Borderline Ve Terapiler Tedavi

Journal of Consulting and Clinical Psychology
Psychotherapies for the Treatment of Borderline Personality Disorder: A

Systematic Review
Karen Crotty, Meera Viswanathan, Sara Kennedy, Mark J. Edlund, Rania Ali, Mariam Siddiqui, Roberta Wines, Piotr
Ratajczak, and Gerald Gartlehner
Online First Publication, October 30, 2023. https://dx.doi.org/10.1037/ccp0000833
CITATION
Crotty, K., Viswanathan, M., Kennedy, S., Edlund, M. J., Ali, R., Siddiqui, M., Wines, R., Ratajczak, P., & Gartlehner, G.
(2023, October 30). Psychotherapies for the Treatment of Borderline Personality Disorder: A Systematic Review. Journal of
Consulting and Clinical Psychology. Advance online publication. https://dx.doi.org/10.1037/ccp0000833
Journal of Consulting and Clinical Psychology
© 2023 American Psychological Association
ISSN: 0022-006X https://doi.org/10.1037/ccp0000833
Psychotherapies for the Treatment of Borderline Personality Disorder:

A Systematic Review
Karen Crotty1, Meera Viswanathan1, Sara Kennedy1, Mark J. Edlund1, Rania Ali1,
Content may be shared at no cost, but any requests to reuse this content in part or whole must go through the American Psychological Association.
Mariam Siddiqui1, Roberta Wines1, Piotr Ratajczak2, 3, and Gerald Gartlehner1, 2

1
RTI International, Research Triangle Park, North Carolina, United States
2
Department for Evidence-based Medicine and Evaluation, Danube University Krems
3
Department of Pharmacoeconomics and Social Pharmacy, Poznan University of Medical Sciences
Objective: Borderline personality disorder (BPD) is the most common personality disorder, affecting 1.8%
This document is copyrighted by the American Psychological Association or one of its allied publishers.
of the general population, 10% of psychiatric outpatients, and 15%–25% of psychiatric inpatients. Practice
guidelines recommend psychotherapies as first-line treatments. However, psychotherapies commonly used
for the treatment of BPD are numerous, and little is known about the comparative effectiveness of each
individual psychotherapy versus treatment as usual (TAU) or other psychotherapies. To systematically
assess the comparative effectiveness of commonly used psychotherapies versus TAU or versus other
psychotherapies for BPD treatment. Method: We conducted systematic literature searches in MEDLINE,
EMBASE, the Cochrane Library, and APA PsycINFO up to July 14, 2022, and searched reference lists of
pertinent articles and reviews. Inclusion criteria were (a) patients 13 years or older with a diagnosis of BPD,
(b) treatment with commonly used psychotherapies, (c) comparison with TAU or another psychotherapy,
(d) assessment of relevant BPD-related health outcomes, and (e) randomized or nonrandomized trials or
controlled observational studies. Two investigators independently screened abstracts and full-text articles
and graded the certainty of evidence using the Grading of Recommendations Assessment, Development,
and Evaluation approach. Results: We found 25 psychotherapy studies meeting inclusion criteria with data
on 2,545 participants. Seventeen studies compared nine psychotherapies with TAU and nine studies
compared eight psychotherapies with another psychotherapy for the treatment of BPD. Overall, both TAU
and included psychotherapies were effective in treating the severity and symptoms of BPD. Moderate
certainty of evidence suggests that systems training for emotional predictability and problem solving is
more effective than TAU for the treatment of BPD; low certainty of evidence suggests that dialectical
behavior therapy, schema therapy, transference-focused psychotherapy, acceptance and commitment
therapy, manual-assisted cognitive therapy, and cognitive behavioral therapy are more effective than TAU
for treating BPD. We were unable to draw conclusions from head-to-head comparisons of psychotherapies,
which were limited to single studies with very low to low certainty of evidence. Conclusions: All commonly
used psychotherapies improve BPD severity, symptoms, and functioning. Our assessment found no strong
evidence suggesting that any one psychotherapy is more beneficial than another.
What is the public health significance of this article?

For clinicians, this work can be used to inform practice guidelines on psychotherapies to treat BPD. For
funders, policymakers, and researchers, this work identifies research gaps and opportunities for future
research in the area.
Keywords: borderline personality disorder, psychotherapies, dialectical behavior therapy, self-harm, suicide
Supplemental materials: https://doi.org/10.1037/ccp0000833.supp
Karen Crotty played a lead role in writing–original draft and writing–review

Karen Crotty https://orcid.org/0000-0002-5633-5040 and editing, a supporting role in project administration, and an equal role in
The authors received funding from the American Psychiatric Association. conceptualization, data curation, formal analysis, funding acquisition,
The authors would like to thank Linda Lux for her help with data investigation, methodology, and supervision. Meera Viswanathan played
abstraction and risk of bias assessment. a supporting role in project administration and an equal role in
This work has not been previously published. The data from the primary conceptualization, data curation, formal analysis, funding acquisition,
studies included as part of this systematic review are all peer-reviewed investigation, methodology, supervision, writing–original draft, and writing–
published studies. A sister publication using the same search strategy but review and editing. Sara Kennedy played a lead role in project administration
not focused on psychotherapies for BPD has been published elsewhere. and a supporting role in data curation, funding acquisition, investigation,
This study was registered with PROSPERO (Registration Number methodology, supervision, writing–original draft, and writing–review and
CRD42020194098). editing. Mark J. Edlund played a supporting role in conceptualization, formal
continued
1
2 CROTTY ET AL.
Borderline personality disorder (BPD) is the most common Method

personality disorder, affecting 1.8% of the general population
(Winsper et al., 2020), an estimated 10% of clinical psychiatric The methods for the systematic review followed the
Agency for Healthcare Quality and Research Methods Guide
outpatients and 15%–25% of psychiatric inpatients (Gunderson,
for Effectiveness and Comparative Effectiveness Reviews (avail-
2009; Torgersen, 2005). Individuals with BPD suffer severe and
able at http://www.effectivehealthcare.ahrq.gov/methodsguide
persistent functional impairment, including high rates of comorbid
.cfm) and the preferred reporting items for systematic reviews
mental disorders, substance use, deliberate self-harm, and suicidal
and meta-analyses (PRISMA) checklist (Page et al., 2021). The
ideation (Leichsenring et al., 2011; Oldham, 2006). Women are
protocol for the systematic review addressing both pharmacologi-

