Comparative Effectiveness of Dialectical Behavior Therapy and Schema Therapy in Borderline Personality Disorder: Insights from the BOOTS Trial

Highlight

– The BOOTS multicenter randomized clinical trial compared dialectical behavior therapy (DBT) and schema therapy (ST) in 204 outpatients with borderline personality disorder (BPD).
– No significant difference was found between DBT and ST in reducing BPD severity over a 3-year period.
– Both treatments demonstrated substantial improvement across multiple clinical outcomes, including symptom severity, functioning, and quality of life.
– Treatment dropout rates were comparable between DBT and ST.

Study Background

Borderline personality disorder (BPD) is a severe psychiatric condition characterized by pervasive instability in affect regulation, impulse control, interpersonal relationships, and self-image. It confers a high individual and societal burden, with elevated risks of self-harm, suicide, and functional impairment. Currently, evidence-based psychotherapies like dialectical behavior therapy (DBT) and schema therapy (ST) have established efficacy in treating BPD symptoms, yet head-to-head comparisons are limited. Understanding which therapeutic modality provides superior outcomes, or if they offer comparable clinical benefits, is critical for optimizing treatment selection in routine clinical practice.

Study Design

The BOOTS (Borderline Optimal Treatment Selection) trial was a 3-year multicenter superiority randomized clinical trial conducted from January 2019 to April 2025 across nine Dutch outpatient centers. The study enrolled 204 adults aged 18 to 65 years who met DSM-5 criteria for BPD. Participants were randomized through computerized covariate-adaptive allocation accounting for sex and baseline BPD severity to receive either DBT or ST. Both interventions were delivered over two years in a combined individual and group therapy format. Assessments were carried out by blinded raters to minimize bias.

The primary endpoint was the rate of change in BPD severity, measured by the Borderline Personality Disorder Severity Index, fifth version (BPDSI-5) total score, from baseline to one-year posttreatment (three years after baseline). Secondary outcomes included individual DSM-5 BPD criteria, general psychiatric symptom severity, functional status, quality of life, psychological well-being, sleep problems, and treatment dropout rates.

Key Findings

Among the 204 randomized participants (172 females, 84.3%; mean age 32.2 years), 95 received DBT and 109 received ST. Intention-to-treat analyses revealed no statistically significant difference between DBT and ST in reducing overall BPD severity at the 36-month follow-up (P = 0.27; effect size r = 0.09). The estimated mean difference on the BPDSI-5 was -1.09 points favoring ST, but with a small effect size (Cohen’s d = 0.15; 95% CI, -0.17 to 0.47), indicating clinically negligible differences.

Both interventions were associated with large within-group improvements. Secondary outcomes, including individual BPD criteria, general symptom burden, global functioning, quality of life, psychological well-being, and sleep disturbance, improved markedly over time without significant differences between treatment arms. Treatment dropout rates were comparable, with 34% vs 29% attrition at one year and 52% vs 46% at two years for DBT and ST, respectively.

These findings establish that both DBT and ST are effective long-term treatment modalities for BPD when delivered in structured combined individual and group formats across diverse outpatient settings.

Expert Commentary

The BOOTS trial offers critical evidence addressing the comparative efficacy of two prominent manualized psychotherapies for BPD. The absence of significant superiority suggests that DBT and ST may represent equally valid treatment options, allowing tailored selection based on patient preference, therapist expertise, or clinical context.

Strengths of the trial include its large sample size, multicenter design, blinded assessments, and long-term follow-up. However, there remain unanswered questions such as the identification of subgroups who may preferentially benefit from one therapy and the mechanisms underlying therapeutic change.

In clinical practice, factors such as accessibility, therapist training, and patient engagement should be weighed alongside efficacy data. Moreover, integrating elements from both therapies might enhance outcomes, especially for complex cases.

Conclusion

The BOOTS randomized clinical trial demonstrates that DBT and ST are both effective psychotherapeutic approaches to managing borderline personality disorder, yielding substantial and sustained improvements. No significant differences emerged in primary or secondary clinical outcomes over three years. These results highlight the importance of flexible, patient-centered treatment planning in BPD care. Further research is warranted to investigate moderators of treatment response, confirm clinical equivalence, and refine personalized therapeutic strategies.

Funding and Trial Registration

The study was funded as part of the BOOTS project and conducted in Dutch outpatient centers. The trial registration identifier is NL-OMON49443, accessible at https://onderzoekmetmensen.nl.

References

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. 2026;83(7):669-681. doi:10.1001/jamapsychiatry.2026.1836
Linehan MM. Cognitive-Behavioral Treatment of Borderline Personality Disorder. Guilford Press; 1993.
Young JE, Klosko JS, Weishaar ME. Schema Therapy: A Practitioner’s Guide. Guilford Press; 2003.