Behaviour Research and Therapy 104 (2018) 44–50

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Behaviour Research and Therapy

journal homepage: www.elsevier.com/locate/brat

The unique contribution of acceptance without judgment in predicting T

nonsuicidal self-injury after 20-weeks of dialectical behaviour therapy group
skills training
Lillian H. Krantza, Shelley McMainb,c, Janice R. Kuoa,∗
a
Ryerson University, Department of Psychology, 350 Victoria Street, Toronto, Ontario, M5B 2K3, Canada
b
Centre for Addiction and Mental Health, Canada
c
University of Toronto, Department of Psychiatry, Canada

A R T I C LE I N FO A B S T R A C T

Keywords: The current research tested whether four dimensions of mindfulness – acceptance without judgment, observing,
Dialectical behaviour therapy describing and acting with awareness – predicted frequency of nonsuicidal self-injury (NSSI) and mediate the
Mindfulness relationship with NSSI outcomes during 20-weeks of Dialectical Behaviour Therapy (DBT) skills training for
Mechanisms borderline personality disorder (BPD). Eighty-four self-harming individuals with BPD were randomized to either
Nonsuicidal self-injury
DBT skills training or to a waitlist control group. A series of regressions revealed no relationship between di-
mensions of mindfulness and NSSI at baseline. There was a significant effect of DBT skills training on NSSI. As
well, mediation analysis indicated that acceptance without judgment, specifically, mediated the relation be-
tween DBT skills training and change in frequency of NSSI.

Borderline personality disorder (BPD) is a severe mental disorder
characterized by intense negative emotions coupled with difficulties
tolerating and regulating these emotions. These deficits in emotion
regulation contribute to a constellation of behavioural difficulties in-
cluding anger outbursts, nonsuicidal self-injury (NSSI), and persistent
feelings of emptiness (American Psychological American Psychiatric
Association, 2013; Linehan, 1993a). Among these behaviours, NSSI
poses a particularly significant risk to individuals with BPD. Up to 90%
of individuals with BPD engage in NSSI (Black, Blum, Pfohl, & Hale,
2004), and BPD is associated with impairment in everyday functioning,
increased risk of suicide attempts and a level of health-care utilization
that surpasses more prevalent disorders such as depression (Bender
et al., 2001; Hamza, Stewart, & Willoughby, 2012; Zanarini et al.,
2008). Thus, gaining a better understanding of NSSI in BPD can have a
significant health and economic impact.
Recently, Dialectical Behaviour Therapy group skills training (DBT-
ST) has been found to be effective for reducing suicidality (Linehan,
1993a). In DBT-ST, clients meet as a group on a weekly basis to learn
skills conceptualized to reduce suicidal behaviours: emotion regulation,
distress tolerance, mindfulness, and interpersonal effectiveness
(Linehan, 1993a). DBT-ST is associated with greater reductions in ir-
ritability, psychoticism, impulsivity, affective instability, and anger at
post-treatment compared to standard group therapy (Soler et al., 2009)
and greater reductions in suicidal behaviour, anger, distress tolerance
and emotion regulation at three month follow-up compared to a waitlist
condition receiving treatment as usual (McMain, Guimond, Barnhart,
Habinski, & Streiner, 2016). Furthermore, Linehan et al. (2015) re-
cently reported that individuals who received DBT-ST alone exhibited
greater improvements in NSSI than those who received individual DBT
without group skills training.
Numerous skills are taught in DBT-ST and little is known about
which “candidate” skills are primarily responsible for obtaining ther-
apeutic outcomes, particularly, reductions in NSSI. Mindfulness is a
natural place to begin dismantling the mechanisms of DBT-ST as it is
the first and the most fundamental skill taught in this treatment
(Linehan, 1993a). Existing definitions of mindfulness orbit around two
core processes: present-centred attention and a non-judgmental or-
ientation toward one's experience (Baer, 2011; Bishop et al., 2004;
Brown, Ryan, & Creswell, 2007; Kabat-Zinn, 2003; Farb, Anderson,
Irving; Segal, 2014; Williams, Teasedale, Segal, & Kabat-Zinn, 2007).
Indeed, in the most fundamental sense, mindfulness is an awareness of
one's present experience without judging or labelling this experience as
‘good’ or ‘bad’. Consistently, Jon Kabat-Zinn (2003) describes mind-
fulness as an “awareness that emerges through paying attention on
purpose, in the present moment, and nonjudgmentally to the unfolding of
experience moment by moment” (p. 145). Similarly, Bishop et al.

∗
Corresponding author.
E-mail addresses: lillian.krantz@psych.ryerson.ca (L.H. Krantz), shelley.mcmain@camh.ca (S. McMain), jkuo@psych.ryerson.ca (J.R. Kuo).