more frequently diagnosed with BPD than men (Skodol & Bender,
cal and nonpharmacological treatments was registered on
2003), but it is unclear whether women simply present for treatment
PROSPERO (Registration Number CRD42020194098). All
more often or BPD is more common among women than among
methods and analyses were determined a priori. This article
men. Symptoms of BPD often first appear during adolescence
presents results for psychotherapies that addressed the following
(Sharp & Wall, 2018). Although most individuals with BPD
key question:
experience symptom improvement during adulthood—with
about 85% reaching diagnostic remission within 10 years after In patients with borderline personality disorder, what is the comparative
diagnosis (Gunderson et al., 2011)—specific symptoms, such as fear effectiveness, and risk of harms of psychotherapies?
of abandonment, impulsivity, intense anger, and an unstable self-
Figure 1 presents the analytic framework for our key questions.
image can persist over a lifetime. Individuals with BPD also
commonly suffer from other mental disorders, including depression,
anxiety, posttraumatic stress disorder, substance use disorders, Literature Searches
and eating disorders. They frequently face social stigma, have poor
We built our searches on an earlier search strategy developed for
social and occupational outcomes (Niesten et al., 2016), and have a
APA (see Supplemental Material) with modifications to make
substantial risk for suicide death (Paris, 2019). Individuals with searches more specific. To ensure optimal recall, we ensured that
BPD are frequent users of general primary care and the societal the revised search strategy detected all studies that met the inclusion
costs of BPD are substantial; the annual direct health care costs and criteria of the original search. We searched MEDLINE, EMBASE,
indirect costs (i.e., lost productivity) are more than 16 times higher the Cochrane Library, and APA PsycInfo from January 1, 2018, to
among patients with BPD compared with matched controls without July 14, 2022, using a variety of terms, medical subject headings,
BPD (Hastrup et al., 2019). and major headings limited to English language and human-only
Clinical practice guidelines recommend psychotherapies as first- studies (see Supplemental Material). To minimize retrieval bias, we
line treatment for BPD (American Psychiatric Association [APA], manually searched reference lists of landmark studies and
2001; National Collaborating Centre for Mental Health, 2018; background articles for relevant citations that electronic searches
Simonsen et al., 2019) with a particular emphasis on dialectical might have missed.
behavior therapy (DBT), a structured modular and hierarchical
treatment consisting of a combination of individual psychotherapy,
group skills training, and telephone coaching, guided by a therapist Criteria for Inclusion/Exclusion of Studies in the Review
consultation team (Linehan, 1993). However, the extent to which Our population of interest were patients 13 years of age or older
guidelines are evidence-based varies: A recent study found that over with a diagnosis of BPD. Included psychotherapies were those that we
half of clinical practice guidelines are not based on systematic found to be most commonly studied in the literature and determined as
reviews, which could lead to potentially misleading and untrust- eligible for inclusion by experts at APA. The following psychothera-
worthy results (Lunny et al., 2021). pies used to treat BPD were included: DBT, mentalization-based
To strengthen evidence-based clinical practice and on behalf treatment (MBT), systems training for emotional predictability and
of the APA, we conducted a systematic review of the comparative problem solving (STEPPS), dynamic deconstructive psychotherapy,
effectiveness of pharmacological and nonpharmacological treat- transference-focused psychotherapy, schema therapy, abandonment
ment approaches for BPD patients. The purpose of the work was to therapy, acceptance and commitment therapy (ACT), manual-assisted
provide an update of APA’s clinical practice guideline on treatments cognitive therapy (MACT), supportive therapy, cognitive behavioral
for BPD. Results for the comparative effectiveness of pharmacotherapy (CBT), and generalized psychiatric treatment. Eligible active
logical treatments for the treatment of BPD were published comparators included treatment as usual (TAU) and other
previously (Gartlehner et al., 2021). The current article presents the psychotherapies (see Supplemental Material, for a list of all eligible
results for the comparative effectiveness of psychotherapy treat- psychotherapy comparators). We defined TAU as interventions
ments for BPD patients. that were described as TAU, had a flexible approach, and did not
analysis, and investigation and an equal role in writing–review and editing. analysis, investigation, and writing–original draft. Gerald Gartlehner played
Rania Ali played a supporting role in data curation, formal analysis, a lead role in conceptualization, funding acquisition, investigation,
investigation, and writing–original draft. Mariam Siddiqui played a methodology, project administration, and writing–review and editing and
supporting role in data curation, formal analysis, investigation, and an equal role in data curation, formal analysis, and writing–original draft.
writing–original draft. Roberta Wines played a supporting role in data Correspondence concerning this article should be addressed to Karen
curation, formal analysis, investigation, methodology, and writing–original Crotty, RTI International, Research Triangle Park, 3040 East Cornwallis
draft. Piotr Ratajczak played a supporting role in data curation, formal Road, NC 27709-2194, United States. Email: kcrotty@rti.org
PSYCHOTHERAPIES FOR BORDERLINE PERSONALITY DISORDER 3
Figure 1
Analytic Framework
Pyschotherapies
Individuals ≥ 13 years Intermediate Outcomes: Health Outcomes:
old with diagnosed Legal system Improvement of symptoms
borderline personality involvement Self-harm behaviors
disorder Changes in core Clinical global impression
illness features Mortality
Specific subgroups Service use Patient reported outcomes
Study withdrawal, drug

discontinuation, and
adverse effects of
interventions
Note. See the online article for the color version of this figure.
adhere to a manualized or prespecified regimen. Outcomes of studies. For RCTs, we used the Cochrane Risk of Bias Tool 2.0 (J.
interest included the improvement of BPD-specific symptoms (e.g., A. C. Sterne et al., 2019). We assigned a “high risk of bias” rating to
self-harm, suicide attempts, depression, anxiety, impulsiveness, studies that had very serious limitations in design or conduct that
emotional regulation, dissociation experience, hopelessness), global might invalidate findings. We resolved disagreements between
clinical assessment, functioning, and adverse events. In addition to the two reviewers by discussion and consensus or by consulting the
randomized controlled trials (RCTs), we included non-RCTs with a third team member.
comparison arm. Non-RCTs often study the effectiveness of
interventions on populations excluded from RCTs and are better Data Synthesis
suited to assessing harms, particularly rare and long-term harms which
are often too small or too short to be reliably assessed by RCTs. The We summarized included studies in narrative form and in
Supplemental Material provides a detailed presentation of inclusion summary tables. To determine whether quantitative (i.e., meta-
and exclusion criteria. analysis) or qualitative analyses were appropriate, we followed
established guidance to assess the clinical and methodological
heterogeneity of the studies under consideration (Gartlehner et al.,
Literature Review, Data Abstraction, and
2012). We found that studies were not similar due to heterogeneity
Data Management in treatment methods, insufficient numbers of similar studies, or
We used DistillerSR to screen the literature (DistillerSR, insufficiency or variation in outcome reporting. We therefore
Evidence Partners, Ottawa, Canada). Two reviewers independently avoided the pooling of clinically distinct populations and instead
reviewed all titles, abstracts, and full-text articles and resolved synthesized the data narratively.
discrepancies by consensus or by involving a third, senior reviewer.
A list of studies excluded (with reasons) at the full-text level can Grading the Certainty of Evidence for Major
be found in the Supplemental Material. For data extraction, we Comparisons and Outcomes
designed, pilot tested, and used a structured data form in DistillerSR
to ensure consistency of data extraction. One reviewer extracted We graded the certainty of evidence of relevant outcomes
data and the second team member verified extracted study data for based on current Grading of Recommendations Assessment,
accuracy and completeness. Development, and Evaluation guidance (Balshem et al., 2011).
Two reviewers assessed each domain for each selected outcome
and resolved differences by consensus discussion. We documented
Assessment of Risk of Bias of Individual Studies
all decisions regarding up- or down-grading the certainty of
To assess the risk of bias of studies, two independent reviewers evidence to ensure transparency. We used GradePro (https://grade
used the risk of bias in nonrandomized studies of interventions pro.org) to rate the certainty of evidence and develop a summary of
(ROBINS-I; J. A. Sterne et al., 2016) for nonrandomized controlled findings tables.
4 CROTTY ET AL.
Role of the Funding Source included, DBT was included as a study arm in 12 studies, MBT in
five studies, STEPPS, schema therapy, and transference-focused
This review was funded by APA. The APA Clinical Guidelines
psychotherapy were each study arms in four studies, and manualized
Committee assisted in the development of key questions, study
supportive therapy was a study arm in three studies. All other
inclusion criteria, and outcome measures of interest but was not
included psychotherapies were investigated in a single study.
involved in data collection, analysis, or article preparation.
We rated just one study as having a low risk of bias (Carter
et al., 2010), 10 studies in 12 publications as some concerns for
Results bias (Bateman et al., 2021; Bateman & Fonagy, 2009; Bos et al.,
Results of Literature Search and Literature Screening 2010; Carlyle et al., 2020; Davidson et al., 2006; Farrell
et al., 2009; Hilden et al., 2021; McMain et al., 2017; Morton
Of 3,754 unique records screened, 25 studies (20 RCTs, three et al., 2012; van den Bosch et al., 2005; Verheul et al., 2003;
nonrandomized trials, one prospective cohort study, and one Weinberg et al., 2006) and 14 studies in 18 publications as high
retrospective cohort study) in 31 publications met inclusion criteria. risk of bias (Arntz et al., 2022; Barnicot & Crawford, 2019; Beck
Figure 2 presents the literature search and selection process. et al., 2020; Blum et al., 2008; Bohus et al., 2004; Clarkin et al.,
Of the included studies, 17 (in 18 publications) compared nine 2007; Doering et al., 2010; Feigenbaum et al., 2012; Giesen-Bloo
commonly used psychotherapies with TAU (Arntz et al., 2022; Beck et al., 2006; González-González et al., 2021; Gregory &
et al., 2020; Blum et al., 2008; Bohus et al., 2004; Bos et al., 2010; Sachdeva, 2016; Guillén Botella et al., 2021; Jørgensen et al.,
Carter et al., 2010; Davidson et al., 2006; Doering et al., 2010;
2013; Links et al., 2013; McMain et al., 2009, 2012; Sachdeva et
Farrell et al., 2009; Feigenbaum et al., 2012; González-González
al., 2013; Spinhoven et al., 2007). Primary reasons for high risk-
et al., 2021; Gregory & Sachdeva, 2016; Hilden et al., 2021;
of-bias ratings were a lack of intention to treat analysis and high
McMain et al., 2017; Morton et al., 2012; van den Bosch et al., 2005;
rates of attrition (see Supplemental Material).
Verheul et al., 2003; Weinberg et al., 2006); nine studies (in 14
Overall, included trials provided data on 2,545 participants.
publications) compared eight commonly used psychotherapies
Studies predominantly enrolled female participants: females
with another psychotherapy for the treatment of BPD (Barnicot &
accounted for all participants in six studies and for more than
Crawford, 2019; Bateman et al., 2021; Bateman & Fonagy, 2009;
80% of participants in 21 of 25 studies. More than half of studies
Carlyle et al., 2020; Clarkin et al., 2007; Giesen-Bloo et al., 2006;
failed to report race or ethnicity. When reported, most participants
Gregory & Sachdeva, 2016; Guillén Botella et al., 2021; Jørgensen
were White. Study durations ranged from 12 weeks to 3 years,
et al., 2013; Links et al., 2013; McMain et al., 2009, 2012; Sachdeva
with the exception of one study that had six sessions over 6–8
et al., 2013; Spinhoven et al., 2007). Among the psychotherapies
weeks (Weinberg et al., 2006). In general, studies excluded
patients with psychiatric comorbidities, such as schizophrenia,
Figure 2 major depressive disorder, alcohol or substance use disorder, or
PRISMA Flowchart bipolar disorder.
Table 1 summarizes the main study characteristics of studies that
Records idenfied through databases: compare commonly used psychotherapies for the treatment of
(n = 3,754) BPD with TAU or with another commonly used psychotherapy.
More detailed information on study characteristics and treatment
effects can be found in the Supplemental Material. Certainty-of-
evidence ratings are also presented with the Supplemental Tables
Records screened: S1–S18.
( n = 3,754) In the following sections, we first present evidence for the
comparative effectiveness of commonly used psychotherapies
versus TAU. Next, we present evidence for the comparative
Records excluded:
( n = 3,566)
effectiveness of commonly used psychotherapies versus another
psychotherapy. Finally, we present evidence related to harms. For
assessing comparative effectiveness, we summarize findings, (when
Records assessed for reported) for three outcome domains: (a) severity of BPD, (b)
eligibility: # of full-text arcles excluded: 157
(n = 188) Ineligible populaon (n = 16) severity of symptoms associated with BPD, (c) and general
Ineligible intervenon (n = 89) psychiatric symptoms and functioning. Effect measures are
Ineligible comparator (n = 1) generally presented as points on clinical assessment scales at
Ineligible outcome (n = 10)
Ineligible ming (n = 3)
endpoint. Characteristics of commonly used scales for the clinical
Study design (n = 26) assessment of patients with BPD can be found in the Supplemental
Duplicate or superseded (n = 3) Material.
Non-English full text ( n =1)
Ineligible country (n = 5)
25 studies Not primary research (n = 3)
reported in 31 publicaons Commonly Used Psychotherapies Versus
Treatment as Usual
Note. PRISMA = preferred reporting items for systematic reviews and Table 2 presents an evidence map with findings for commonly
meta-analyses. used psychotherapies versus TAU.
Table 1
Study Characteristics of Commonly Used Psychotherapies Versus TAU or Versus Another Commonly Used Psychotherapy for the Treatment of BPD
Author (year) Number of participants

