The BOOTS multicenter randomized trial, published in JAMA Psychiatry by Wibbelink and colleagues, compared dialectical behavior therapy with schema therapy in 204 adults with borderline personality disorder. Both treatments combined group and individual therapy over two years, with outcomes followed for three years.
Borderline symptoms and a broad range of secondary outcomes improved substantially in both conditions, but neither treatment demonstrated superiority. Retention was a significant challenge: by two years, approximately 52% of participants assigned to DBT and 46% assigned to schema therapy had dropped out, with no significant difference between conditions. The study was designed to test superiority, so the absence of a significant difference should not be interpreted as formal proof that the treatments are equivalent.
Clinical Takeaway: Current evidence does not support presenting either DBT or schema therapy as the universally better treatment for BPD. Selection can reasonably incorporate the patient’s goals and preferences, available therapist competence, need for telephone coaching or crisis structure, relevance of schema-mode work, and the service’s ability to sustain a coherent treatment team. Regardless of model, monitor outcomes and treatment engagement from the beginning and address attendance problems, alliance ruptures, and therapy-interfering behavior early.