https://doi.org/10.1016/j.brat.2018.02.006
Received 26 September 2017; Received in revised form 23 February 2018; Accepted 23 February 2018
Available online 01 March 2018
0005-7967/ © 2018 Elsevier Ltd. All rights reserved.
L.H. Krantz et al.
(2004) identify two dimensions of mindfulness as the self-regulation of
attention to “immediate experience,” that is characterized by “curiosity,
openness and acceptance” (p. 232). Brown and Ryan (2003) describe
mindfulness as involving present-centred consciousness and a non-
judgmental or “nonconceptual, nondiscriminatory awareness” (p.
213–214). In the case of DBT- ST, Jon Kabat-Zinn’s (2003) definition of
mindfulness is adopted and broken down into four subskills that are
used to promote the cultivation of mindfulness. The three skills of ob-
serving one's current experience, describing one's current experience, and
acting with awareness align with the component of present-centred at-
tention and the skill of acceptance without judgment captures the mind-
fulness component of nonjudgment (Linehan, 1993a).
Mindfulness has been described as conceptually reciprocal to spe-
cific mechanisms that are theoretically and empirically linked to NSSI.
Indeed, theoretical models propose that NSSI functions as a form of
experiential avoidance, which involves an unwillingness to engage with
aspects of one's experience and attempts to alter its “form and fre-
quency” even when such avoidance is detrimental (Hayes, Wilson,
Gifford, Follette, & Strosahl, 1996). This claim is supported by evidence
suggesting that the intention to avoid or suppress aversive and un-
wanted internal experiences is the primary reason for engaging in NSSI
among student (e.g. Klonsky, 2009), community (e.g. Kamphuis,
Ruyling, & Reijntjes, 2007), correctional (e.g. Chapman & Dixon-
Gordon, 2007), inpatient psychiatric (e.g. Briere & Gil, 1998) and BPD
samples (Brown, Comtois & Linehan, 2002; Kleindienst et al., 2008;
Sadeh et al., 2014). Furthermore, experimental research suggests that
negative emotion decreases during or following NSSI in both self-report
and physiological indices (e.g. heart rate and skin conductance; Brain,
Haines, & Williams, 1998; Welch, Linehan, Sylvers, Chittams, & Rizvi,
2008; Reitz et al., 2012). Hence, theory and data suggest that the desire
to escape one's present experience plays a central role in maintaining
NSSI and that, mindfulness deficits may contribute to the avoidant
processes that lead to NSSI. Consistently, mindfulness deficits have
been linked to BPD and NSSI (Baer, Smith, & Allen, 2004; Nicastro,
Jermann, Bondolfi, & McQuillan, 2010; Wupperman, Fickling,
Klemanski, Berking, & Whitman, 2013; Wupperman, Neumann, &
Axelrod, 2008; Wupperman, Neumann, Whitman, & Axelrod, 2009).
Moreover, mindfulness has been found to increase over the course of
DBT (Nicastro et al., 2010; Perroud, Nicastro, Jermann, & Huguelet,
2012) and mediate the treatment effect of DBT-ST on NSSI (McMain,
Boritz, & Barnhart, 2016).
While theory and research support mindfulness as a likely me-
chanism of change in DBT, as reviewed above, mindfulness is a multi-
dimensional construct and its components appear to have unique re-
lationships with BPD severity. Studies examining mindfulness have
found that describing, acting with awareness, and acceptance without
judgment (i.e. nonjudgment) are significantly lower in BPD compared to
student and community samples (Baer et al., 2004; Nicastro et al.,
2010). However, observing does not significantly differ between BPD,
student, and community samples, and has been found to either have no
correlation or a negative correlation with indices of psychological
functioning in these samples (Baer, Smith, Hopkins, Krietemeyer, &
Toney, 2006; Baer et al., 2004; Nicastro et al., 2010). Notably, the skill
of acceptance without judgment may be the most pronounced deficit
among individuals with BPD, with mean scores on this skill being the
lowest of the four skills and differing most from student and community
samples (Baer et al., 2004; Nicastro et al., 2010). Consistently, Perroud
et al. (2012) found that, when controlling for confounds such as de-
pression and hopelessness, only the acceptance without judgment facet of
mindfulness increased and was associated with improvements in BPD
severity during an intensive 4-week version of DBT as well as during a
course of subsequent comprehensive DBT. Although these findings were
not significant after correcting for multiple tests, Perroud et al. (2012)
suggests that acceptance without judgment may have a unique relation-
ship with BPD pathology.
