was defined as participation

assigned treatment (N 66). However, due

treatment

sessions of the
one

or

analyses

more
was

measure

Group

at

one

or

more

22 and Individual

time
=

point, the

26.

BETWEEN GROUP OUTCOMES

With respect to treatment outcome findings, multivariate analysis of vari

ance for the two treatment groups at 12 months (end of treatment) and 24

(1-year posttreatment follow-up) on the major outcome variables

no statistically significant differences in outcome between the
experimental group treatment and the individual treatment-as-usual con
trol on any of the dependent variables (behavioral indicators, social adjust
ment, global symptoms, or depression). IGP therapists valued the cotherapy
months
showed

and group structure of the treatment, and in contrast to the individual

therapists reported the dilution of the intensity of the patient demands,
decreased

anxiety

in

initiating treatment,
patients.

and increased

empathic

connec

tions with each of the

Despite

the

of the treatments in terms of outcome effects,

comparability

the group treatment is

cost-effective than

open-ended psychodynamic
psychotherapy. Even with a cotherapy group model of treatment, the
patient-therapist contact time is considerably reduced. Typically 7 patients
were treated in each
group, for 30 sessions by 2 therapists; this is an
of
90
hours
(1 1/2 hour per session, x 30 sessions, x 2
equivalent
which
therapists),
compares favorably with 210 contact hours if the same
7 patients were treated by individual therapists for 30 sessions.
more

TOTAL COHORT EFFECTS OF TREATMENT

Although
with

treatment

to the

group comparisons did

not

yield significant findings

outcome variables under

study, a multivariate
analysis of variance demonstrated that both treatment groups did experi
ence significant improvements over time as reflected on behavioral indica
tors, social adjustment, global symptoms, and depression. These results
are reported as analyses of the total cohort over time (Table 1).
respect

major

For the measures of behavioral dysfunction (OBI), social adjustment

(SAS), global symptom index (HSCL-90), and depression (BDI), the total
BPD cohort demonstrated statistically significant improvements at 12
month follow-up. These improvements were sustained at 24 month follow-

up such that the

significant

follow-up persisted

on

all

differences between inclusion and 24 month

measures.

195

SHORT-TERM BROUP TREATMENT FOR BPD

TABLE 1. Cohort

Analysis

of Variance

Scale Means at Three: Points in Time

OBI

(10.88)a

BDI

SAS

HSCL

2.13 (0.42)

1.76 (0.68)

25.9 (9.89)

Pretreatment

32.01

12 months

30.99 (12.67)

1.91 (0.50)

1.26(0.69)

18.4

(12.46)

24 months

23.61 (10.58)

1.89

1.03 (0.78)

14.6

(12.29)

nb

48

F2.84)
.04c

aStandard deviation

Ns vary because of
cp= .0001.

in

missing

45

43

10
F2.94)
.76c
Note.

(0.56)

parentheses for

each

are

in themselves

the

Because

17

.93

mean score.

analysis of the four

subjects into the study showed

correlated with the other

which

F2.90)

data.

An intercorrelational
inclusion of

46

16
F2.88)
.42

highly

at time of

measures

that the OBI is

independently
adjustment,

of symptoms and social

correlated (Table 2).

measures

functions

OBI

outcome

as

an

accumulative

index of behavioral

be examined inde
dysfunction,
in
each
Thus
it
is
to
assess
behavior endorsed
possible
change
pendently.
of
variance
for each of the
each
multivariate
analyses
patient. Separate
by
cohort
at
12of
the
OBI
for
the
total
and
24-month
eight dimensions
time
effects
on
all
dimensions
eight
followups yielded statistically significant

individual behavioral dimensions

of the OBI. For

example,

the group of

patients

can

who endorsed

"previous

to treatment showed

significant improvement on this

dimension at both 12- and 24-month follow-up. Of particular importance
were the findings showing that the dimensions most frequently endorsed
by the sample (between 85% and 100%) changed significantly posttreatmentandat 1 -year follow-up (problems with impulse control, FI2.76]
5.53,
hospitalizations" prior

<

.006;

use

of mental health and social services, FI2.92]

3.4, p < .038).
analysis was conducted to explore the effects on outcome
=

An additional

of intensity of exposure to treatment. For the total cohort,

attended 3 to 9 treatment sessions
10

or more

measures

sessions

analysis

on

were

compared

each of the outcome

of variance. There

were

measures

no

subjects

who had

with those who received

using

significant

repeated

differences in

outcome between the two treatment-time exposure groups; that is, the low
exposure group made gains comparable to those of the high exposure group
on

all of the outcome

measures.

