International Journal of Psychiatry in Clinical Practice, 2012; 16: 189–196

ORIGINAL ARTICLE

Mindfulness skills in borderline personality disorder patients during

dialectical behavior therapy: Preliminary results

NADER PERROUD, ROSETTA NICASTRO, FRANÇOISE JERMANN &

PHILIPPE HUGUELET

Department of Psychiatry and Mental Health, University Hospitals of Geneva, Geneva, Switzerland

Abstract
Objective. One of the components of dialectical behavior therapy (DBT) is the use of mindfulness skills as a core component
of treatment for subjects with borderline personality disorder (BPD). In this study, we investigated changes in and correlates
of mindfulness skills over a 1-year follow-up including a 4-week session of intensive DBT followed by 10 months of stand-
ard DBT. Methods. Fifty-two BPD subjects were assessed several times using the Kentucky Inventory of Mindfulness Skills
(KIMS) which describes mindfulness in four discrete dimensions: observing (Obs), describing (Des), acting with awareness
(AwA) and accepting without judgment (AwJ). Results. AwJ was the only dimension that increased significantly over time
after adjustment for potential confounding factors (β ⫽ 0.24; P ⫽ 0.0002). Increases in AwJ correlated with improvement
in BPD symptoms. Conclusions. This study highlights the usefulness of investigating changes in mindfulness dimensions
during DBT. AwJ is a possible mechanism for positive change. Encouraging this skill should lead to a more adaptive
response to problematic situations and counteract impulsive and problematic behaviors. The lack of specific control groups
means that these findings are preliminary and replication is required.

Key Words: Borderline, mindfulness, dialectical behavior therapy, psychotherapy

Objective
Borderline personality disorder (BPD) is charac-
terized by marked instability in affects, disturbed
interpersonal relationships and unstable self-identity.
It includes lack of emotional control and harmful
impulsivity such as suicide attempts and/or self-
destructive behaviors. It is often comorbid with
other psychiatric disorders and is associated with
severe functional impairment and high utilization of
healthcare [1–3].
Among the theoretical frameworks proposed for
BPD, poor mindfulness skills have been advanced as
a potential core phenomenon underlying this com-
plex disorder [4]. Mindfulness has been defined in
many ways, but perhaps one of the most commonly
used definitions comes from Jon Kabat-Zinn, who
defines mindfulness as “paying attention in a par-
ticular way: on purpose, in the present moment, and
non-judgmentally” [5]. It has been shown that com-
pared to the community sample, individuals suffering
from BPD have poor mindfulness skills [6]. These
deficits may be linked to the emotional dysregula-
tion, difficulties in interpersonal relationships and
harmful behaviors which are the main characteristics
of BPD [4,7–9].
Mindfulness meditation, as used in dialectical
behavior therapy (DBT) [3], is a concept derived
from Eastern meditation practice. Mindfulness train-
ing is a central component of DBT. One of the char-
acteristics of DBT is the teaching of mindfulness as
a skill in its own right supporting the other skills
taught in group and individual sessions [3].
In DBT, mindfulness is described as three differ-
ent but correlated skills (Observing, Describing and
Participating) which should be applied in three ways
(non-judgmentally, one-mindfully and effectively). The
first skill, Observing, is direct perception of experi-
ences, without the addition of concepts or categories.
Describing involves adding a descriptive label to what
is observed. Participating refers to entering fully and

Correspondence: Nader Perroud, Department of Psychiatry, Division of General Psychiatry, University Hospital of Geneva and University of Geneva, Rue
du 31-Décembre 8, 1207 Geneva, Switzerland. Tel: ⫹41 22 305 4511. Fax: ⫹41 22 305 4599. E-mail: nader.perroud@hcuge.ch

(Received 12 May 2011; accepted 7 March 2012 )