The relationship between acceptance without judgment, BPD and NSSI
45
Behaviour Research and Therapy 104 (2018) 44–50
fits previous theory and research in a number of ways. The tendency to
judge the self and experience oneself as flawed (i.e. to experience
shame) is linked to NSSI (Hastings, Northman, & Tangney, 2000;
Kleindienst et al., 2008; Schoenleber, Berenbaum, & Motl, 2014;
Tangney & Dearing, 2002) as well as increased likelihood of engaging
in NSSI among individuals with BPD (Brown, Linehan, Comtois,
Murray, & Chapman, 2009). In addition, individuals with BPD have
been found to use NSSI to punish the self (Rosenthal, Cukrowicz,
Cheavens, & Lynch, 2006) and are more likely to use NSSI for self-
punishment than self-harming individuals without BPD (Bracken-Minor
& McDevitt-Murphy, 2014). Hence, the central function of NSSI as a
form of punishment in BPD further underscores the likely role of failing
to accept one's self and one's experience without judgment in the
etiology of NSSI. The limited research aiming to delineate the specific
relationships between acceptance without judgment, BPD, and NSSI is a
notable gap in the literature.
Indeed, research has been limited to the effect of general mind-
fulness on NSSI outcomes during DBT-ST (McMain et al., 2016) and no
study has specifically looked at whether acceptance without judgment
might account for reductions in NSSI. Using data from a larger RCT
(McMain, Guimond, Barnhart, Habinski, & Streiner, 2017), the current
research was a secondary analysis intended to address the gaps in the
extant literature by examining 1) the relationship between different
dimensions of mindfulness (observing, describing, acting with awareness
and acceptance without judgment) and NSSI in a sample of suicidal in-
dividuals with a diagnosis of BPD and 2) whether changes in specific
dimensions of mindfulness account for changes in NSSI after 20-weeks
of DBT-ST among suicidal individuals with BPD. We hypothesized that
1) acceptance without judgment will predict the frequency of NSSI while
the other three components of mindfulness will not be significant pre-
dictors of NSSI and 2) acceptance without judgment will mediate reduc-
tions in the frequency of NSSI over the course of DBT-ST while the other
three components of mindfulness will not mediate outcomes. Further-
more, we hypothesize that the aforementioned effects exist in-
dependently of the effect of BPD severity and severity of major de-
pressive disorder (MDD), both of which are known to increase the
likelihood of engagement in NSSI.
1. Method
1.1. Participants
Participants were 84 individuals with BPD enrolled in a large two-
arm randomized-clinical trial (RCT) intended to evaluate the effec-
tiveness of a 20-week DBT skills training group at the Centre for
Addictions and Mental Health (CAMH) in Toronto, described in
McMain et al. (2017). A full description of the participants, design, and
procedures in the trial can be found in McMain et al. (2017). Partici-
pants were required to meet the following criteria: (a) a full BPD di-
agnosis according to the Diagnostic and Statistical Manual Version IV
(DSM IV), (b) engagement in a minimum of two prior incidents of self-
injury, suicidal or nonsuicidal, in the last 5 years, one of which must
have occurred in the 10 weeks prior to screening (c) age 18–60, and (d)
English proficiency. Participants were excluded if they presented with
(a) DSM IV psychotic disorders, bipolar disorder I and dementia or (b)
an organic brain disorder or mental retardation. Participants who had
received DBT skills group treatment in the past six months were also
excluded, however, all participants were permitted to continue with
other treatment-as-usual (TAU) such as doctors’ visits, pharmacological
treatment and other co-occurring therapies other than DBT.
1.2. Measures
1.2.1. Screening measures
BPD was diagnosed using the International Personality Disorder Exam
– BPD Module (IPDE-BPD; Loranger, 1995). High inter-rater reliability
L.H. Krantz et al.
was observed for the number of BPD symptoms on the IPDE (intra-class
correlation coefficient = 0.97). The presence of DSM IV Axis I disorders
was assessed using the Structured Clinical Interview for the Diagnostic and
Statistical Manual-IV, Axis I, Patient Version (SCID-I; First, Spitzer,
Gibbon, & Williams, 2002). NSSI was evaluated using The Lifetime
Suicide Attempt Self-Injury Interview (L-SASII; previously Lifetime
Parasuicide Count; Linehan & Comtois, 1996), an interview-based as-
sessment that evaluates the frequency and severity of suicidal and
nonsuicidal self-injury. The L-SASII was administered at baseline to
assess the total frequency of NSSI over the lifespan. The L-SASII is a
lifetime version of the Suicide Attempt Self-Injury Interview (SASII),
which has good interrater reliability (.85-.93; Linehan, Comtois, Brown,
Heard, & Wagner, 2006a) and has been used in numerous treatment
trials to assess NSSI (e.g. McMain et al., 2009). The L-SASII and diag-
nostic assessments were conducted by assessors who were masked to
participants’ assignment to treatment.