Study design Interventions Study population Risk of
Funding Duration Setting, country Sample demographics Primary outcome bias
Commonly used psychotherapy versus TAU (K = 17; 18 publications)

Arntz et al. (2022) N = 495 randomized (one withdrew consent) Males and females; 18–65 years of age, met Mage: 34 BPDSI at 3, 6, 12, 18, High
RCT ST: Two individual and/or group therapy sessions criteria for DSM-IV BPD, BPDSI-IV % female: 86 24, and 36 months
Other, SLaM, BDCFT, per week for 1 year; then tapering from once per score greater than 20 % race/ethnicity:
and various other week to biweekly and then monthly during Year Outpatient, multicenter, the Netherlands, Ethnic majority (per
nonprofit funders 2, with additional individual sessions on request. Australia, Germany, Greece, United study site): 92
TAU: A range of individualized service provisions Kingdom Ethnic minority: 8
and professional mental health care.
24 months
Follow-up: 12 months
Beck et al. (2020) N = 112 Females and one male; 14–17 years of age; Mage: 16 Borderline Personality High
RCT MBT: Three introductory sessions, 37 weekly (90 meeting a minimum of four DSM-5 BPD % female: 99 Features Scale for
Government, region min) group sessions for patients, and six sessions criteria and having a total score above % race/ethnicity: NR Children at 12
New for parents. clinical cutoff (>67) on The Borderline months
Zealand other, TAU: At least 12 individual supportive sessions, one Personality Features Scale for Children
TrygFonden per month, comprising psychoeducation, Child and adolescent psychiatric outpatient
counseling, and crisis management, and sessions clinics, Denmark
as needed.
12 months
Blum et al. (2008) N = 165 Males and females; 18 years of age and Mage: 32 BPD-specific High
RCT STEPPS: 20 weekly sessions; components included older; subjects with DSM-IV BPD who % female: 83 psychiatric
Government, NIMH psychoeducation about BPD, emotion could designate a mental health % race/ethnicity: symptoms
management skills training, and behavior professional and a friend or relative to White: 94 (Zanarini Rating
management skills training. serve as system members Black: 2 Scale for BPD)
TAU: Individual psychotherapy, medication, and Outpatient, inpatient, and community, Other: 3 measured at 20
case management. United States weeks
20 weeks
Bohus et al. (2004) N = 50 Females; 18–45 years of age; DSM-IV M (SD) age: 30 NR High
Nonrandomized clinical DBT: Combined weekly individual psychotherapy criteria for BPD using SCID-II and % female: 100
trial sessions, weekly skills training groups, and DIB-R; one suicide attempt or minimum % race/ethnicity: NR
Government, DFG; weekly supervision and consultation meetings for two nonsuicidal self-injurious acts in the
BPDRF foundation the therapists. last 2 years
TAU (waitlist): A range of individualized service Inpatient, single center, Germany
PSYCHOTHERAPIES FOR BORDERLINE PERSONALITY DISORDER
provisions and professional mental health care

