No pain, no gain revisited: the impact of positive and negative psychotherapy experiences on treatment outcome.

Objective: Psychotherapy may have many benefits for patients with mental health problems, but patients may also have negative experiences related to the therapy. Not much is known about these negative psychotherapy experiences and their impact on treatment outcome. The aim of this study was to examine the association between positive and negative psychotherapy experiences and treatment outcome. Methods: A total of 130 patients participated in the study. They received treatment as usual and were assessed for positive and negative psychotherapy experiences at mid-treatment and post-treatment using the Positive and Negative Experiences of Psychotherapy Questionnaire (PNEP). Treatment outcome was measured by the Outcome Questionnaire - 45 (OQ-45). Multiple linear regression was used to analyze the data. Results: All patients reported positive psychotherapy experiences at mid-treatment. At least one negative experience was reported by 69% of participants. After correction for baseline severity (i.e., OQ-45 at baseline) and relevant demographic variables, positive psychotherapy experiences at mid-treatment emerged as a predictor for treatment outcome. In contrast, negative psychotherapy experiences did not predict treatment outcome. However, reporting more negative experiences was associated with reporting fewer positive experiences at mid- and end of treatment. Conclusion: Both positive and negative psychotherapy experiences commonly occur. Although in this study negative psychotherapy experiences did not predict treatment outcome in terms of symptom reduction, the findings do suggest that negative experiences may influence the way in which patients evaluate their treatment. Although positive experiences outweigh negative experiences, patients should be informed that negative experiences may also occur.

A Scale for Measuring Positive and Negative Experiences of Psychotherapy (PNEP): First Psychometric Findings of a New Instrument for Monitoring Clients' Experiences.

BACKGROUND: Clients' adverse experiences during psychotherapy are rarely monitored in clinical practice or research trials. One obstacle here is the lack of a measure to gauge both positive and negative experiences during psychotherapy. We developed and evaluated a new instrument for measuring such experiences. METHOD: The Positive and Negative Experiences of Psychotherapy (PNEP) questionnaire was developed based on pilot data, a literature review, and two existing scales for measuring primarily adverse experiences during psychotherapy. Mental healthcare clients (N = 200) anonymously completed and evaluated the PNEP. Subsequently, a sample of professionals (N = 34) who underwent psychotherapy in the context of their training filled in the PNEP twice, with a 2-week interval in between. RESULTS: The positive and negative experiences subscales of the PNEP were found to possess excellent internal consistencies (αs ≥ 0.90). The PNEP test-retest reliability was 0.93 for the positive experiences subscale and 0.78 for the negative experiences subscale. For the positive subscale, four factors were extracted: symptom reduction and positive well-being, high quality of therapy and therapeutic relation, personal growth and acceptance and interpersonal functioning. For the negative subscale, exploratory factor analysis suggested a three-factor solution: escalation of symptoms and emotional distress, low quality of therapy and therapeutic relation and (self-)stigmatization and dependency. Participants related a median of 13 positive and six negative therapy experiences to their most recent treatment. The most frequently endorsed negative experiences were having more negative thoughts and memories, feeling emotionally overwhelmed and an increase in stress due to the therapy. A minority of participants (10.5%) reported no negative treatment experiences. CONCLUSIONS: In the field of psychotherapy, the evaluation of risks and benefits is crucial for assessing safety and effectiveness. The PNEP could be a promising instrument for achieving this objective, although further research is needed to replicate and expand upon the current findings.

Problem resolution scale: A single-item instrument for easily assessing clinical improvement.

This study describes the development and tests the validity of the Problem Resolution Scale (PRS)-a single-item measure developed by researchers at Systemic Practice Research Network (SYPRENE) for assessing the degree to which the focal problem of therapy is perceived as resolved. Data were collected at termination from 747 clients seen across 18 therapists. Results suggested good construct validity, supported by a strong correlation between client and therapist perceptions as assessed by the PRS (r = 0.71, p < 0.001). Good criterion validity was also supported by strong correlations between client-reported psychological well-being and functioning at termination and both client-reported (r = -0.63; p < 0.001) and therapist-reported (r = -0.66; p < 0.001) problem resolution scores. Linear mixed model regression and stratified correlation analysis controlling for the therapist and presenting problem effects confirmed criterion validity. Results provide initial evidence for the validity and utility of the PRS.

Understanding "patient deterioration" in psychotherapy from depressed patients' perspectives: A mixed methods multiple case study.