1.2.2. Outcome measures
A modified L-SASII (L-SASII; previously Lifetime Parasuicide Count;
Linehan & Comtois, 1996) that focused on the prior 10 weeks (rather
than the full lifespan) was used to monitor changes in NSSI over the
course of the trial. Detailed information was obtained regarding total
frequency and method of NSSI and of medical treatment over the pre-
vious 10 week period.
The Kentucky Inventory of Mindfulness Skills was used to assess four
dimensions of mindfulness (KIMS; Baer et al., 2004): (1) Observing in-
ternal and external stimuli, (2) Describing or applying words to stimuli
in a nonjudgmental way, (3) Acting with awareness by being fully im-
mersed in one's current activity, (4) Accepting without judgment by al-
lowing one's experience to be just as it is rather than attempting to
change or escape it. Scores on each subscale are used to determine
deficits in specific areas of mindfulness or total scores can provide a
general assessment of mindfulness skills; however, psychometric testing
suggests that the KIMS does not reflect a single underlying dimension
and that it may be best to use subscale scores (Coffey, Hartman, &
Fredrickson, 2010). In BPD samples, the KIMS demonstrates good test-
retest reliability over a two week period, demonstrates sensitivity to
change over four weeks of DBT (Nicastro et al., 2010) and the KIMS
subscales had acceptable to good internal consistency in the current
study at baseline (Observe = .91; Describe = .92; Acting with Aware-
ness = .74; Acceptance without Judgment = .85).
1.2.3. Potential covariates
The Borderline Symptom List-23 (BSL-23; Bohus et al., 2009) and
Beck Depression Inventory-II (BDI-II; Beck, Steer, & Brown, 1996) were
included as measures of borderline symptoms severity and depression
severity, respectively, to ensure that clinical variables linked to NSSI
were properly randomized. Both measures had very high internal
consistency in the current study (BDI = .93 and BSL = .92).
1.3. Procedure
Participants in the parent study provided informed consent before
entering the trial and were then randomly assigned to DBT-ST plus TAU
or waiting list plus TAU. No additional consent was required for the use
of data from the parent study for this secondary analysis. Prior to
commencing DBT-ST, each participant attended a 90 min individual
orientation session. Participants then engaged in the 20-week DBT-ST
program which was an abridged version of the original 12 month
treatment outlined in the DBT manual (Linehan, 1993a). DBT-ST cov-
ered all the core treatment modules of the original 12 month manual
(i.e., mindfulness, emotion regulation, distress tolerance, interpersonal
effectiveness), with an added dialectics module (Miller, Rathus, &
Linehan, 2006). Each of these five modules were taught over four
consecutive weeks except for mindfulness, which was taught as a single
session at the beginning of each of the other modules.
46
Behaviour Research and Therapy 104 (2018) 44–50
Each DBT-ST group was led by two group leaders. There were a total
of five therapists in the study and each had a minimum of 5 years of
experience with DBT and had participated in DBT training workshops.
To ensure treatment fidelity, ad hoc and regular weekly supervision
were provided to therapists by the principal investigator of the parent
study, a clinical psychologist with extensive clinical and research ex-
perience with DBT. Treatment fidelity was also evaluated using the DBT
Global Rating Scale (Linehan, 1993b). The parent study found an
average adherence rating of 4.44 (McMain et al., 2017, which is above
the adherence cut-off of 4.0.
1.4. Data analysis
Hypothesis 1. The hypothesis that accepting without judgment would be
the only mindfulness component to account for variance in NSSI at
baseline was tested using a series of regression models. Total scores for
each of the KIMS subscales were simultaneously entered as predictors of
the total number of incidents of NSSI on the L-SASII at baseline. A
negative binomial distribution was modeled to account for the over
dispersion in the count outcome for total NSSI (Cameron & Trivedi,
2013).
Hypothesis 2. The hypothesis that accepting without judgment would be
the only mindfulness component to have an indirect effect on changes
in the frequency of NSSI over 20 weeks of DBT was tested using
contemporary mediation procedures (Hayes & Rockwood, 2016; Hayes,
2009). The significance of the indirect effects of treatment condition on
NSSI through each mindfulness subscale was assessed by drawing 5000
bootstrap samples and examining the 95% bias corrected confidence
intervals (Fritz & MacKinnon, 2007). Bias corrected bootstrapping is a
nonparametric resampling method that has been shown to have the
most power to detect a significant mediating effect. Bootstrapping
analyses generate point estimates and 95% confidence intervals
between which the true coefficient of the indirect effect is believed to
lie. The point estimates of the indirect effects were considered
significant if the confidence interval does not contain zero (Hayes &
Rockwood, 2016; Hayes, 2009).