3 months
Bos et al. (2010) N = 79 Males and females; 18 years of age and Mage: 32 BPD-40 and SCL-90 Some
RCT STEPPS: 18 weekly therapy sessions; components older; met DSM-IV criteria for BPD; % female: 86 at 1 year concerns
Other included psychoeducation about BPD, emotion BDSI-IV with scores exceeding the % race/ethnicity: NR
management skills training, and behavior established cutoff on one or both
management skills training. subscales
TAU: Individual psychotherapy, medication, and Outpatient, multicenter, the Netherlands
case management.
24 weeks
(table continues)
5
Table 1 (continued) 6
Carter et al. (2010) N = 76 Females; 18–65 years of age; DSM-IV Mage: 25 Deliberate self-harm Low
Design: RCT DBT: Combined weekly individual psychotherapy criteria for BPD; history of multiple % female: 100 and hospitalizations
NR sessions, weekly skills training groups, and episodes of deliberate self-harm with at % race/ethnicity: NR because of self-
weekly supervision and consultation meetings for least three self-reported episodes in harm at 6 months
the therapists. preceding 12 months
TAU (waitlist): A range of individualized service Outpatient, single center, Australia
provisions and professional mental health care.
12 months
Davidson et al. (2006) N = 106 Males and females; 18–65 years of age; met Mage: 32 Suicidal acts, Some
RCT CBT: Average of 27 sessions of CBT over 12 criteria for at least five items of the BPD % female: 84 psychiatric concerns
Other, foundation months in addition to TAU; each session lasted 1 using the DSM-IV Axis II personality % race/ethnicity: hospitalization,
hr. disorders; received either inpatient White: 100 accident, and
TAU: Case management provided by hospital and psychiatric services or an assessment at emergency
primary and community care services. accident and emergency services attendance at 24
24 months Outpatient, multicenter, United Kingdom months
Doering et al. (2010) N = 104 Females; 18–45 years of age; diagnosis of Mage: 28 Suicide attempts, High
RCT TFP: Modified psychodynamic therapy consisted of BPD by DSM-IV criteria % female: 100 dropout from
Other, Austrian bank two 50-min sessions delivered every week by Outpatient, multicenter, Austria and % race/ethnicity: NR therapy at 12
experienced clinical psychologists or medical Germany months
doctors, along with medications as needed for 1
year of treatment.
TAU: Individualized standard care from community
psychiatrists.
12 months
Farrell et al. (2009) Females; 18 and 65 years of age; diagnosis NR Some
CROTTY ET AL.
N = 32 Mage: 36
RCT ST: 30 weekly 1.5-hr group sessions. Treatment of BPD using DIB-R and Borderline % female: 100 concerns
Government, NIMH focused on emotional awareness, Syndrome Index; individual % race/ethnicity: NR
psychoeducation, distress management, and psychotherapy of at least 6 months
schema-focused change work. duration and stable
TAU: Weekly individual psychotherapy in the Outpatient, multicenter, United States
community.
8 months
Follow-up: 6 months
Feigenbaum et al. N = 42 Males and females; 18–65 years of age; Mage: 35 CORE-OM at 12 High
(2012) DBT: Combined weekly individual psychotherapy DSM-IV criteria for cluster B personality % female: 73 months
RCT sessions, weekly skills training groups, and disorder % race/ethnicity: NR
Government, C&IHA, weekly supervision and consultation meetings for Outpatient, single center, United Kingdom
NTRHA the therapists.
TAU (waitlist): A range of individualized service
12 months
(table continues)
Table 1 (continued)

González-González N = 118 Males and females; DSM-5 diagnosis for Mage: 34 NR High
et al. (2021) STEPPS: 20 weekly sessions of group STEPPS BPD, including self-harm or aggressive % female: 85
Prospective cohort psychotherapy, five sessions of group impulsive behaviors for the past 2 years. % race/ethnicity: NR
None psychotherapy for companions, monthly sessions Outpatient, single center, Spain
of individual and family psychotherapy, and the
possibility of therapy in case of an emergency;
this was combined with usual medication and/or
psychiatric consultations.
TAU: Individual psychotherapy, medication, and
case management.
18 months
Gregory and Sachdeva N = 41 Males and females; 18 years of age and Mage: 33 BEST at 12 months High
(2016)a DBT: Combined weekly individual psychotherapy older; met SCID-II and individual % female: 81
Retrospective cohort sessions, weekly skills training groups, and assessment profile criteria for BPD % race/ethnicity:
APsaA weekly supervision and consultation meetings for Outpatient, single center, United States Caucasian: 88
the therapists. Other: 12
TAU: A range of individualized service provisions
and professional mental health care.
12 months
Gregory and Sachdeva N = 44 Males and females; 18 years of age and Mage: 29 BEST at 12 months High
(2016)a DDP: Weekly individual sessions over a 12-month older; met SCID-II and individual % female: 81
Retrospective cohort period and combined elements of translational assessment profile criteria for BPD % race/ethnicity:
APsaA neuroscience, object relations theory, and Outpatient, single center, United States Caucasian: 88
deconstruction philosophy. Other: 12
TAU: Unstructured psychotherapy.
12 months
Hilden et al. (2021) N = 42 Males and females; age NR; met DSM-IV Mage: 29 BSL-23 at 20 weeks Some
RCT ST: 20 weekly 90-min sessions. criteria for BPD as assessed by SCID-II % female: 83 concerns
Other TAU: Once-monthly psychiatrist visits and 45-min Outpatient, single center, Finland % race/ethnicity: NR
therapy sessions.
20 weeks
McMain et al. (2017) N = 84 Males and females; 18–60 years of age; met Mage: 30 Frequency of suicidal Some
RCT DBT: Brief DBT—Skills training only. DSM-IV criteria for BPD; two suicidal % female: 79 or nonsuicidal self- concerns
Ontario Mental Health TAU (waitlist): A range of individualized service and/or NSSI episodes in the past 5 years, % race/ethnicity: NR injurious episodes
Foundation provisions and professional mental health care. with one occurring within 10 weeks prior at 32 weeks
20 weeks to enrollment
Follow-up: 32 weeks Outpatient, single center, Canada
Morton et al. (2012) N = 41 Males and females; 18–55 years of age; ≥4 Mage: 35 BEST at 13 weeks Some
RCT ACT: Weekly group sessions that included DSM-IV criteria of BPD; registered client % female: 93 concerns
NR performing mindfulness exercises, doing of a public sector adult mental health % race/ethnicity: NR
emotions skills training, focusing on awareness of service
one’s values, and identifying choice points for Outpatient, multicenter, Australia
action.
TAU: Case management provided by public mental
health services.
13 weeks
(table continues)
7
Verheul et al. (2003) N = 64 Females; 18–70 years of age, diagnosed Mage: 35 NR Some
van den Bosch et al. DBT: Combined weekly individual psychotherapy with BPD; referred by psychologist or % female: 100 concerns
(2005) sessions, weekly skills training groups, and psychiatrist willing to sign an agreement % race/ethnicity: NR
RCT weekly supervision and consultation meetings for to commit to delivering 12 months of
Dutch Health Insurance the therapists. TAU
Company TAU (waitlist): A range of individualized service Outpatient, various settings, the Netherlands
52 weeks
Weinberg et al. (2006) N = 30 Females; 18–40 years of age; met DSM-IV Mage: 28 NR Some
RCT MACT: Six sessions, over 6–8 weeks, incorporating and DIB-R criteria for BPD; history of % female: 100 concerns
Other, foundation elements of DBT, CBT, and bibliotherapy, repetitive deliberate self-harm with at least % race/ethnicity:
modified to focus on deliberate self-harm; each one episode during the month before White: 93
session was structured around a chapter of a enrollment Nonwhite: 7
booklet, covering functional analysis of episodes Outpatient, single center, United States
of parasuicide (defined as deliberate self-harm or
suicide attempts), emotion regulation strategies,
problem-solving strategies, management of
negative thinking, management of substance use,
and relapse prevention strategies.
TAU: Standard of care not further specified.
Six sessions (duration NR)
Commonly used psychotherapy versus another commonly used psychotherapy (K = 13)

Barnicot and Crawford N = 90 Males and females; met criteria for DSM-IV Mage: 31 NR High
(2019) DBT: Weekly individual therapy and group skills BPD; were about to begin either % female: 72
CROTTY ET AL.
Nonrandomized clinical training, telephone skills coaching, and team outpatient DBT or MBT % race/ethnicity:
trial consultation. Outpatient, multicenter, United Kingdom White: 64
Government, NIH MBT: Weekly or fortnightly individual therapy and Black and minority: 36
weekly group therapy along with a short-term 10-
week group program offering psychoeducation
and support aimed at helping patients get a better
understanding of their problems and suggestions
for better ways of dealing with them.
12 months
Bateman and Fonagy N = 134 Males and females; 18–65 years of age; Mage: 31 Suicide, self-injury, Some
(2009) MBT: 18-month manualized weekly combined diagnosis of BPD using DSM-IV criteria; % female: 80 and hospitalizations concerns
Bateman et al. (2021) individual and group psychotherapy. suicide attempt or episode of life- % race/ethnicity: at 18 months
RCT Supportive therapy: SCM involving individual and threatening self-harm within last 6 months White: 72
Other, foundation group sessions, therapy based on supportive Outpatient, single center, United Kingdom Black: 18
approach with case management, advocacy Other: 10
support, and problem-oriented psychotherapeutic
interventions.
Both groups also received crisis contact and crisis
plans, pharmacotherapy, general psychiatric
review, and written information about treatment.
18 months
(table continues)
Table 1 (continued)