OBJECTIVE: This study scrutinizes the meaning of deterioration in psychotherapy beyond the widely used statistical definition of reliable symptom increase pre-to-post treatment. METHOD: An explanatory sequential mixed-methods multiple case study was conducted, combining quantitative pre-post outcome evaluation of self-reported depression symptoms and qualitative analysis of patients' interviews. In a Randomized Controlled Study on the treatment of Major Depression, three patients showing reliable increase in symptom severity on the BDI-II pre-to-post therapy were selected. An interpretative phenomenological analysis (IPA) was performed on individual interviews conducted pre-, peri- and post-treatment. RESULTS: Cross-case outcome experiences were: (1) uncontrollable complaints; (2) remaining questions and uninternalized insights and (3) persisting interpersonal difficulties. Within-case idiosyncratic differences revealed that the statistical classification of "deterioration" not necessarily corresponds to a "deteriorated experience," nor univocally indicates unwanted therapy effects. Our findings point at the influences of the patient's (lack of) agency in the process, a discrepancy between patients' expectations and the therapy offer, the therapeutic relationship, interpersonal difficulties, and contextual influences. CONCLUSION: The meaning of symptomatic deterioration should be interpreted within a patient's idiosyncratic context. The multi-faceted nature of deterioration requires further research to rely on multiple perspectives and mixed methods.

What treatment outcomes matter in adolescent depression? A Q-study of priority profiles among mental health practitioners in the UK and Chile.

Evidence-based and person-centred care requires the measurement of treatment outcomes that matter to youth and mental health practitioners. Priorities, however, may vary not just between but also within stakeholder groups. This study used Q-methodology to explore differences in outcome priorities among mental health practitioners from two countries in relation to youth depression. Practitioners from the United Kingdom (UK) (n = 27) and Chile (n = 15) sorted 35 outcome descriptions by importance and completed brief semi-structured interviews about their sorting rationale. By-person principal component analysis (PCA) served to identify distinct priority profiles within each country sample; second-order PCA examined whether these profiles could be further reduced into cross-cultural "super profiles". We identified three UK outcome priority profiles (Reduced symptoms and enhanced well-being; improved individual coping and self-management; improved family coping and support), and two Chilean profiles (Strengthened identity and enhanced insight; symptom reduction and self-management). These could be further reduced into two cross-cultural super profiles: one prioritized outcomes related to reduced depressive symptoms and enhanced well-being; the other prioritized outcomes related to improved resilience resources within youth and families. A practitioner focus on symptom reduction aligns with a long-standing focus on symptomatic change in youth depression treatment studies, and with recent measurement recommendations. Less data and guidance are available to those practitioners who prioritize resilience outcomes. To raise the chances that such practitioners will engage in evidence-based practice and measurement-based care, measurement guidance for a broader set of outcomes may be needed.

The association of sociodemographic characteristics with work disability trajectories during and following long-term psychotherapy: a longitudinal register study.

PURPOSE: This register-based study examined the trajectories of depression or anxiety disorder-related work disability during and following long-term psychotherapy and identified sociodemographic factors that indicate membership in different trajectory groups. METHODS: Data were drawn from national registers (Statistics Finland, Social Insurance Institution of Finland). Participants included a random sample of Finnish working-age individuals (18-55 years) who started psychotherapy treatment between 2011 and 2014 and were followed for 5 years: 1 year before and 4 years after the onset of psychotherapy (N = 3 605 individuals; 18 025 person-observations across five time points). Group-based trajectory modeling was applied to assign individuals to work disability trajectories by the number of annual mental health-related work disability months. Multinomial logistic regression was used to examine the associations between trajectory group membership and baseline sociodemographic factors of age, gender, occupational status, and geographical area of residence. RESULTS: Four mental health-related work disability trajectories were identified: stable very low (72%), decrease (11%), persistent low (9%) and persistent high (7%). Those with older age, female gender, lower occupational status, and living in sparsely populated geographical areas were more likely to belong to the most unfavorable trajectory group of persistent high work disability. The presence of multiple risk characteristics substantially increased the probability of belonging to the most adverse trajectory group. CONCLUSIONS: Sociodemographic factors were associated with the course of mental health-related work disability in association with psychotherapy. Rehabilitative psychotherapy does not function as an equal support resource for work ability in all parts of the population.