Estimates of the total and direct effects were obtained. An estimate
of the total effect (i.e. the combined direct and indirect effect) of
treatment condition (i.e. DBT-ST versus waitlist) on NSSI at the end of
20 weeks of treatment was obtained using a generalized linear model
with treatment as the predictor. An estimate of the effect of treatment
condition on change in each mindfulness subscale from pre to post-
treatment was obtained using a linear regression model. A negative
binomial regression model (due to the over-dispersed nature of this
count outcome; Cameron & Trivedi, 2013) predicting NSSI from both
treatment condition and the mindfulness subscale (i.e. mediator) was
also estimated. Each mindfulness scale was used as the dependent
variable in separate mediation analyses. All analyses were conducted
using R 3.0.1.
Missing Data. Due to the limited sample size, an imputation
method was used. Participants with missing NSSI at the end of treat-
ment had their NSSI scores at the 10 week mark imputed for the out-
come (i.e., their 10 week KIMS scores were used to estimate the KIMS
change scores).
2. Results
2.1. Descriptive statistics
The majority of the sample was female (78.6%) with an average age
of 29.67 (SD = 8.62). Most participants had never been married
(72.6%) and the remaining participants were separated, divorced or
widowed (14.29%) and married or common law (13.1%). In terms of
education, 5% had less than a high school education, 9.5% graduated
high school, 34.5% had some college or technical school, and 50% had
L.H. Krantz et al. Behaviour Research and Therapy 104 (2018) 44–50

Table 1 Table 2
Tests of differences in participant demographics by condition. Diagnostic comorbidities as totals and percentages.

Demographic Waitlist DBT p Diagnosis DBT WL Full Sample p

N 42 42 Major depressive disorder

Age 32.05 ( ± 9.06) 27.29 ( ± 7.45) 0.01* Lifetime 18 (42.86) 17 (40.48) 35 (41.67) 0.83
Sex 0.43 Current 23 (54.76) 20 (47.62) 43 (51.19) 0.51
Male 11 (26.19%) 7 (16.67%) Panic disorder
Female 31 (73.80%) 35 (83.33%) Lifetime 2 (4.76) 3 (7.14) 5 (5.95) 0.65
Education 0.44 Current 4 (9.52) 8 (19.05) 12 (14.29) 0.21
Less Than High School 1 (2.38%) 4 (9.52%) Post-traumatic stress disorder
High School 3 (7.14%) 5 (11.90%) Lifetime 5 (11.90) 6 (14.29) 11 (13.10) 0.75
Some College or 17 (40.48%) 13 (30.95%) Current 8 (19.05) 11 (26.19) 19 (22.62) 0.43
University Any anxiety disorder
> = College degree 21 (50.00%) 20 (47.62%) Lifetime 23 (54.76) 24 (57.14) 47 (55.95) 0.83
Employment 0.40 Current 21 (50.00) 30 (71.43) 51 (60.71) 0.04
Unemployed 10 (23.80%) 10 (23.80%) Substance abuse
On Public Assistance/ 11 (26.19%) 13 (30.95%) Lifetime 4 (9.52) 2 (4.76) 6 (7.14) 0.40
Disabled Current 7 (16.67) 4 (9.52) 11 (13.10) 0.33
Student 3 (7.14%) 8 (19.05%) Substance dependence
Part-Time Employed 4 (9.52%) 2 (4.76%) Lifetime 11 (26.19) 13 (30.95) 24 (28.57) 0.63
Full-Time Employed 14 (33.33%) 9 (21.43%) Current 24 (57.14) 23 (54.76) 47 (55.95) 0.83
Marital status 0.18 Any eating disorder
Single/Divorced/ 30 (71.46%) 36 (85.71%) Lifetime 2 (4.76) 3 (7.14) 5 (5.95) 0.65
Widowed Current 5 (11.90) 8 (19.05) 13 (15.48) 0.37
(Re)Married/ 12 (28.55%) 6 (14.28%)
Separated Note. DBT = dialectical behaviour therapy, WL = waitlist.
Children 0.58
0 33 (78.57%) 36 (85.71%)
> =1 9 (21.43%) 6 (14.28%) Table 3
Income 12,600$ [626; 33,750] 10,500$ [5; 29,500] 0.28 Bivariate correlations for key study variables.
BDI-II 36.70 ( ± 11.46) 32.68 ( ± 10.95) 0.04*
1 2 3 4 5 6 7
BSL-23 58.75 ( ± 19.64) 56.35 ( ± 16.51) 0.37
KIMS 105.42 ( ± 15.51) 101.46 ( ± 19.21) 0.45
1. KIMS Obs 1.00 – – – – – –
NSSI 10.00 [2.00; 20.00] 5.00 [3.00; 18.00] 0.90
2. KIMS Des .38∗∗ 1.00 – – – – –
SA 0.00 [0.00; 1.00] 0.00 [0.00; 1.00] 0.75
3. KIMS AA -.10 .26∗ 1.00 – – – –
4. KIMS NJ -.11 -.25∗ -.17 1.00 – – –
Note. WL = Waitlist, DBT = Dialectical Behaviour Therapy Skills Training, BDI = Beck
5. BSL -.00 -.17 -.27∗ .52∗∗∗ 1.00 – –
Depression Inventory II, BSL-23 = Borderline Symptom List 23, KIMS = Kentucky
6. BDI -.13 -.11 -.23∗ .41∗∗∗ .66∗∗∗ 1.00 –
Inventory of Mindfulness Skills, NSSI = Nonsuicidal Self-Injury and SA = Suicide 7. NSSI .09 .19 .10 -.13 .01 -.06 1.00
Attempts. Variables represented as mean ( ± standard deviations), median [IQR], or
frequencies (percentages). *p < .01. ∗
p < .05, ∗∗p < .01, ∗∗∗p < .001.