Carlyle et al. (2020) N = 72 Males and females; diagnosis of BPD using Mage: 32 Nonsuicidal self-harm Some
RCT MBT: Manualized weekly 1-hr individual sessions SCID-II % female: 99 and suicide concerns
NR and weekly 1.5-hr group sessions. Outpatient, single center, New Zealand % race/ethnicity: attempts at 18
Supportive therapy: Enhanced therapeutic case New Zealand months
management with case managers using the European: 79
published manual of SCM. European other: 12.5
18 months Mauri: 6
Other: 3
Clarkin et al. (2007) N = 90 Males and females; 18–50 years of age; met Mage: 31 Suicidal behavior at High
RCT DBT: Weekly individual therapy, weekly group DSM-IV criteria for BPD % female: 92 12 months
Other, foundation sessions, and telephone skills coaching. Outpatient, multicenter, United States % race/ethnicity:
TFP: Two individual weekly sessions focused White: 68
primarily on the dominant affect-laden themes Black: 10
that emerge in the patient–therapist relationship. Hispanic: 9
Supportive therapy: One weekly session Asian: 6
supplemented with additional sessions as needed. Other: 8
12 months
Giesen-Bloo et al. N = 88 Males and females; 18–60 years of age; Mage: 31 BPDSI at 36 months High
(2006) TFP: Two sessions per week; focused on the DSM-IV diagnosis of BPD; BPDSI-IV % female: 93
Spinhoven et al. (2007) patient–therapist relationship. score greater than 20 % race/ethnicity: NR
RCT0 ST: Two sessions per week; involving integrated Outpatient, multicenter, the Netherlands
Government, Dutch cognitive therapy focused on four schema modes.
Health Care 3 years
Insurance
Board
Gregory and Sachdeva N = 52 Males and females; age 18 years and older; Mage: 31 BEST scores at 12 High
(2016)a DBT: Weekly individual therapy, weekly group met SCID-II and individual assessment % female: 81 months
Sachdeva et al. (2013) sessions, and telephone skills coaching. profile criteria for BPD % race/ethnicity:
Retrospective cohort DDP: Weekly individual sessions that combined Outpatient, single center, United States Caucasian: 88
APsaA elements of translational neuroscience, object Other: 12
relations theory, and deconstructionist
philosophy.
12 months
Guillén Botella et al. N = 72 Males and females; 14–60 years of age; met Mage: 32 BSL-23 at 6 months High
(2021) DBT: Includes weekly individual therapy and group criteria in DSM-5 for BPD % female: 94
Nonrandomized clinical skills training, telephone skills coaching, and Outpatient, multicenter, Spain % race/ethnicity:
trial team consultation. Caucasian: 100
NR STEPPS: Includes group therapy, a reinforcement
team, telephone consultations with relatives,
consultations with other professionals, and
weekly clinician meetings.
6 months
(table continues)
9
Jørgensen et al. (2013) N = 111 randomized, n = 85 treated Males and females; age 21 and older; met Mage: 30 GAF at 24 months High
RCT MBT: Weekly individual therapy, weekly group DSM-IV criteria for BPD as assessed by % female: 96
NR therapy, monthly group psychoeducational SCID-II; GAF score above 34 % race/ethnicity: NR
program. Outpatient, single center, Denmark
Supportive therapy: Biweekly group therapy,
monthly group psychoeducational program.
Both groups also participated in a
psychoeducational program with group-based
psychoeducation once a month for 6 months and
were offered medical treatment in accordance
with APA recommendation.
24 months
Links et al. (2013) N = 180 Males and females; 18–60 years of age; Mage: 30 Suicidal episodes, High
McMain et al. (2009) DBT: Weekly individual therapy and group skills DSM-IV criteria for BPD; at least two % female: 86 nonsuicidal self-
McMain et al. (2012) training, weekly telephone coaching with explicit episodes of suicidal or nonsuicidal self- % race/ethnicity: NR injury at 12 months
RCT focus on self-harm and suicidal behavior, and injurious episodes in the past 5 years, at
Government weekly therapist team consultation. least one of which was in the 3 months
General psychiatric management: Weekly preceding enrollment
individual therapy that was expanded away from Both inpatient and outpatient, Canada
focusing on self-harm and suicidal behaviors and
included medication management; general
psychiatric therapy also included mandated
therapist supervision weekly meetings.
12 months
CROTTY ET AL.
Note. We used the Cochrane Risk of Bias Tool 2.0 for RCTs, and the Risk of Bias in Nonrandomized Studies of Interventions (ROBINS-I) for non-RCTs. Use of the term “some concerns for risk of
bias” for non-RCTs equates to “moderate risk of bias” on the ROBINS-I tool (see Supplemental Material). ACT = acceptance and commitment therapy; APsaA = American Psychoanalytic Association;
BDCFT = Bradford District Care National Health Service Foundation Trust; BDSI-IV = Borderline Syndrome Index–IV; BEST = borderline evaluation of severity over time; BPD = borderline
personality disorder; BPD-40 = Borderline Personality Disorder Checklist–40; BPDRF = Borderline Personality Disorder Research Foundation; BPDSI = Borderline Personality Disorder Severity Index;
BSL-23 = Borderline Symptom List–23; C&IHA = Camden and Islington Health Authority; CBT = cognitive behavioral therapy; CORE-OM = Clinical Outcomes in Routine Evaluation–Outcome
Measure; DBT = dialectical behavior therapy; DDP = dynamic deconstructive psychotherapy; DFG = German Research Foundation; DIB-R = Diagnostic Interview for Borderlines–Revised; DSM =
Diagnostic and Statistical Manual of Mental Disorders; GAF = global assessment of functioning; MACT = manual-assisted cognitive therapy; MBT = mentalization-based treatment; N = sample size;
NIH = National Institutes of Health; NIMH = National Institute of Mental Health; NR = not reported; NSSI = nonsuicidal self-injury; NTRHA = North Thames Regional Health Authority; RCT =
randomized controlled trial; SCID = Structured Clinical Interview for DSM-IV; SCL-90 = Symptom Checklist–90; SCM = structured clinical management; SLaM = South London and Maudsley
National Health Service Foundation Trust; ST = schema therapy; STEPPS = systems training for emotional predictability and problem solving; TAU = treatment as usual; TFP = transference-focused
psychotherapy; APA = American Psychiatric Association.
a
Gregory and Sachdeva (2016) is a three-arm trial with a total N = 68.
Table 2
Evidence Map With Findings for Commonly Used Psychotherapies Versus TAU
Number (K) of Studies
Range of Study Durations
Commonly used Outcomes
psychotherapies Number (n) of Participants by Outcome
versus treatment Certainty of Evidence
as usual Incidence Withdrawa
Incidence
Global Impression and of Serious l Due to
Severity of BPD Severity of Symptoms Associated with BPD of Adverse
Functioning Adverse Adverse

Events
Events Events
Dialectical K=2 K=6 K=2 No evidence No evidence K=1

Behavior Therapy 20 weeks–12 months 3 -12 months 3 months–20 weeks 12 months
(DBT) vs. TAU n = 41
(Bohus et al., 2004;
Carter et al., 2010; Severity of BPD Anger, Dissociative Impulsiveness Self-harm General Functioning
Feigenbaum et al., n = 125 depression experiences n = 84 (n = 357), psychopatho (n = 50)
2012; Gregory & n = 227 n = 102 suicidal logy
Sachdeva, 2016; and (n = 134)

