For many therapists working with borderline personality disorder, one question comes up again and again:
Should this client receive DBT or Schema Therapy?
In a recent episode of “What’s the Schemata”, Chris Hayes and Robert Brockman explored a new large randomised clinical trial comparing Dialectical Behaviour Therapy and Schema Therapy for people with severe borderline personality disorder.
Their conclusion was not a dramatic “winner takes all” result.
It was more clinically useful than that.
Both treatments worked.
Both produced large improvements.
Both appeared to maintain those gains after treatment ended.
And perhaps most interestingly, the study raised deeper questions about how different therapies may help clients reach similar outcomes.
No clear winner, but very good news
The study compared DBT and Schema Therapy across multiple outpatient clinics in the Netherlands. Clients received two years of treatment, followed by a year of follow-up.
Both treatments led to significant improvements in borderline personality disorder symptoms and other measures of wellbeing.
Chris and Rob noted that this is important because DBT and Schema Therapy come from quite different clinical traditions. DBT is often more skills-based, focused on emotion regulation, distress tolerance, interpersonal effectiveness and reducing high-risk behaviour. Schema Therapy is more attachment-focused, working with unmet emotional needs, schemas, modes and the development of a stronger Healthy Adult.
Yet in this trial, both pathways appeared to help.
For clinicians, this is a useful reminder: effective therapy does not always need to look the same on the surface to create meaningful change.
Skills, regulation and deeper emotional healing
One of the most useful parts of the discussion was Chris and Rob’s comparison of the mechanisms behind each model.
DBT may be understood as a more self-regulation model. The client learns skills, practises them, generalises them and uses them when emotions become overwhelming.
Schema Therapy, by contrast, often begins as more of a co-regulation model. Through limited reparenting and the therapeutic relationship, the therapist helps the client experience emotional regulation, care and protection in vivo. Over time, the hope is that this becomes internalised as Healthy Adult functioning.
This distinction matters clinically.
Some clients may need immediate skills to manage crises, reduce self-harm or survive intense emotional storms. Others may be ready to explore the deeper emotional meanings underneath their patterns: shame, abandonment, mistrust, defectiveness or unmet childhood needs.
The episode also raises a practical question: do therapists need to treat these models as competing, or can they learn from each other?
Can DBT and Schema Therapy be integrated?
Chris and Rob were careful not to reduce the discussion to “Schema Therapy versus DBT.”
A more useful question may be:
What does this client need, at this stage of treatment?
For example, DBT skills may be helpful inside Schema Therapy when a client is highly distressed between sessions. Skills such as distress tolerance, grounding or temperature-based regulation may help reduce the intensity of a mode so the client can stay safe and return to deeper work.
Equally, Schema Therapy may help explain why a client is not using a skill they already know. A Detached Protector, Angry Child, Punitive Parent or Vulnerable Child mode may be blocking access to the client’s healthier capacities.
This is where the clinical conversation becomes interesting. DBT may help clients manage the storm. Schema Therapy may help them understand why the storm keeps forming.
Both matter.
Dropout and readiness for treatment
The study also showed relatively high dropout rates across both treatments.
Chris and Rob reflected on what this might mean. Was it the intensity of a two-year treatment? The group format? The severity of the client group? Readiness for change? Practical issues? Or, in some cases, did some clients leave because they had improved enough to return to work or life demands?
The key point is that dropout should not be treated as a side issue. For services offering intensive treatment, readiness, preparation and fit may be just as important as the model itself.
What should therapists take from this?
The episode’s most practical message is that both DBT and Schema Therapy can be highly effective when delivered in a structured, consistent way by trained clinicians.
For therapists choosing training pathways, DBT may be especially relevant for high-risk, crisis-heavy, emotionally dysregulated presentations. Schema Therapy may offer broader transdiagnostic value, particularly for personality disorders, entrenched patterns, trauma-related presentations and treatment-resistant clients.
But the larger message is not about defending one model.
It is about becoming more thoughtful in matching treatment to the client.
Who needs skills first?
Who needs attachment-based emotional repair?
Who is ready to go deeper?
Who needs more stabilisation before they can do that work?
Chris and Rob unpack these questions in more depth in the full episode of What’s the Schemata. To listen, press play below.