ISSN 1365-1501 print/ISSN 1471-1788 online © 2012 Informa Healthcare
DOI: 10.3109/13651501.2012.674531
190 N. Perroud et al.
completely into an experience. Non-judgmentally
involves letting go of all judgments, including both
good and bad judgments, about self and others. One-
mindfully means attending to one thing at a time and
finally effectively asks clients to practice giving up
being “right” in favor of doing “what works”. These
skills teach patients to observe non-judgmentally, to
bring their full attention to current experience but
also to accept the current situation as it is. It is pri-
marily related to the quality of awareness that an
individual contributes to his/her present experience
and his/her ability to enter into and participate in this
experience without labeling it as good or bad [3]. As
proposed by Linehan [3], the practice of mindfulness
will ultimately help patients to overcome their diffi-
culties by reducing their attempts to control their
private experience, empower them to deal with emo-
tionally distressing periods and increase individuals’
ability to experience and tolerate the current moment
while helping them to avoid becoming over-involved
in the experience (through rumination for example).
Mainly inspired by DBT, the practice of mindfulness
was later conceptualized into four discrete behavioral
skills: observing (Obs), describing (Des), acting with
awareness (AwA) and accepting without judgment
(AwJ). This conceptualization has empirical support
[10] mainly through the utilization of internationally
accepted scales such as the Kentucky Inventory of
Mindfulness Skills (KIMS) [6].
Studies investigating the effect of DBT indicate
that mindfulness skills increase significantly over
time and that this improvement could be correlated
with improvement in overall BPD symptoms [11].
Similar results were also recently observed for inten-
sive DBT (I-DBT) [6]. Despite the observation that
individual mindfulness-related skills increase dur-
ing DBT, the clinical and demographic correlates
of these changes are still poorly understood.
We therefore investigated changes in the four
discrete behavioral skills of mindfulness and their
impact on BPD symptoms during a one-year DBT
treatment which included a 4-week I-DBT and the
four standard DBT modules. We expected to see an
increase in the four mindfulness dimensions but
with less marked improvement during I-DBT than
standard DBT.
Methods
Participants
Fifty-four outpatients who recently had contact with
psychiatric or medical services for suicidal or para-
suicidal behaviors, severe impulse control disorders,
anger problems, or who had experienced multiple
therapeutic failures in other treatment programs were
admitted to the program. The setting of the program
has been described elsewhere [12,13]. Briefly, patients
were referred by their physician. All participants
received psychopharmacological treatment that was
refined by a psychiatrist if necessary before and
during follow-up. However, most of the participants
remained with the same psychopharmacological
treatment during the entire DBT follow-up. They
were assessed for psychiatric diagnoses using the Mini
International Neuropsychiatric Interview (MINI)
[14]. Psychotic disorder, bipolar affective disorder
type 1, pervasive developmental disorder, mental
retardation, and neurological disorder were exclusion
criteria. Each participant was interviewed by either a
trained psychiatrist or a psychologist prior to accep-
tance into treatment. Participants were eligible only
if they fulfilled clinical criteria for a diagnosis of BPD
based on the International Personality Disorder
Examination Screening Questionnaire (IPDE-SQ)
for Axis II pathology [15] and the Screening Inter-
view for Axis II Disorder (SCID-II) BPD part [16].
Of the 54 participants, two did not fulfill the five
required criteria for BPD according to DSM-IV and
were therefore excluded from the subsequent analy-
ses. The study was approved by the ethics committee
of Geneva University Hospital. Informed written
consent was obtained from all participants.
Treatment
Participants were first referred to an I-DBT for 4
weeks of treatment as previously described [12,13]
to provide an overview of the behavioral skills that
were to be developed later during standard DBT.
I-DBT is an adaptation of standard DBT. All
patients had individual and group therapy. Behav-
ioral targets were chosen within a DBT framework
with suicidal behaviors treated as a priority followed
by behaviors that interfere with therapy and then by
behaviors that interfere with quality of life. The pro-
gram also included a “medication” group with the aim
of providing an overview of psychotropic treatments
and psychiatric illnesses. Other groups included
behavioral skills training covering the four modules
of DBT: emotion regulation, interpersonal effec-
tiveness, distress tolerance and repeated mindfulness
training to increase mindfulness skills [12].
Participants were then referred to standard DBT
as described by Linehan [7], which also includes
mindfulness theory and practice. The mindfulness
module was given for 3 weeks before each of the other
three standard DBT modules: emotion regulation,
interpersonal effectiveness and distress tolerance.
Mindfulness practice was proposed in each group. Of
note and this is a slight adaptation of the standard
DBT, depending on the needs of the participant, some
 Mindfulness in DBT 191
of the clients were offered the possibility to complete – The French version of the Beck Depression
only one or two of the standard DBT modules. Inventory II (BDI-II) [17] assesses the current
Both treatments combined weekly individual ses- severity of depression symptoms (score range:
sions with the primary therapist and weekly skills 0 - 63) with a score higher than 28 indicating
training groups. During treatment, participants were severe depression The psychometric proper-
followed by an individual DBT therapist (nurse or ties of the French BDI-II have been described
psychologist) with training in DBT with the aim of previously [18].
increasing the behavioral skills learned during I-DBT – The French version of the Beck Hopelessness
and standard DBT [12]. Adherence to treatment was Scale (BHS) [BHS; 19] was used to estimate the
discussed weekly in the frame of the DBT team ses- degree of pessimism and negativity about the
sions. Patients were also offered telephone contact future (score range: 0–20). The psychometric
with therapists between 08.30 and 18.00 h only dur- properties of the French BHS have been
ing the work week. Of note, in this perspective, the described previously [20].
proposed treatment may not be considered as full – The French version of the KIMS is a 39-item
standard DBT per se. All therapists attended weekly self-report questionnaire [10] composed of four
consultation team sessions, which included mindful- factors: (a) Observing (Obs) or the ability to pay
ness practice and assured that DBT was provided as attention and cultivate openness, awareness and
evidence based. observation of what is noticeable in the present
moment; (b) Describing (Des) or the ability to
find adequate words to depict the richness of
Assessment procedure
what is experienced and observed; (c) Acting
All scales were administered one week prior to the with Awareness (AwA) or engagement in the
commencement of both I-DBT and standard DBT activity or experience, maintaining the focus of
and on the last day of the I-DBT and of each of the attention on whatever is being experienced with-
standard DBT modules resulting in six evaluations out trying to avoid a painful feeling or extend a
(Figure 1). All patients were assessed using the fol- pleasant moment and (d) Accepting without
lowing questionnaires: Judgment (AwJ) or the ability to accept what is