Do routine outcome monitoring measures tell the same story? Evaluating outcome trajectories and clinical outcomes for the outcome rating scale and outcome questionnaire - 45.

Routine outcome monitoring (ROM) of psychotherapy improves client outcomes and reduces premature terminations. Two ROM systems with the most empirical support are the OQ System (Lambert, 2010) and the Partners for Change Outcome Management System (PCOMS; Duncan, 2012; Miller et al., 2005). We evaluated if the global distress measures, the Outcome Rating Scale (ORS; PCOMS) and the Outcome Questionnaire-45.2 (OQ-45; OQ System) show similar outcome trajectories and rates of reliable and clinically significant change when completed by the same clients.Participants (N = 290) were clients from archived data collected in a training clinic for a psychology doctoral program in the western United States, who completed both the ORS and OQ-45 across treatment.Bi-variate correlations between the ORS and OQ-45 were highly correlated at the first session (r = -.73), and for later sessions linear and quadratic estimates were only moderately related (rs = -.31 to -.57). Statistically significantly more clients indicated both reliable change and clinically significant change on the ORS compared to the OQ-45.The results indicate that these measures are correlated but not interchangeable in relation to the conclusions they generate about treatment outcomes. Measurement tools should be carefully considered given the potential for different conclusions to be drawn regarding treatment progress and outcomes.

Dynamic and static predictive modelling of psychotherapy outcome-Comparison of two statistical approaches.

OBJECTIVE: Improving prediction abilities in the therapy process can increase therapeutic success for a variety of reasons, such as more personalised treatment or resource optimisation. The increasingly applied methods of dynamic prediction seem to be very promising for this purpose. Prediction models are usually based on static approaches of frequentist statistics. However, the application of this statistical approach has been widely criticised in this research area. Bayesian statistics has been proposed in the literature as an alternative, especially for the task of dynamic modelling. In this study, we compare the performance of predicting therapy outcome over the course of therapy between both statistical approaches. METHOD: Based on a sample of 341 patients, a logistic regression analysis was performed using both statistical approaches. Therapy success was conceptualised as reliable pre-post improvement in brief symptom inventory (BSI) scores. As predictors, we used the subscales of the Outcome Questionnaire (OQ-30) and the Helping Alliance Questionnaire (HAQ) measured every fifth session, as well as baseline BSI scores. RESULTS: The influence of the predictors during therapy differs between the frequentist and the Bayesian approach. In contrast, predictive validity is comparable with a mean area under the curve (AUC) of 0.76 in both model types. CONCLUSION: Bayesian statistic provides an innovative and useful alternative to the frequentist approach in predicting therapy outcome. The theoretical foundation is particularly well suited for dynamic prediction. Nevertheless, no differences in predictive validity were found in this study. More complex methodology as well as further research seems necessary to exploit the potential of Bayesian statistics in this area.

Understanding the psychological therapy treatment outcomes for young adults who are not in education, employment, or training (NEET), moderators of outcomes, and what might be done to improve them.

BACKGROUND: To determine: whether young adults (aged 18-24) not in education, employment or training (NEET) have different psychological treatment outcomes to other young adults; any socio-demographic or treatment-related moderators of differential outcomes; and whether service-level changes are associated with better outcomes for those who are NEET. METHODS: A cohort was formed of 20 293 young adults treated with psychological therapies in eight Improving Access to Psychological Therapies services. Pre-treatment characteristics, outcomes, and moderators of differential outcomes were compared for those who were and were not NEET. Associations between outcomes and the following were assessed for those that were NEET: missing fewer sessions, attending more sessions, having a recorded diagnosis, and waiting fewer days between referral and starting treatment. RESULTS: Those who were NEET had worse outcomes: odds ratio (OR) [95% confidence interval (CI)] for reliable recovery = 0.68 (0.63-0.74), for deterioration = 1.41 (1.25-1.60), and for attrition = 1.31 (1.19-1.43). Ethnic minority participants that were NEET had better outcomes than those that were White and NEET. Living in deprived areas was associated with worse outcomes. The intensity of treatment (high or low) did not moderate outcomes, but having more sessions was associated with improved outcomes for those that were NEET: odds (per one-session increase) of reliable recovery = 1.10 (1.08-1.12), deterioration = 0.94 (0.91-0.98), and attrition = 0.68 (0.66-0.71). CONCLUSIONS: Earlier treatment, supporting those that are NEET to attend sessions, and in particular, offering them more sessions before ending treatment might be effective in improving clinical outcomes. Additional support when working with White young adults that are NEET and those in more deprived areas may also be important.