Note. KIMS = Kentucky Inventory of Mindfulness Skills, Obs = Observe, Des = Describe,
graduated college or university. With respect to employment, 23.8% AA = Acting with Awareness, NJ = Nonjudgment, BSL-23 = Borderline Symptom List
were unemployed, 27.4% worked full-time, 7.1% worked part-time, 23, BDI = Beck Depression Inventory II, and NSSI = Nonsuicidal Self-Injury.
13.1% were full-time students, 11.9% were disabled, and 16.7% were
receiving public assistance. Consistently, 39.3% made less than $15,000 weeks). Median imputation of NSSI at the end of treatment was used for
per year, 9.5% made between $15,000 and $29,000, 13.1% made be- 6 participants without 10-week KIMS scores. There was a linear
tween $30,000 and $49,000, and 20.2% provided no answer. On downward trend from baseline to the end of treatment hence the 10
average, participants reported 2.25 (SD = 0.20) co-morbid current week scores provided a conservative estimate of the treatment effect.
DSM-IV Axis I disorders and 2.81 (SD = 0.21) lifetime DSM-IV Axis I
disorders. The mean number of lifetime suicide attempts was 61.1 2.2.1. Tests of hypothesis 1: acceptance without judgment will predict the
(SD = 491). frequency of NSSI while the other mindfulness dimensions will not
Significance tests for between group differences (by treatment In contrast to our hypothesis, at baseline, none of the KIMS subscales
condition) were calculated for all demographic, diagnostic, and base- were significantly associated with NSSI: describe (β = −0.01,
line measurements and can be found in Tables 1and2. Bivariate corre- z = −0.58, p = 0.56), acting with awareness (β = −0.05, β = −1.23,
lations between all key variables in the study are reported in Table 3. p = 0.22), acceptance without judgment (β = 0.02, z = 0.66, p = 0.51)
Between treatment group differences were examined with the use of and observe (β = 0.01, z = 0.81, p = 0.42).
independent samples t-tests for continuous variables (age and income)
and chi-square tests for categorical variables (sex, education, employ-
2.2.2. Tests of hypothesis 2: acceptance without judgment will uniquely
ment status, marital status, number of children). No significant differ-
mediate reductions in the frequency of NSSI over the course of DBT-ST
ences between the groups were found at baseline for demographic
See Fig. 1. A significant total effect of treatment condition on NSSI
variables, with the exception of age (Waitlist: M=32, SD=9.15; DBT:
was found (β = −1.22, z = 2.21 p = 0.04); patients in DBT-ST had
M=27.3, SD=7.52; p = 0.01). Because BDI and age differed between
lower rates of NSSI at post-treatment compared to individuals on the
the treatment conditions at baseline, these variables were included as
waitlist. DBT-ST was significantly associated with greater change in
covariates in each analysis. The BSL did not differ between conditions
acceptance without judgment from pre-post treatment compared to the
at baseline and was not included as a covariate (see Table 1).
waitlist condition (β = 3.83, t = 2.28, p = 0.03) and an increase in
KIMS acceptance without judgment change scores was associated with a
2.2. Missing data decrease in NSSI at the end of treatment while controlling for treatment
condition (β = −.10, z = −3.50, p < 0.001). Bias corrected bootstrap
Out of 84 participants, the NSSI and the KIMS subscales contained results for the indirect effects of treatment condition on NSSI through
between 10 and 16 missing data points at the end of treatment (i.e. 20 acceptance without judgment was significant (Indirect effect = −12.85,

47
L.H. Krantz et al.
Figure 1. Model illustrating the indirect effect of change in acceptance without judgment
on the relationship between Treatment Condition and NSSI. Acceptance without judg-
ment was measured using the scores on the Accepting without Judgment subscale of the
Kentucky Inventory of Mindfulness Skills. Treatment Condition = 20-weeks of DBT
versus 20-weeks ofWaitlist; NSSI=frequency of non-suicidal self-injury; β= beta coeffi-
cient, 95% CI= 95% bias corrected confidence intervals.