(A) 45 (B) 45

40 40
Describing
Observing

35 35

30 30

25 25

20 20

I−S I−E S−S M1 M2 M3 I−S I−E S−S M1 M2 M3

(C) 45 (D) 45
Accepting without Judgment

40 40
Acting with Awareness

35 35

30 30

25 25

20 20

I−S I−E S−S M1 M2 M3 I−S I−E S−S M1 M2 M3

Figure 1. Changes in mindfulness dimensions (Obs (A), Des (B), AwA (C) and AwJ (D)) during the study. The bars represent standard
deviation. (I-S ⫽ I-DBT start; I-E ⫽ I-DBT end; S-S ⫽ standard-DBT start; M1 ⫽ end of module 1 (emotion regulation skills)∗; M2 ⫽ end
of module 2 (interpersonal effectiveness)∗; M3 ⫽ end of module 3 (distress tolerance)∗. The order of the modules could be changed
depending on the places available in a module and the needs of the participants.
192 N. Perroud et al.
observed in a nonjudgmental way rather than to
evaluate the experience as good or bad, right or
wrong. Items are rated on a five-point scale
ranging from 1 (never or very rarely true) to 5
(always or almost always true). The psychometric
properties of the French KIMS have been
described previously [6].
Finally, at the beginning and end of the study, each
participant completed the International Personality
Disorder Examination Screening Questionnaire
(IPDE-SQ) for Axis II pathology [15] and the
Screening Interview for Axis II Disorder (SCID-II)
BPD part [16].
Demographic and additional clinical data were
obtained from a standard questionnaire given to all
participants before entering the program. These data
were checked against notes from psychiatric, medical
and surgical units and by contacting the referrers.
Statistical analyses
Linear mixed models with maximum likelihood
estimation where treatment time was a fixed effect
and the individual a random effect, as described
elsewhere [21,22], were used to analyze the effect
of I-DBT and standard DBT on the four dimen-
sions of mindfulness. Using this model, we analyzed
the effects of the four mindfulness dimensions (Obs,
Des, AwA and AwJ) on BPD symptoms during
I-DBT and standard DBT. The results of regression
models are presented as standardized regression
coefficients (β) with 95% confidence intervals which
can be interpreted as effect size.
Predictors of dropout from the study were
assessed using Cox proportional hazard regression as
previously described [13].
As we analysed the changes of four dimensions
during two consecutive therapies (I-DBT and standard
DBT) (two tests per dimension) as well as their impact
on BPD symptoms (one test per dimension) a cor-
rection for multiple testing was required. For a Bonfer-
roni correction on the P values, we used P ⫽ 0.05/
(8 ⫹ 4) ⫽ 0.0042 as a threshold for significance.
All analyses were performed using STATA
release 10.
Results
Baseline clinical/demographic characteristics
and patient flow
Tables I and II show the baseline clinical and demo-
graphic characteristics of the 52 subjects. All par-
ticipants had a score of 5 at least on the SCIDII and/
or IPDE-SQ BPD dimension (Pearson’s correlation
between the two scales: 0.71, p ⬍ 0.0001). Most of
the participants were female (n ⫽ 47; 90.4%), single
(n ⫽ 35; 67.3%), childless (n ⫽ 35; 67.3%), and were
