Impact of Treatment Accessibility on Clinical Course of Parasuicidal Patients

To the Editor.— The December 1991ARCHIVESarticle by Linehan et al1represents a potentially important contribution to the treatment of parasuicidal patients with borderline personality disorder (BPD). Their experimental treatment—dialectical behavioral therapy (DBT)—yielded positive outcomes in comparison with the control group, who received "treatment as usual in the community." It is unclear, however, to what degree this differential outcome reflects the specific effects of the experimental treatment rather than other factors. Did patients pay for DBT? Although the authors credit the lower attrition rate in the experimental group to DBT, it could just as easily reflect economic factors limiting the frequency and intensity of outpatient treatment received by control patients. Often an experimental treatment is provided free or at a reduced fee. If this were the case it might confer a distinct advantage on patients receiving DBT. The parasuicidal patients with BPD in this study were severely and