Therapeutic alliance and clinical outcomes in teletherapy and in-person psychotherapy: A noninferiority study during the COVID-19 pandemic.

OBJECTIVE: The current study aimed to inform the varied and limited research on clinical variables in the context of teletherapy. Questions remain about the comparative quality of therapeutic alliance and clinical outcome in the context of teletherapy compared to in-person treatment. METHODS: We utilized a cohort design and a noninferiority statistical approach to study a large, matched sample of clients who reported therapeutic alliance as well as psychological distress before every session as part of routine clinical practice at a university counseling center. A cohort of 479 clients undergoing teletherapy after the emergence of the COVID-19 pandemic was compared to a cohort of 479 clients receiving in-person treatment before the onset of the pandemic. Tests of noninferiority were conducted to investigate the absence of meaningful differences between the two modalities of service delivery. Client characteristics were also examined as moderators of the association between modality and alliance or outcome. RESULTS: Clients receiving teletherapy showed noninferior alliance and clinical outcome when compared to clients receiving in-person psychotherapy. A significant main effect on alliance was found with regard to race and ethnicity. A significant main effect on outcome was found with regard to international student status. Significant interactions on alliance were found between cohort and current financial stress. CONCLUSIONS: Study findings support the continued use of teletherapy by demonstrating commensurate clinical process and outcome. Yet, it will be important for providers to be aware of existing mental health disparities that continue to accompany psychotherapy - in person and via teletherapy. Results and findings are discussed in terms of research and clinical implications. Future directions for researching teletherapy as a viable treatment delivery method are also discussed.

Empathic reflections by themselves are not effective: Meta-analysis and qualitative synthesis.

Objective: We present a mixed methods systematic review of the effectiveness of therapist empathic reflections, which have been adopted by a range of approaches to communicate an understanding of client communications and experiences. Methods: We begin with definitions and subtypes of empathic reflection, drawing on relevant research and theory, including conversation analysis. We distinguish between empathic reflections, reviewed here, and the relational quality of empathy (reviewed in previous meta-analyses). We look at how empathic reflections are assessed and present examples of successful and unsuccessful empathic reflections, also providing a framework of the different criteria used to assess their effectiveness (e.g., association with session or treatment outcome, or client next-turn good process). Results: In our meta-analysis of 43 samples, we found virtually no relation between presence/absence of empathic reflection and effectiveness, both overall and separately within-session, post-session and post-treatment. Although not statistically significant, we did find weak support for reflections of change talk and summary reflections. Conclusions: We argue for research looking more carefully at the quality of empathy sequences in which empathic reflections are ideally calibrated in response to empathic opportunities offered by clients and sensitively adjusted in response to client confirmation/disconfirmation. We conclude with training implications and recommended therapeutic practices.

Research evidence on psychotherapist skills and methods: Foreword and afterword.

This article serves as both the foreword and the afterword to the special section of Psychotherapy Research devoted to research reviews of psychotherapist skills and methods: it introduces the interorganizational Task Force that guided the reviews and then features its conclusions. We begin by operationally defining therapist skills and methods and then contrasting them with other components of psychotherapy. Next, we consider the typical assessment of skills and methods and how they are linked with outcomes (immediate in-session, intermediate, and distal) in the research literature. We summarize the strength of the research evidence on the skills and methods reviewed in the 8 articles in this special section and in the companion special issue in Psychotherapy. We end with diversity considerations, research limitations, and the formal conclusions of the interorganizational Task Force on Psychotherapy Skills and Methods that Work.

Individual behavioral activation in the treatment of depression: A meta analysis.

OBJECTIVE: Behavioral activation (BA) is an extensively examined treatment for depression which is relatively simple to apply in comparison to other psychotherapies. BA aims to increase positive interactions between a person and the environment. All previous meta-analyses focused on BA in groups and guided self-help, but none focused on BA in individual psychotherapy. The goal of the current meta-analysis is to examine the pooled effects of trials comparing individual BA to control conditions. METHODS: We conducted systematic searches and conducted random effects meta-analyses to examine the effects of BA. RESULTS: We included 22 randomized controlled trials (with 819 patients) comparing individual behavioral activation with waitlist, usual care, or other control conditions on distal treatment outcomes. Nine studies were rated as low risk of bias. We found a large effect (Hedges' g = 0.85; 95% CI: 0.57; 1.1) with high heterogeneity (75%; 95% CI: 62; 83). When only studies with low risk of bias were considered, the effect size was still significant (g = 0.56; 95% CI: 0.09; 1.03), with high heterogeneity (I2 = 80%; 95% CI: 66; 89; prediction interval: -0.85; 1.98). CONCLUSION: BA is an effective, relatively simple type of therapy that can be applied broadly in differing populations/.