not working (unemployed, on sick leave or in receipt
of a disability pension) (n ⫽ 31; 59.6%). Mean age
was 30.5 (SD ⫽ 7.7) and the depression score at
baseline was 32.6 on the BDI (SD ⫽ 9.6).
Eleven of the 52 patients (21.1%) completed only
one or two of the standard DBT modules (this was
agreed with the therapist before entering the study) or
stopped therapy temporarily with the therapist’s agree-
ment. Six patients (11.5%) dropped out during the
study. None of the baseline mindfulness dimensions
and none of the other baseline characteristics was
associated with dropout and non-completion of the
whole treatment. Available numbers at the start and
end of each assessment periods were as follows: start
of I-DBT n ⫽ 52; end of I-DBT n ⫽ 52; start of stan-
dard DBT n ⫽ 51; end of first module n ⫽ 40; end of
second module n ⫽ 38; end of third module n ⫽ 35.
Changes in mindfulness during DBT
Observing. There was a significant change in Obs
during the entire therapy (I-DBT ⫹ standard DBT)
(β ⫽ 0.13; P ⫽ 0.042; 95% CI from 0.01 to 0.24)
(Table II). When standard DBT only is considered,
there was also a significant increase in Obs over time
(β ⫽ 0.14; P ⫽ 0.001; 95% CI from 0.06 to 0.23)
(Figure 1A). However, this was no longer significant
after adjusting for changes in severity of depression
and hopelessness during the study, which suggests
that the observed effect was mainly accounted for by
these two variables.
Describing. There was a slight significant increase in
Des over time (β ⫽ 0.16; P ⫽ 0.022; 95% CI from 0.02
to 0.31) which was mainly accounted for by the time
spent in standard DBT (β ⫽ 0.18; P ⫽ 0.004; 95% CI
from 0.06 to 0.31) (Figure 1B). As for Obs, it was no
longer significant after adjusting for changes in severity
of depression and hopelessness during the study.
Acting with awareness. Figure 1C clearly indicates
that there was no significant increase in AwA during
the entire therapy (I-DBT ⫹ standard DBT) or stan-
dard DBT alone (β ⫽ 0.11; P ⫽ 0.102; 95% CI from
–0.02 to 0.23 and β ⫽ 0.11; P ⫽ 0.065; 95% CI from
–0.02 to 0.22).
Accepting without judgment. There was a significant
increase in AwJ over time (from 19.8 (SD ⫽ 6.8) to
27.2 (SD ⫽ 8.1); β ⫽ 0.39; P ⬍ 0.0001; 95% CI from
0.24 to 0.54) (Figure 1D).This was mainly accounted
for by the time spent in standard DBT (β ⫽ 0.41;
 Mindfulness in DBT 193
Table I. Clinical and demographic characteristics at baseline.

Mean SD

Age 30.5 7.7

Age at first hospitalization 28.1 7.9
Education (Years) 12.9 2.7
N %
Gender Female 47 90.4
Number of hospitalization None 21 38.9
One 17 31.5
Two or more 16 29.6
Marital status Single 35 67.3
Married/co-habiting 8 15.4
Separated/divorced or 9 17.3
widowed
Number of children 0 35 67.3
1 7 13.5
2 5 9.6
3 or more 5 9.6
Profession Full-time or part-time work 14 26.9
Unemployed 6 11.5
On sick leave 20 38.5
Disability pension 5 9.6
Student 7 13.5
Comorbid Diagnoses Recurrent MDD 42 80.8
Bipolar disorder type II 5 0.1
Schizo-affective disorder 2 0.04
Substance use disorder 3 0.06
History of suicide attempts 27 51.9
Treatment at baseline Antidepressants 28 53.8
Neuroleptics 17 32.7
Antidepressants ⫹ neuroleptics 5 0.1
Mood stabilizers 2 0.04