McMain et al., nonsuicidal
2017; Verheul et al., self-
2003) injuries
(n = 184)
LOW for similar effect VERY LOW for similar LOW for LOW for LOW for VERY LOW for greater VERY LOW
effects similar effects greater greater effect with DBT for similar
effect with effect with risks
DBT DBT
Mentalization- K=1 K=1 K=1 No evidence No evidence No evidence
Based Treatment 12 months 12 months 12 months
(MBT) vs. TAU
(Beck et al., 2020) Severity of BPD BPD symptoms Functioning
n = 112 n = 112 n = 112
LOW for similar effects LOW for similar effects LOW for similar effects
STEPPS vs. TAU K=3 K=1 K=2 K=1 K=1 No evidence No evidence No evidence
(Blum et al., 2008; 20 weeks–24 months 20 weeks–12 months 20 weeks– 20 weeks 12 months
Bos et al., 2010; 12 months
González-González Severity of BPD
et al., 2021) n = 362 Depression, impulsiveness Self-harm General Functioni Quality of
n = 165 attempts, suicide psychopatho ng n = 124 life
attempts logy n = 244 N = 79
n = 165
MODERATE for LOW for greater effect with STEPPS LOW for similar MODERAT LOW for Moderate
greater effect with effects E for greater greater for greater
STEPPS effect with effect effect
STEPPS with with
STEPPS STEPPS
Dynamic K=1 K=1 K=1 No evidence No evidence No evidence

Deconstructive 12 months 12 months 12 months
Psychotherapy
(DDP) vs. TAU Severity of BPD Functioning
(Gregory & n = 44 n = 44
Sachdeva, 2016) Depression Self-injuries,
n = 44 suicide attempts
n = 44
VERY LOW for greater VERY LOW for greater effect with VERY LOW for VERY LOW for greater effect with
effect with DDP DDP similar effects DDP
Schema Therapy K=2 K=2 K=3 No evidence No evidence No evidence

(ST) vs. TAU 20 weeks–36 months 20 weeks–14 months N=527
(Arntz et al., 2022; 14 – 36 months
Farrell et al., 2009;
Hilden et al., 2021; Severity of BPD BPD symptoms Depression Anxiety General psychopathology, Quality of
Leppänen et al., n = 529 n = 28 n = 35 n = 35 funconing life
2016) n = 522 n = 494
LOW for inconsistent LOW for greater effect with LOW for similar effect LOW for greater effect MODERAT
findings ST with ST E for greater
effect with
ST
Transference- K=1 K=1 K=1 K=1 No evidence No evidence No evidence

Focused 12 months 12 months 12 months 12 months
Psychotherapy General Functioning
(TFP) vs. TAU Severity of BPD Anxiety, depression, suicide attempts psychopathology n = 104
(Doering et al., n = 104 n = 104 n = 104
2010)
LOW for greater effect VERY LOW for similar effects VERY LOW for LOW for greater
with TFP similar effects effect with TFP
(table continues)
12 CROTTY ET AL.
Table 2 (continued)
Range of Study Durations
Commonly used Outcomes
Number (n) of Participants by Outcome
psychotherapies
Certainty of Evidence
versus treatment
Incidence Withdrawa
as usual Incidence
Global Impression and of Serious l Due to
Events
Events Events
Acceptance and K=1 K=1
Commitment n = 41 n = 41 No evidence No evidence No evidence No evidence
Therapy (ACT) vs. 13 weeks 13 weeks
TAU (Morton et al.,
2012) Severity of BPD Anxiety, depression, emotion regulation, hopelessness
LOW for greater effect LOW for greater effect with ACT
with ACT
Manual Assisted K=1

Cognitive Therapy No evidence n = 30 No evidence No evidence No evidence No evidence
(MACT) vs. TAU 6 months post-treatment
(Weinberg et al.,
2006) Deliberate self-harm
LOW for greater effect with MACT

Cognitive No evidence K=1 K=1 No evidence No evidence No evidence
Behavioral n = 102 n = 102
Therapy (CBT) vs. 24 months 24 months
TAU (Davidson et
al., 2006) Anxiety, mean number of suicidal acts Depression, Quality of life, social functioning
proportion of
participants with
suicidal acts
LOW for greater effect with CBT LOW for similar LOW for similar effects
risks
Similar effects Favors psychotherapy Inconsistent findings
Note. K = number of studies; n = number of participants; TAU = treatment as usual; BPD = borderline personality disorder; STEPPS = systems training
for emotional predictability and problem solving. See the online article for the color version of this table.
Dialectical Behavior Therapy Versus Treatment as Usual treated with DBT and TAU after 12 months (Gregory &
Sachdeva, 2016).
Six studies (seven publications), four RCTs (Carter et al., 2010;
Feigenbaum et al., 2012; McMain et al., 2017; van den Bosch et al.,
2005; Verheul et al., 2003), a nonrandomized trial (Bohus et al., Severity of Symptoms Associated With Borderline
2004), and a retrospective cohort study (Gregory & Sachdeva, 2016) Personality Disorder
evaluated the efficacy of DBT compared with TAU. Overall, these
studies provided data on 357 participants. We rated three studies as Two RCTs reported fewer suicide attempts by participants
having a high risk of bias (Bohus et al., 2004; Feigenbaum et al., assigned to the DBT group than by participants assigned to TAU
2012; Gregory & Sachdeva, 2016), two as some concerns for risk of reaching statistical significance in just one (8% vs. 6%, p < .04;
bias (McMain et al., 2017; van den Bosch et al., 2005; Verheul et al., McMain et al., 2017; van den Bosch et al., 2005; Verheul et al.,
2003), and one as low risk of bias (Carter et al., 2010). Follow-up 2003). In contrast, two other studies (one RCT; Feigenbaum et al.,
durations ranged from 4 to 12 months. All except one study 2012) and one cohort study (Gregory & Sachdeva, 2016) reported
(Gregory & Sachdeva, 2016) employed a waitlist design where no significant differences in suicide attempts between treatment
participants in the TAU groups were offered DBT at the end of the groups.
study. Overall, we found low strength of evidence favoring DBT All studies reported on self-harm, defined variously as deliberate
over TAU for the treatment of one or more BPD-related outcomes. self-harm, self-injury, and self-mutilation. Most trials showed
greater reductions in self-harm in the DBT group than in the TAU
group. The only study rated as low risk of bias also reported
Severity of Borderline Personality Disorder numerically fewer episodes of self-harm, but no statistically
significant differences in the number or proportion of self-harm
In one study (N = 84), participants receiving brief DBT achieved episodes between those receiving TAU and those receiving DBT
significantly greater reductions on the Borderline Symptom List–23 (Carter et al., 2010). Two trials (N = 114) reported a reduction in
compared with participants in the TAU group at the end of the self-mutilating behaviors (35% vs. 57%; p = .003 and 62% vs. 31%,
intervention (5 months; −22.6 vs. −10.3, p < .01) but not at the 8- p = .039) among participants receiving DBT compared with those
month follow-up (McMain et al., 2017). A retrospective cohort receiving TAU (Bohus et al., 2004; Verheul et al., 2003).
study (N = 41) reported no significant differences on the borderline Two studies reported on dissociative experiences, aggression,
evaluation of severity over time (BEST) scale between participants anger, depression, and impulsiveness (see Table 2; Bohus et al.,
2004; Feigenbaum et al., 2012; McMain et al., 2017). However, Severity of Symptoms Associated With Borderline
findings were graded as very low certainty of evidence, preventing Personality Disorder
us from drawing any conclusions from the data.
One study reported significant improvement in impulsiveness
(72.7 vs. 76.8, p = .004) and depression (22.0 vs. 25.8, p = .03) for
participants in the STEPPS group when compared with TAU at 5
Global Impression and Functioning
months (Blum et al., 2008). The same study reported no significant
In one study, more participants in the brief DBT group than in the differences in the number of suicide attempts or self-harm acts at 12
TAU group achieved clinically relevant improvements on the months.