DISCUSSION
Few randomized trials of treatments for BPD

or
any other category of
disorder have been conducted. Linehan et al. (1991) conducted
a controlled, experimental study of dialectical behavior
therapy in combined
individual and group format for 46 parasuicidal women. The

personality

experimental

MUNROE-BLUM AND MARZIALI

196

TABLE 2. Intercorrelations of Outcome Measures

BDI

.17

HSCL-90

.20

.62*

SAS

.16

.57*

Note. N

HSCL90

HSCL90

BDI

OBI

.45*

Beck Depression Inventory;

Objective Behaviors Index; BDI
Hopkin Symptom Checklist; SAS Social Adjustment Scale.

65; OBI

.001

*p<

treatment

effectively

reduced both the

frequency

and

lethality

of parasuici-

dal behavior in comparison with routine community treatment. However,

to be noted in the Linehan study is the fact that the comparison treatment
was not monitored as to type, intensity, or comparable level of training of
the

therapists.

study reported here used a comparison-con

dynamic psychotherapy) with therapists of com

In contrast, the

trol treatment (individual

parable levels of training.

In general, psychotherapy
strategies

have not shown the

studies that compare alternative treatment

superiority of one treatment over another, as

study reported here. It is our belief that the heterogeneity

population with respect to the variability in the presentation and
nature of comorbid clinical conditions will demand more investigation of
subgroup responses to allow us to adequately identify the optimal matching
of psychosocial and psychotherapeutic interventions with specific patient
characteristics and needs. Related analyses are in progress using the study

is the

case

in the

of the BPD

data.

experimental treatment (IGP) has

investigation. Even with
these preliminary findings on a heterogeneous and significantly impaired
BPD sample, patients who participated in the short-term group treatment
made significant gains on behavioral and clinical indicators of well-being,
at least equivalent to those of patients engaged in longer-term individual
therapies. With more patients receiving beneficial treatment over a shorter
period of time, and with the investment of fewer professional resources, the
economic cost advantages of IGP are obvious.
Of particular clinical relevance, the BPD cohort experienced a significant
rate of change at follow-ups on the measure of behavioral functioning (OBI),
which captures social dysfunction not measured by standardized ap
proaches such as the SAS, BDI, and HSCL-90. This confirms earlier findings
from small sample size studies that changes for patients with BPD in
psychotherapy treatments may be primarily behavioral rather than characterological in nature. For example, in this study the cohort analyses
demonstrated
although the sample represented a severe BPD group sig
nificant improvement on important indicators of social dysfunction, includ
ing hospitalizations, suicide attempts, problems with impulse control, and
The

study

results did show that the

merit and deserves further clinical and scientific

use

of mental health and social services.

Further, of clinical relevance is the fact that the IGP therapists reported
anxiety and greater satisfaction with the group treatment than did the

less

individual

psychotherapy therapists.

The presence of

cotherapist

in the

197

SHORT-TERM BROUP TREATMENT FOR BPD

IGP

approach

the

study
study found

may

we were

trained with

that
a

explain this response in part. Over the several years of

able to also test and refine our training approach. The

multidisciplinary range

of

therapists

could be

of treatment has great

for

potential

application

mental health services and social service

in

range of community

Given the clear cost

agencies.

benefits of IGP treatment, the assessment of this treatment in

treatment

effectively

modest investment of trainer/supervisor time. The IGP model

settings

range of

is warranted.

In summary, we believe that the IGP model of intervention is in keeping

with the development of new service approaches for personality disordered

patients.

It

responds

to the demand for

and for treatments that

can

be offered

called for in the American health

Canadian health

such

as

care

IGP could

care

briefer, less expensive treatments

by

range of

service

providers

as

reform movement and reflected in the

In addition, group models of intervention

therapists' frequent aversive reactions when

system.

help allay

confronted with the prospects of treating borderline personality disorder

and may add to patients' satisfaction with treatment. In tandem, the "bad

press" that accompanies the treatment of the

and patients would be tempered. Perhaps, as
the title of a recent article, "the

beginning

disorder for both

of wisdom is

therapists

(1992) indicates

Vaillant

never

calling

in

patient

borderline." He argues that the borderline label often reflects the clini
cian's subjective response to a cluster of patient problems and charac
a

teristics rather than

accuracy; thus, in any encounter with BPD

attitudes influence both their perceptions and man

diagnostic

patients, therapists'
agement of this group of patients. The
attention to

therapist subjective

IGP model of treatment pays special

endorses the view that

reactions and

patients with borderline personality disorder share the universal need for
care, respect, empathic response, and mastery; when these elements are
provided in a therapeutic context, the patients' abilities to make choices
and to control their destinies

are

enhanced.

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