P ⬍ 0.0001; 95% CI from 0.28 to 0.54) and was not
significant for I-DBT (β ⫽ 0.32; P ⫽ 0.182; 95% CI
from –0.18 to 0.91). After adjustment for the sever-
ity of BDI and BHS scores throughout the study (as
time-dependent covariates), the results still showed
a significant increase in AwJ over time (β ⫽ 0.24;
P ⫽ 0.0002; 95% CI from 0.11 to 0.36). The results
remained significant after adjustment for baseline
avoidance scores, number of hospitalizations and
baseline pharmacological treatment.
Neither drop-outs nor the effective number of
weeks each subject attended DBT did correlate with
improvement in mindfulness skills.
Effect of AwJ on BPD symptoms
There was a non-significant decrease in BPD symp-
toms over time (6.9 (SD ⫽ 1.2) to 6.2 (SD ⫽ 1.9);
β ⫽ –0.12; P ⫽ 0.101; 95% CI from –0.26 to 0.02).
Interestingly, after adjustment for baseline borderline

Table II. Baseline and end–of–treatment scores for BDI, hopelessness, SCIDII, IPDE and KIMS (P ⫽ P values for the mixed linear
models).

Baseline scores Scores at the end of treatment

Mean SD Median Range Mean SD Median Range P

BDI 32.6 9.6 32 9–50 18.8 12.5 18 0–46 ⬍ 0.0001

Hopelessness 12.5 5.1 13 3–20 8.5 5.3 8 0–19 ⬍ 0.0001
SCID-II BDL 6.9 1.2 7 5–9 6.2 1.9 6 1–9 0.101
IPDE BDL 6.9 1.4 7 5–9 6.3 1.7 6.5 1–9 0.098
KIMS Obs 38.5 9.4 37 19–60 40.9 9.2 42 20–55 0.042
Des 23.9 6.8 22 13–37 26.5 6.2 27 13–39 0.022
AwA 25.1 6.8 24 13–43 29.4 7.3 30 20–49 0.102
AwJ 19.8 6.8 18 9–36 27.2 8.1 26 9–43 ⬍ 0.0001
194 N. Perroud et al.
personality score, increases in AwJ during therapy
were associated with a greater decrease in BPD
symptoms (β ⫽ –0.22; P ⫽ 0.021; 95% CI from –0.42
to –0.03). This was however no longer significant
after correction for multiple tests. No other effect of
mindfulness was observed.
Conclusion
We found that DBT was associated with an increase
in mindfulness skills over time with an effect that was
more pronounced in standard DBT. Of the four
dimensions of mindfulness, AwJ was the only one
that increased significantly over time after adjustment
for several potential confounding factors. Moreover,
increases in AwJ correlated with improvement in
BPD symptoms.
To our knowledge, this is the first study to explore
in such detail the changes in mindfulness and related
predictors in both I-DBT and standard DBT.
AwJ significantly increased during DBT. This is
an important finding as we found that increases
in AwJ correlated with treatment response. If con-
firmed, these results could have an important impact
for BPD subjects. It has already been shown that
variability in BPD symptoms and related areas of
behavioral dysfunction are to a great extent explained
by mindfulness deficits [4,8]. A growing body of evi-
dence suggests that iterative and continuous attempts
to control private experience through inhibition,
suppression or avoidance are associated with BPD
symptoms [23,24]. From this perspective, increasing
acceptance may be an effective approach in the
treatment of BPD. Our results are consistent with
these findings and emphasize the major role played
by AwJ. We hypothesize, therefore, that increasing
mindfulness and AwJ in particular throughout the
DBT skills modules, teaches patients to bring non-
judgmental awareness to their emotional experiences
and thus prevents BPD patients from feeling over-
whelmed by their negative emotions [25]. Several
studies have demonstrated these mechanisms in
depression [26]. This is also concordant with Baer
and coworkers [10] who found that psychological
symptoms were negatively correlated with KIMS
scores suggesting that mindfulness scores are related
to mental health especially in BPD [6]. The original-
ity of our findings lies in the possible effect over time
of AwJ on BPD symptoms. As the later finding was
no longer significant after correction for multiple
tests, this results needs to be replicated with a larger
sample size so that mindfulness training in DBT can
be better oriented.
We previously showed an increase in the Des sub-
scale (and a trend for AwA) in a large cohort of BPD
patients following I-DBT [6]. We were unable to
replicate these findings in our cohort of patients
following I-DBT and standard-DBT. The smaller
sample size and different analysis method should
explain these discrepancies. It is important to note,
however, that even though we observed a small non-
significant increase in mindfulness subscales, at least
for Des, during I-DBT (Figure 1), this change clearly
did not last after I-DBT ended. Our results show a
major effect of standard DBT on mindfulness
changes and on AwJ in particular, suggesting that
these changes require a long process.
Surprisingly, we did not find a significant increase
in the other three mindfulness skills: AwA, Des and
Obs. This could indicate either that our clients were
deficient in developing these dimensions or that our
therapists were ineffective in explaining or “teaching”
them. Unfortunately we did not have a measure of
adherence and competence of the therapists during
treatment and we are thus not able to answer this
question. The main explication is probably the small
sample size not allowing us to highlight smaller mag-
nitude of change in the three other dimensions.
Unfortunately, no other study has, to our knowledge,
investigated in detail these kinds of changes in mind-
fulness dimensions during DBT and clearly further
investigations are needed to corroborate and try to
understand these intriguing results.
Our results also underline the value of assessing
mindfulness as a multifactorial concept. Even if the
four aspects evaluated share variance, these sub-
scales also describe different aspects of mindfulness
[10,27]. From this perspective, KIMS is an appropri-
ate scale not only for measuring these four facets of
mindfulness but also, as evidenced in our study, for
detecting changes in mindfulness skills over time in
BDP subjects participating in DBT. Recent research
has identified a fifth factor (non-reactivity), which was
incorporated into a new scale, the Five-Facet Mind-
fulness Scale [28]. Future studies should try to
extend our findings using this new factor.
This study has several limitations. The first is that
mindfulness is self-reported and that we are measur-
ing specifically what we taught (see Grossman [29]
for more details). Moreover only one of the mindful-
ness dimensions significantly increased during the
course of the study and thus the observed improve-
ment applies only to this facet and not namely to
mindfulness as a whole concept. Secondly, without a
control group it is impossible to state whether the
observed improvements are exclusively explained by
participation in therapy or reflect a natural change in
mindfulness skills and/or are correlated to other
components of the treatment. Thus our findings
should be considered as preliminary and replication
is therefore required. Moreover, it is impossible to