95% CI= (−51.27, −0.45)) and mediated 63.3% of the total effect of
treatment condition on NSSI. None of the other KIMS subscale change
scores had significant associations with treatment: observe (β = 1.70,
t = 0.97, p = 0.33), acting with awareness (β = 2.07, t = 1.69, p = 0.10)
and describe subscales (β = 0.54, t = 0.52, p = 0.61). When controlling
for treatment, the effect of change in observe (β = 0.0004, z = 0.01,
p = 0.99), acting with awareness (β = −0.01, z = −0.31, p = 0.75) and
describe subscale (β = 0.05, z = 0.05, p = 0.32) on NSSI was non-sig-
nificant, as were the indirect effects of change in KIMS observe (Indirect
effect = −0.09, 95% CI= (−6.96, 6.11)), acting with awareness (In-
direct effect = −0.35, 95% CI= (−11.43, 11.95)) and describe sub-
scale (Indirect effect = 1.84, 95% CI= (−2.54, 10.43)).
3. Discussion
The present study was the first to directly test the relationship be-
tween four distinct mindfulness dimensions (observe, describe, acting
with awareness, and acceptance without judgment) and frequency of NSSI
among individuals with a diagnosis of BPD at baseline and over the
course of 20-weeks of DBT skills training.
3.1. Baseline mindfulness and NSSI
We did not find support for the hypothesis that acceptance without
judgment would be the only facet of mindfulness to predict the fre-
quency of NSSI prior to commencing treatment. At baseline, we found
no relationship between acceptance without judgment or any facets of
mindfulness and NSSI. The conflict between our findings and the extant
literature might be attributable to our study sample. Indeed, whereas all
participants in the current study were required to meet full criteria for
BPD and have engaged in recurrent and recent suicidal or nonsuicidal
self-injury, previous studies (e.g., Wupperman et al., 2008, 2009, 2013)
reporting cross-sectional relationships between mindfulness, BPD
symptoms, and NSSI used student and psychiatric samples with “BPD
features” that were not required to have a diagnosis of BPD. Thus, the
conflicting findings between the current study and previous research
might be explained by conceptual differences between “BPD features,”
that only reflect a general propensity for impulsive and self-destructive
behaviour, and a full BPD diagnosis with recent self-injurious beha-
viour. A second distinction between previous studies (i.e., Wupperman
et al., 2008, 2009, 2013) and ours arises in potential functional dif-
ferences in NSSI between BPD versus non-BPD samples. Indeed, re-
search suggests that “BPD features” - such as NSSI- within non-BPD
samples present differently than samples with a BPD diagnosis. For
example, Bracken-Minor and McDevitt-Murphy (2014) compared NSSI
among individuals that did and did not meet screening criteria for BPD.
Although they found no difference in number of lifetime incidents of
NSSI or methods of NSSI between the groups, individuals with BPD
more frequently endorsed a greater number and range of functions for
48
Behaviour Research and Therapy 104 (2018) 44–50
NSSI while affect regulation was the predominant function for those in
the non-BPD group, leaving other functions scarcely endorsed; in-
dividuals who met BPD screening criteria were significantly more likely
to report using NSSI to punish themselves, prevent suicide, and prevent
dissociation. Indeed, it is possible that, previous studies examining BPD
features in student and non-BPD psychiatric samples are measuring
distinct phenomena from those that occur among individuals with BPD.
The null baseline findings might also be explained by research
suggesting that mindfulness skills have inconsistent and counter-theo-
retical associations with adaptive functioning among inexperienced
meditators. Baer et al. (2008) compared outcomes of experienced
meditators with three samples of non-meditators (i.e., students, com-
munity members, and a sample matched to the meditators on demo-
graphic variables) on the Brief Symptom Inventory (BSI). The in-
vestigators found that mindfulness was either related to increased
symptoms or had no relationship with symptom severity among non-
meditators, but was negatively correlated with symptoms among ex-
perienced meditators. This variation in findings might be explained by
the fact that understanding and being trained in mindfulness skills
might cause experienced meditators to answer the questions on mind-
fulness self-report measures with more accuracy and insight into their
behaviour than inexperienced meditators (Baer et al., 2006, 2008). For
example, an experienced meditator might have a different interpreta-
tion of KIMS items (e.g. “I pay attention to sounds, such as clocks
ticking, birds chirping, or cars passing”) than a non-experienced med-
itator. KIMS items reflect specific skills that are coached in DBT
mindfulness training and it is conceivable that a non-meditator would
be more likely to have these experiences with negative implications
(e.g. hypervigilance). Thus, extant research suggests that the lack of
meditation experience or mindfulness could moderate the benefits of
mindfulness skills. While there is no precise information about prior
meditation or mindfulness experience of our sample, it may be that our
sample was more inexperienced in mindfulness and thus made different
interpretations or had different experiences of the skills measured by
the KIMS, leading to a lack of association between mindfulness and
NSSI at baseline.
