Dialectical Behavior Therapy and Schema Therapy Show Comparable Effectiveness in Borderline Personality Disorder: JAMA

Although Dialectical Behavior Therapy and Schema Therapy are established treatments for borderline personality disorder, scarce head-to-head research has left a significant clinical gap in treatment selection. Consequently, Carlijn J. M. Wibbelink, MSc, and her colleagues conducted a multicenter trial across nine Dutch centers to evaluate the comparative effectiveness of these two primary therapeutic approaches.

Therefore, the three-year multicenter superiority Randomized Clinical Trial (RCT), known as the Borderline Optimal Treatment Selection (BOOTS) project, enrolled 204 adult outpatients across nine Dutch centers to evaluate two years of combined group and individual therapy. Using blinded assessments and computerized randomization, the study measured the primary endpoint of Borderline Personality Disorder Severity Index, fifth version score changes, while secondary outcomes focused on quality of life, functioning, and treatment retention.

• Equivocal Severity Reduction: Analysis by BOOTS demonstrated that both specialized treatments yielded large, significant reductions in disorder severity with no statistical difference between the two modalities, yielding a p-value of .27 and an effect size of 0.09.

• Comparable Long-Term Gains: At the final 36-month assessment, the BOOTS trial found a minimal estimated mean difference of -1.09 on the severity index, representing a small Cohen d effect size of 0.15.

• Uniform Secondary Improvements: No significant differences were observed across any secondary endpoints in the BOOTS investigation, as both therapeutic approaches were associated with marked enhancements in quality of life, overall functioning, and general symptom relief.

• Matched Retention Rates: Retention was comparable between the two arms, with BOOTS noting dropout rates for dialectical therapy at 52% and schema therapy at 46% by the two-year mark.

The results suggest that neither therapeutic modality demonstrated superiority over the other, as both interventions facilitated substantial and sustained clinical improvements for outpatients across the 36-month observation period.

Thus, the trial concludes that clinicians can feel confident in utilizing either evidence-based framework to support meaningful long-term progress in patients with this personality disorder.

While these findings are promising, the study acknowledges the need for further research to establish statistical equivalence and to clarify which specific patient profiles might benefit most from one modality over the other.

Wibbelink CJM, Kamphuis JH, Sinnaeve R, et al. Dialectical Behavior Therapy vs Schema Therapy for Patients With Borderline Personality Disorder: The BOOTS Multicenter Randomized Clinical Trial. JAMA Psychiatry. Published online April 22, 2026.