Routine Outcome Monitoring (ROM) and Feedback: Research Review and Recommendations.

OBJECTIVE: To provide a research review of the components and outcomes of routine outcome monitoring (ROM) and recommendations for research and therapeutic practice. METHOD: A narrative review of the three phases of ROM - data collection, feeding back data, and adapting therapy - and an overview of patient outcomes from 11 meta-analytic studies. RESULTS: Patients support ROM when its purpose is clear and integrated within therapy. Greater frequency of data collection is more important for shorter-term therapies, and use of graphs, greater specificity of feedback, and alerts are helpful. Overall effects on patient outcomes are statistically significant (g ≈ 0.15) and increase when clinical support tools (CSTs) are used for not-on-track cases (g ≈ 0.36-0.53). Effects are additive to standard effects of psychological therapies. Organizational, personnel, and resource issues remain the greatest obstacles to the successful adoption of ROM. CONCLUSION: ROM offers a low-cost method for enhancing patient outcomes, on average resulting in an ≈ 8% advantage (success rate difference; SRD) over standard care. CSTs are particularly effective for not-on-track patients (SRD between ≈ 20% and 29%), but ROM does not work for all patients and successful implementation is a major challenge, along with securing appropriate cultural adaptations.

Enhancing emotion regulation.

Background: Emotion regulation (ER) refers to the process of modulating an affective experience or response. Objectives: This is a systematic review of the research on therapist methods to facilitate patient ER, including affect-focused, experiential methods that aim to enhance immediate patient emotion regulation, and structured psychoeducation, skills training in ER. Method: A total of 10 studies of immediate and intermediate outcomes of emotion regulation methods were examined. A total of 38 studies were included in the meta-analysis of distal treatment effects on emotion regulation. Results: In eight studies with 84 clients and 33 therapists, we found evidence of positive intermediate outcomes for affect-focused therapist methods and interpretations. A meta-analysis of 26 studies showed that the average effect size of ER methods from pre- to post-treatment was large (g = 0.82). Conclusions: Both affect-focused and structured skill training are associated with distal improvements in emotion regulation. When working with ER in psychotherapy, therapists must consider how patients' cultural backgrounds inform display rules, as well as what might be considered adaptive or maladaptive. The article concludes with training implications and therapeutic practices based on the research evidence.

Facilitating dyadic synchrony in psychotherapy sessions: Systematic review and meta-analysis.

Objective: This paper highlights the facilitation of dyadic synchrony as a core psychotherapist skill that occurs at the non-verbal level and underlies many other therapeutic methods. We define dyadic synchrony, differentiate it from similar constructs, and provide an excerpt illustrating dyadic synchrony in a psychotherapy session. Method: We then present a systematic review of 17 studies that have examined the associations between dyadic synchrony and psychotherapy outcomes. We also conduct a meta-analysis of 8 studies that examined whether there is more synchrony between clients and therapists than would be expected by chance. Results: Weighted box score analysis revealed that the overall association of synchrony and proximal as well as distal outcomes was neutral to mildly positive. The results of the meta-analysis indicated that real client-therapist dyad pairs exhibited synchronized behavioral patterns to a much greater extent than a sample of randomly paired people who did not actually speak. Conclusion: Our discussion revolves around how synchrony can be facilitated in a beneficial way, as well as situations in which it may not be beneficial. We conclude with training implications and therapeutic practices.

The alliance-outcome association in borderline and obsessive-compulsive personality disorder.

Personality disorders are considered a possible factor affecting the relationship between therapeutic alliance and therapy outcome. The present study investigated the alliance-outcome effect in patient groups with borderline personality disorder (BPD) and obsessive-compulsive personality disorder (OCPD). Data derived from a sample of n = 66 patients, treated in a day care hospital setting with a dialectical-behavioral and schema therapeutic treatment concept. Patients rated their symptom severity at admission, early alliance after 4-6 therapy sessions and symptom severity as well as alliance at discharge. Results showed no significant differences between BPD and OCPD patients regarding symptom severity and alliance. Multiple regression analyses indicated that the alliance was a significant predictor of symptom reduction, however only in the OCPD group. Our results showed an exceptionally strong alliance-outcome relationship in OCPD patients, suggesting that focusing on building a strong alliance and measuring it early in therapy may be especially beneficial for this patient group. For patients with BPD, a more regular screening of the therapeutic alliance might be helpful.