Symptom Checklist–90–Revised at 8 months (43.8% vs. 18.4%; p =
.024; McMain et al., 2017). Likewise, another study reported greater Global Impression and Functioning
improvements in the global severity index (0.56 vs. 0.07; p = .005;
Bohus et al., 2004) and the Global Assessment of Functioning Scale In general, compared with TAU, participants receiving STEPPS
(11.4 vs. 1.3; p = .003) after 4 months of treatment with DBT than experienced greater improvements in global symptoms, functioning,
with TAU (Bohus et al., 2004). and quality of life at the end of treatment with no difference between
treatments on some measures over the longer term. At their primary
endpoints, both RCTs reported significant improvement on the
MBT Versus Treatment as Usual Symptom Checklist–90 (SCL-90) at 5 months, 12.5 versus 14.1
(data scaled), p = .03 (Blum et al., 2008), and at 12 months, 199.2
MBT is a psychodynamic treatment rooted in attachment and
versus 222.7, p = .001 (Bos et al., 2010). One study reported
cognitive theory. Treatment consists of weekly combined
significant improvement for the STEPPS group when compared
individual and group psychotherapy, focusing on the mentalizing
with TAU at 5 months in clinical global impressions (CGI) severity
strengths and failures associated with the affective, impulsive, and
(4.4 vs. 4.7, p < .001) and CGI improvement (2.7 vs. 3.8, p < .001)
interpersonal symptoms of BPD (Bateman et al., 2021). One RCT ratings, but found no significant differences between 5 months and
(N = 112), rated as high risk of bias, evaluated the efficacy of MBT 12 months on the SCL-90 or CGI severity or improvement ratings
compared with TAU in 14–17-year-old participants (Beck et al., (Blum et al., 2008).
2020). This was the only study of adolescents with BPD meeting Regarding functioning, one study reported significant differences
inclusion criteria. After 12 months of treatment, the study reported favoring the STEPPS group at 5 months (50.5 vs. 43.5, p < .001 on
no significant differences between groups in severity of BPD, the Global Assessment Scale) but no significant differences between
severity of symptoms, and global impression and functioning (see 5 and 12 months (Blum et al., 2008). The same study reported no
Supplemental Material). significant differences in social adjustment (measured by the Social
Adjustment Scale at 5 months and between 5 and 12 months).
One study rated reported significant improvement in the World
Systems Training for Emotional Predictability and
Health Organization Quality of Life Brief scale for the STEPPS
Problem Solving Versus Treatment as Usual
group when compared with TAU at 12 months (12.6 vs. 11.3 p =
STEPPS is a group treatment that combines cognitive behavior .006; Bos et al., 2010).
elements and skills training with a systems component for
individuals with whom a patient regularly interacts (Blum et al., Dynamic Deconstructive Psychotherapy Versus
2008). Two RCTs—one rated as some concerns for risk of bias (Bos Treatment as Usual
et al., 2010) and the other as high risk of bias (Blum et al., 2008)—
and a high risk-of-bias prospective cohort study (González- Dynamic deconstructive psychotherapy combines elements of
González et al., 2021) evaluated the efficacy of STEPPS compared translational neuroscience, object relations theory, and deconstruc-
with TAU. Together, the studies provided data on 362 participants. tion philosophy (Gregory & Remen, 2008). A retrospective cohort
Overall, across multiple outcomes, moderate-to-low certainty of study of 44 participants rated high risk of bias (Gregory & Sachdeva,
evidence favored STEPPS over TAU for the treatment of BPD. 2016) evaluated the efficacy of dynamic deconstructive psycho-
therapy compared with TAU. At 12 months’ follow-up, outcomes
related to severity of BPD, severity of symptoms, and functioning
Severity of Borderline Personality Disorder tended to favor dynamic deconstructive psychotherapy (Table 2 and
in the Supplemental Material). However, results were graded as very
Both trials reported significant improvements in the severity of low certainty of evidence, meaning that we have very low
BPD, 9.8 versus 13.4, p = .001 on the Zanarini Rating Scale for BPD confidence that the findings reflect the true effect. Therefore, we
(Blum et al., 2008) and 78.2 versus 88.6, p = .001 on the Borderline cannot draw conclusions from the data.
Personality Disorder Checklist–40 (Bos et al., 2010), at the primary
endpoint (5 and 12 months, respectively). Similarly, using the BEST
Schema Therapy Versus Treatment as Usual
scale, the cohort study reported significantly improved BPD severity
at 2 years for participants receiving STEPPS compared with those Schema therapy combines emotional awareness training,
receiving TAU (47.3 vs. 28.8, p < .01; González-González psychoeducation, distress management training, and schema change
et al., 2021). work (Farrell et al., 2009). Three RCTs (N = 569) evaluated the
14 CROTTY ET AL.
efficacy of schema therapy (Arntz et al., 2022; Farrell et al., 2009; for participants receiving schema therapy in addition to TAU
Hilden et al., 2021). One compared schema therapy plus TAU to compared to those receiving TAU alone (Farrell et al., 2009).
TAU alone (Farrell et al., 2009). The other two compared schema
therapy alone to some form of TAU (Arntz et al., 2022; Hilden et al., Transference-Focused Psychotherapy Versus
2021). Two were rated as some concerns for risk of bias (Farrell et
Treatment as Usual
al., 2009; Hilden et al., 2021), and one was rated as high risk of bias
(Arntz et al., 2022). Transference-focused psychotherapy is a modified psychody-
namic psychotherapy for people with BPD (Doering et al., 2010).
One RCT (N = 104), rated as high risk of bias, evaluated the efficacy
Severity of Borderline Personality Disorder of transference-focused psychotherapy compared with TAU
Two RCTs reported on the severity of BPD with mixed findings (Doering et al., 2010).
(Arntz et al., 2022; Hilden et al., 2021). Both studies reported
differences from baseline rather than endpoint scores. One study Severity of Borderline Personality Disorder
(N = 42), rated some concerns for risk of bias, found no statistically
significant difference between participants receiving schema Transference-focused psychotherapy was superior to TAU for the
therapy and those receiving TAU in Borderline Symptom List– number of Diagnostic and Statistical Manual of Mental Disorders,
23 decline at 20 weeks (6.95 in the schema therapy group vs. 12.55 Fourth Edition (DSM-IV) diagnostic criteria (on average for BPD)
in the TAU group, p = .34; Hilden et al., 2021). In the other trial, and for the proportion of participants having fewer than five DSM-IV
rated high risk of bias, at 3 years’ follow-up, participants receiving borderline criteria after 1 year (42.3% vs. 15.4%; p = .002; Doering
schema therapy (either predominantly group or combined individual et al., 2010).
and group therapy) reported significantly greater reductions from
baseline in BPD severity index total scores compared with Severity of Symptoms Associated With Borderline
participants receiving TAU with a medium-to-large effect size Personality Disorder
(standardized mean difference [SMD] 0.73; p = .001; Arntz et al.,
2022). Similarly, compared with TAU, treatment with schema At 12 months’ follow-up, the study found greater improvements
therapy resulted in greater reductions in borderline personality in the severity of BPD among participants receiving transference-
disorder checklist scores at 3 years’ follow-up (SMD, 0.33; p = .04; focused psychotherapy compared with TAU—significantly more
Arntz et al., 2022). participants in the transference-focused psychotherapy group met
fewer than five DSM-IV criteria for BPD at 12 months (42.3% vs.
15.4%; p = .002).
Severity of Symptoms Associated With Borderline The study also measured suicide attempts, depression, and
Personality Disorder anxiety, but these outcomes were graded as very low certainty
of evidence, which prevented us from drawing meaningful
Two RCTs reported on the severity of symptoms associated with conclusions.
BPD, with mixed findings (Farrell et al., 2009; Hilden et al., 2021).
One study, rated some concerns for risk of bias, reported no
significant difference among participants receiving schema therapy Global Impression and Functioning
and those receiving TAU in mean overall anxiety severity and Transference-focused psychotherapy was significantly superior
impairment scale scores and in depression scores at 20 weeks to TAU for global assessment of functioning scores (58.62 vs.
(Hilden et al., 2021). Another study, also rated some concerns for 56.06; p = .002) but not for the Brief Symptom Inventory.
risk of bias, reported significant improvements (lower scores) on the
borderline symptom index at 14 months for participants receiving
schema therapy compared to those receiving TAU (15.75 vs. 33.08, Acceptance and Commitment Therapy Versus
respectively, at endpoint, p < .001; Farrell et al., 2009). Treatment as Usual
Acceptance and commitment therapy is an action-oriented
Global Impression and Functioning approach to psychotherapy that stems from traditional behavior
therapy and CBT. ACT applies mindfulness and acceptance
Two RCTs reported on functioning and general psychopathology processes, and commitment and behavior change processes, to
(Arntz et al., 2022; Farrell et al., 2009) and one reported on quality the creation of psychological flexibility (Hayes et al., 1999). One
of life (Arntz et al., 2022). All found treatment with schema therapy RCT (N = 41) rated as some concerns for risk of bias, evaluated the
more effective than TAU. In one study, rated high risk of bias, at 36 efficacy of ACT in addition to TAU compared with TAU alone
months’ follow-up schema therapy was significantly superior to (Morton et al., 2012).
TAU for global assessment of functioning scores (SMD, 0.49; p =
.008), brief symptom inventory scores (SMD, 0.42; p = .005), and Severity of Borderline Personality Disorder
on the World Health Organization Quality-of-Life scale (SMD,
0.26; p = .01; Arntz et al., 2022). Similarly, another study, rated as After 13 weeks of treatment, the study reported significantly
some concerns for risk of bias, reported significantly better global greater improvements from baseline on the BEST scale for
assessment of functioning scores (66.19 vs. 48.24, p < .001) and participants in the ACT plus TAU group compared with TAU
Symptom Checklist–90 scores (0.96 vs. 1.93, p < .001) at 14 months alone (−11.8 vs. −2.4; p = .028; Morton et al., 2012).
Severity of Symptoms Associated With Borderline Global Impression and Functioning