exclude an effect of the medication as drug changes
during follow-up were not recorded. However, as
mentioned above, most of the participants remained
with the same psychopharmacological treatment
during the entire follow-up suggesting that an increase
in mindfulness skills is not related to medication
changes. Thirdly, the frequency of mindfulness prac-
tice was not assessed and it is therefore impossible
to determine whether those who practiced mindful-
ness more often had better outcomes. Fourthly,
no specific scales assessing emotion regulation and
functioning were included in this study, which meant
that we could not link the observed changes in mind-
fulness skills to this core dimension of BPD. Finally,
and this limitation relates to the statistical model, it
is impossible to state whether the improvement in
BPD symptoms is the cause or consequence of the
increase in AwJ.
The current study suggests that the KIMS is an
appropriate instrument for measuring the four facets
of mindfulness and their hypothetical changes in
BPD patients following mindfulness training during
DBT. Our results temptingly suggest that increase in
AwJ or in the ability to accept reality as it is without
attempts to avoid, escape, or change it and without
self-criticism [3,30] may possibly be part of the
mechanism by which favorable changes in DBT
occur. Encouraging this skill should result in a more
adaptive response to problematic situations and thus
counteract impulsive and problematic behaviors in
BPD patients.
Key points
• DBT is associated with an increase in mindful-
ness skills
• The KIMS is an appropriate instrument for
measuring the four facets of mindfulness and
their hypothetical changes in BPD patients
following mindfulness training during DBT
• Considering the lack of a control group it
is impossible to state whether the observed
improvements are exclusively explained by par-
ticipation in therapy and thus our findings
should be considered as preliminary and replica-
tion is therefore required
Acknowledgements
None.
Statement of interest
None to declare.
Mindfulness in DBT 195
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