The art and science behind socratic questioning and guided discovery: a research review.

Socratic questioning is used to enhance the process of guided discovery in psychotherapy sessions. OBJECTIVE: Socratic questioning and guided discovery are defined, and assorted clinical examples are provided. METHODS: The limited research on the impact of Socratic questioning is reviewed and integrated with 30 + years of clinical experience. RESULTS: The scant research suggests that Socratic questioning significantly reduces depression from one session to the next, particularly for patients with a pessimistic cognitive bias, but there is no research on patient improvements at the end of psychotherapy. CONCLUSION: Socratic questions and guided discovery can facilitate sensitivity to issues related to diversity and can be useful in psychotherapy training. The Socratic approach relies on an integration of the research evidence, ancient philosophy, and contemporary cognitive therapy.

Session-to-session effects of therapist adherence and facilitative conditions on symptom change in CBT and IPT for depression.

OBJECTIVE: The objective of this study was to analyze the effect of adherence to both specific technique factors and facilitative condition variables (e.g., therapists' involvement, understanding and support) in Cognitive Behavior Therapy (CBT) and Interpersonal Psychotherapy (IPT). In addition, we were interested in whether the effect of therapist adherence would depend on the level of the working alliance. METHOD: Three sessions each from 74 patients diagnosed with Major Depressive Disorder who were randomized to 14 sessions of IPT or CBT were rated for adherence using a modified version of The Collaborative Study Psychotherapy Rating Scale-6 (CSPRS-6). Data was analyzed using Multilevel Modeling. RESULTS: No effects of adherence to specific factors on outcome were found in neither CBT nor IPT. Facilitative conditions were associated with better outcome in CBT but not in IPT, even after adjustment for the quality of the working alliance. No interaction effects were found. CONCLUSIONS: Our findings highlight the importance of relational factors in CBT, but do not support the need for specific adherence to any of the two treatments. Possible explanations of the findings and directions for future research are discussed.Trial registration: ClinicalTrials.gov identifier: NCT01851915.

The Effectiveness of 6 versus 12 Months of Dialectical Behavior Therapy for Borderline Personality Disorder: A Noninferiority Randomized Clinical Trial.

INTRODUCTION: Evidence-based psychotherapies for borderline personality disorder (BPD) are lengthy, posing a barrier to their access. Brief psychotherapy may achieve comparable outcomes to long-term psychotherapy for BPD. Evidence is needed regarding the comparative effectiveness of short- versus long-term psychotherapy for BPD. OBJECTIVE: The aim was to determine if 6 months of Dialectical Behavior Therapy (DBT) is noninferior to 12 months of DBT in terms of clinical effectiveness. METHODS: This two-arm, single-blinded, randomized controlled noninferiority trial with suicidal or self-harming patients with BPD was conducted at two sites in Canada. Participants (N = 240, M (SD)age = 28.27 (8.62), 79% females) were randomized to receive either 6 (DBT-6) or 12 months (DBT-12) of comprehensive DBT. Masked assessors obtained measures of clinical effectiveness at baseline and every 3 months, ending at month 24. DBT-6 and DBT-12 were outpatient treatments consisting of weekly individual therapy sessions, weekly DBT skills training group sessions, telephone consultation as needed, and weekly therapist consultation team meetings. RESULTS: The noninferiority hypothesis was supported for the primary outcome, total self-harm (6 months: margin = -1.94, Mdiff [95% CI] = 0.16 [-0.14, 0.46]; 12 months: margin = -1.47, Mdiff [95% CI] = 0.04 [-0.17, 0.23]; 24 months: margin = -1.25, Mdiff [95% CI] = 0.12 [-0.02, 0.36]). Results also supported noninferiority of DBT-6 for general psychopathology and coping skills at 24 months. Furthermore, DBT-6 participants showed more rapid reductions in BPD symptoms and general psychopathology. There were no between-group differences in dropout rates. CONCLUSIONS: The noninferiority of a briefer yet comprehensive treatment for BPD has potential to reduce barriers to treatment access.