3.2. Change in acceptance without judgment accounts for the effect of DBT-
ST
The hypothesis that treatment would predict reductions in NSSI
indirectly via increases in acceptance without judgment was supported. As
expected, we found that acceptance without judgment had the only sig-
nificant indirect effect of the four mindfulness facets. This is consistent
with Perroud et al. (2012) findings that acceptance without judgment was
the only facet of mindfulness that significantly increased over the
course of DBT and that this increase was accompanied by decreases in
BPD severity. Taken together, acceptance without judgment seems to have
a unique and positive effect on both NSSI and BPD severity.
The positive impact of increasing acceptance without judgment on
BPD and NSSI is consistent with research suggesting that NSSI is a
method of regulating emotions and avoiding aversive experiences
(Brown et al., 2002; Chapman, Gratz, & Brown, 2006). As mentioned,
experiential avoidance requires a judgment that one's experience is
good or bad followed by taking action to escape that experience. Ac-
ceptance without judgment, thus, theoretically counteracts both com-
ponents of this process such that one's experience is not categorized as a
good experience to be accepted or a bad experience to be avoided.
Rather, all experiences are experienced just “as they are” and accepted
rather than escaped through behaviours such as NSSI.
In addition, the positive impact of increasing acceptance without
judgment on BPD and NSSI is consistent with research suggesting that
shame and self-deprecation are core mechanisms leading to the devel-
opment of NSSI (Crowe, 2004; Gratz, Rosenthal, Tull, Lejuez, &
Gunderson, 2010; Rüsch et al., 2007; Scheel et al., 2013). Indeed,
theorists believe that shame-proneness develops from judgments that
L.H. Krantz et al.
something is wrong with the self (Dearing & Tangney, 2011) and in-
dividuals are believed to seek relief from these aversive experiences of
the self through NSSI (Hastings et al., 2000; Kleindienst et al., 2008;
Schoenleber et al., 2014; Tangney & Dearing, 2002). The adoption of
acceptance without judgment to one's experience of the self may reduce
shame and self-deprecation and, in turn, frequency of NSSI.
3.3. Limitations and implications for practice and research
The current study had a number of limitations. First, this study was
not powered for mediation analyses, which may affect the reliability
and validity of our findings. Second, participants were permitted to
continue with external treatments other than DBT, which may have
included anything from anti-depressant treatment to non-DBT group or
individual therapy, and we were unable to control for these effects.
Third, our 20-week intervention is significantly shorter than traditional
DBT and there may not have been sufficient time for the full effects of
DBT-ST to emerge. Finally, given the known differences between in-
experienced and experienced meditators, future studies that measure
and control for participants’ meditation and mindfulness experience
prior to and during treatment are needed.
The most striking implication of this study is the elucidation of
acceptance without judgment as a specific mechanism that can account
for NSSI, thus, providing a basis for generating more targeted inter-
ventions. Indeed, this research suggests that, of the different facets of
mindfulness, strengthening acceptance without judgment skills might be
the most “efficient” route for targeting NSSI in DBT. Specifically, cur-
rent DBT mindfulness modules might be streamlined by focusing on
acceptance without judgment skills and related modules, such as com-
passion and loving-kindness (Linehan, 2014). Still, a number of un-
answered questions remain about the impact of acceptance without
judgment on NSSI which should be examined in future research. In
service of streamlining DBT, one future objective could be to determine
whether offering acceptance without judgment skills in the absence of the
other mindfulness modules would yield similar reductions in NSSI than
interventions with all mindfulness modules. Relatedly, larger studies
that have sufficient power to examine treatment trajectories can help to
determine when and how improvements in mindfulness and NSSI
emerge and plateau, which can provide a basis for identifying an ap-
propriate length of DBT-ST. As well, this study only examined fre-
quency of NSSI and the relationship between mindfulness and other
dimensions of NSSI such as severity or level of intent to die should be
investigated. Similarly, many of the other BPD criteria beyond NSSI are
rooted in experiential avoidance (Crowe, 2004; Iverson, Follette,
Pistorello, & Fruzzetti, 2012; Kuo & Linehan, 2009) and the effect of
acceptance without judgment can also be explored in relation to other
criteria (e.g., intense anger) in order to strengthen the basis for
streamlining DBT to emphasize acceptance without judgment skills.
While much remains to be examined, the current study suggests that
individuals with BPD can reduce habitual judgments of their experience
and, consequently, their engagement in NSSI. The findings provide
encouraging support that a streamlined treatment that focuses on ac-
ceptance without judgment could benefit individuals with BPD.
Funding
This work was supported by the Ontario Mental Health Foundation
[NCT01193205 08/31, 2010].
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