Beyond DBT: Why Borderline Personality Disorder Deserves More Than One Evidence-Based Treatment Option

When someone receives a diagnosis of Borderline Personality Disorder (BPD), the referral pathway is often almost automatic:

"Find a DBT therapist."

There's a good reason for this. Dialectical Behaviour Therapy (DBT), developed by Dr. Marsha Linehan, has one of the strongest evidence bases for treating BPD. It has helped countless individuals reduce self-harm, improve emotional regulation, and build lives worth living.

But somewhere along the way, "gold standard" became synonymous with "the only evidence-based therapy."

The science doesn't support that conclusion.

DBT is highly effective, but it isn't the only effective treatment.

One of the largest and most rigorous recent randomized clinical trials, the BOOTS study compared Dialectical Behaviour Therapy (DBT) with Schema Therapy (ST) in people diagnosed with Borderline Personality Disorder.

The findings were clear.

Both therapies resulted in substantial improvements in BPD symptoms, psychosocial functioning, quality of life, and recovery. Importantly, neither therapy demonstrated overall superiority over the other. Participants benefited significantly regardless of whether they received DBT or Schema Therapy.

This reinforces an important clinical message: there is more than one evidence-based pathway to treating Borderline Personality Disorder.

For some clients, DBT's structured skills-based approach may be the ideal fit. For others, Schema Therapy's emphasis on attachment, unmet emotional needs, and long-standing maladaptive patterns may resonate more deeply.

The goal should not be to identify the "best" therapy, but the best therapy for that individual.

Where does EMDR fit in?

EMDR (Eye Movement Desensitization and Reprocessing) has traditionally been associated with PTSD. However, growing research suggests its applications extend beyond trauma disorders alone.

A recent randomized controlled trial compared EMDR with Cognitive Behaviour Therapy (CBT) in individuals with personality disorders, including participants diagnosed with Borderline Personality Disorder. The study found that EMDR was not inferior to CBT across the primary clinical outcomes that were measured. Participants in both treatment groups showed meaningful improvements, with EMDR demonstrating comparable effectiveness while also being safe and well tolerated.

Although this does not mean EMDR should replace DBT or Schema Therapy as a first-line treatment for every person with BPD, it does challenge the assumption that trauma-focused therapies have little role in treating personality disorders.

Considering that a significant proportion of individuals with BPD have histories of childhood trauma, attachment disruptions, neglect, or interpersonal violence, this finding is clinically meaningful.

For clients whose symptoms are closely linked to unresolved traumatic experiences, EMDR may be an appropriate component of a comprehensive treatment plan.

We need to stop "therapy funneling."

In clinical practice, referrals for Borderline Personality Disorder are frequently funnelled into DBT programs by default.

While this is understandable given DBT's strong evidence base, it can unintentionally narrow treatment options for clients.

Many psychologists today are extensively trained in EMDR, Schema Therapy, CBT, ACT, Mentalization-Based Therapy (MBT), Transference-Focused Psychotherapy (TFP), and other evidence-based approaches.

These therapies are not competing teams.

They are different tools designed to help different people in different ways.

Clinical formulation should guide treatment, not simply the diagnostic label.

Evidence-based practice means offering evidence-based choices.

Evidence-based practice rests on three equally important pillars:

• The best available research evidence.

• Clinical expertise.

• The client's preferences, values, goals, and individual presentation.

  
  

When we automatically recommend only one therapy for every individual with BPD, we move away from individualized care and toward one-size-fits-all treatment.

The evidence increasingly supports a broader perspective.

DBT remains one of the most extensively researched and valuable treatments for Borderline Personality Disorder. It has earned its place in every discussion about BPD treatment.

At the same time, high-quality research demonstrates that Schema Therapy is similarly effective for many clients. Emerging randomized evidence also shows that EMDR can produce outcomes comparable to CBT in people with personality disorders, including individuals with BPD, supporting its consideration when trauma is a significant maintaining factor.

The takeaway

The question should no longer be:

"Is DBT the treatment for Borderline Personality Disorder?"

Instead, we should be asking:

"Which evidence-based therapy is the right fit for this particular client, at this particular stage of recovery?"

As psychologists, psychiatrists, and mental health professionals, we owe our clients more than familiarity with a single model.

We owe them informed choice.

If your clinic has trained EMDR therapists, Schema Therapists, DBT practitioners, CBT therapists, and other qualified professionals, referrals for Borderline Personality Disorder should reflect that breadth of expertise rather than defaulting to one modality alone.

Moving beyond therapy tribalism isn't about diminishing DBT.

It's about recognising that our clients deserve access to the full spectrum of evidence-based care.

References

1. Arntz, A., et al. (2025). Effectiveness of Dialectical Behavior Therapy vs Schema Therapy for Borderline Personality Disorder: The BOOTS Randomized Clinical Trial. JAMA Psychiatry. https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2848044

2. Triscari, M. T., et al. (2025). Eye Movement Desensitization and Reprocessing (EMDR) versus Cognitive Behavioral Therapy (CBT) in Personality Disorders: A Randomized Controlled Trial. Psychotherapy. https://pmc.ncbi.nlm.nih.gov/articles/PMC12059781/

3. Healing Hearts Foundation. Beyond DBT: Expanding Evidence-Based Treatment Options for Borderline Personality Disorder. https://healingheartsdotfoundation.wordpress.com/

About the author:

Pritha Saha Dutta is a counseling psychologist based in Mumbai and founder of Indian Mental Health Summit