Personality Disorder
No significant differences between treatment groups were
Participants who received ACT in addition to TAU had detected for the Social Functioning Questionnaire and the
significantly greater improvements from baseline on the Beck European Quality of Life–5 Dimension instrument after 12 months
Hopelessness Scale than participants treated with TAU only (−4.7 (Davidson et al., 2006).
vs. +0.7; p = .006), the Difficulties in Emotion Regulation Scale
(−18.7 vs. +5.6; p = .008), and the subscale for anxiety of the Commonly Used Psychotherapies Versus Other
Depression Anxiety Stress Scale (−3.66 vs. +2.08; p = .025). Commonly Used Psychotherapies
Changes on the subscales for depression and stress of the Depression
Anxiety Stress Scale were also greater for the ACT group but did not Table 3 provides an overview of the findings of the evidence
achieve statistical significance (Morton et al., 2012). comparing commonly used psychotherapies with other
psychotherapies.
Manual-Assisted Cognitive Therapy Versus DBT Versus MBT, STEPPS, Dynamic Deconstructive
Treatment as Usual Psychotherapy, Transference-Focused Psychotherapy,
Manual-assisted cognitive therapy incorporates elements of DBT, and Supportive Therapy
CBT, and bibliotherapy (Weinberg et al., 2006). One some concerns
As outlined in Table 3 and in the Supplemental Material, one
for risk-of-bias RCT (N = 30) evaluated the efficacy of MACT,
nonrandomized clinical trial (N = 90) rated high risk of bias,
compared with TAU (Weinberg et al., 2006).
compared DBT with MBT for BPD (Barnicot & Crawford, 2019).
Another nonrandomized clinical trial (N = 72) rated high risk of
bias, compared DBT with STEPPS (Guillén Botella et al., 2021). A
Severity of Symptoms Associated With Borderline three-armed retrospective cohort study (reported in two publica-
Personality Disorder tions) rated high risk of bias, compared DBT (N = 25) with dynamic
deconstructive psychotherapy (N = 27) and TAU in 68 patients with
The study reported significant reductions in the frequency (1.98
BPD (Gregory & Sachdeva, 2016; Sachdeva et al., 2013). A three-
vs. 6.69, p < .001), and severity (0.51 vs. 1.01, p < .001) of
armed RCT (N = 62) rated as high risk of bias compared DBT with
deliberate self-harm for participants in the MACT group when
transference-focused psychotherapy and with supportive therapy
compared with TAU after 6 months of treatment. The authors
(Clarkin et al., 2007). These studies reported on multiple outcomes,
recorded the use of the Parasuicide History Interview to identify the
including BPD severity, symptoms, and global functioning (Table 3
frequency or severity of deliberate self-harm but did not specify the
and in the Supplemental Material). However, for each comparison,
range of the scale for assessing severity.
the certainty of evidence was graded as very low, which prevented
meaningful conclusions. Therefore, there is currently insufficient
Cognitive Behavioral Therapy Versus evidence to determine the comparative effectiveness of DBT versus
these other psychotherapies.
Treatment as Usual
The borderline personality disorder study of cognitive therapy Dialectical Behavior Therapy Versus Manualized
(BOSCOT; N = 106) randomized trial rated as some concerns for
General Psychiatric Management for Borderline
risk of bias, evaluated the efficacy of CBT in addition to TAU
compared with TAU alone (Davidson et al., 2006).
One RCT, described in three publications and rated high risk of
bias, compared DBT with well-specified manualized general
Severity of Symptoms Associated With Borderline psychiatric management in 180 patients with BPD (Links et al.,
Personality Disorder 2013; McMain et al., 2009, 2012).
The proportion of participants who engaged in suicidal acts

Severity of Borderline Personality Disorder
(defined as acts that were deliberate, life threatening, and resulting in
or requiring medical intervention) was not significantly different At the end of the 12-month treatment phase and again at the 36-
between treatment groups after 24 months’ follow-up. The number month follow-up, there was no significant difference in severity of
of mean suicidal acts per person had not reached significant BPD on the Zanarini Rating Scale for BPD among patients receiving
differences at 12 months but was significantly lower for participants DBT and those receiving general psychiatric management.
in the CBT group than the TAU group after 24 months (0.87 vs.
1.73; p = .02). Improvements on the State-Trait Anxiety Inventory Severity of Symptoms Associated With Borderline
were significantly greater for participants in the CBT group
compared with those treated with TAU after 24 months but not after
12 months (5.4 vs. 0.5; p = .01). There were no significant After 12 months of treatment and at the 36-month follow-up, there
differences between treatment groups on the Beck Depression were no significant differences between DBT and general
Inventory or in the number of hospitalizations after 12 months. psychiatric management across multiple measures of symptom
16 CROTTY ET AL.
Table 3
Evidence Map With Findings for Commonly Used Psychotherapies Versus Another Commonly Used Psychotherapy
Number (n) of Participants
Commonly used Range of Study Durations
psychotherapies Outcomes
versus other Certainty of Evidence
commonly used Incidence Withdrawa
Incidence
psychotherapies Global Impression and of Serious l Due to
Events
Events Events
DBT vs. MBT K=1 K=1 No evidence No evidence No No evidence
(Barnicot & n = 90 n = 90 evidence
Crawford, 2019) 12 months 12 months
Severity of BPD Dissociative experiences, emotional dysregulation, self-harm
incidents
VERY LOW for similar VERY LOW for similar effects
effects
DBT vs. K=1 K=1 K=1 No evidence No No evidence
manualized n = 180 n = 180 n = 180 evidence
general psychiatric 12 months 12 months 12 months
management for
BPD (Links et al., Severity of BPD Depression Nonsuicidal self- Interpersonal functioning, symptom
2013; McMain et injuries, suicidal distress
al., 2012; McMain episodes
et al., 2009) LOW for similar effects LOW for similar effects at 12 months LOW for similar LOW for similar effects
effects
LOW for greater effect with general
psychiatric management at 36 months
DBT vs. STEPPS K=1 K=1 K=1 No evidence No No evidence
(Guillén Botella et n = 72 n = 72 n = 72 evidence
al., 2021) 6 months 6 months 6 months
Severity of BPD Anxiety, depression, dissociation experiences, suicide risk Quality of life
VERY LOW for greater VERY LOW for similar effects VERY LOW for similar effects
effect with DBT
DBT vs. DDP K=1 K=1 K=1 No evidence No No evidence

(Gregory & n = 52 n = 52 n = 52 evidence
Sachdeva, 2016; 12 months 12 months 12 months
Sachdeva et al.,
2013) Severity of BPD Depression, self-harm Suicide attempts Disability
VERY LOW for greater VERY LOW for greater effect with VERY LOW for VERY LOW for greater effect with DDP
effect with DDP DDP similar effects
DBT vs. TFP vs. No evidence K=1 K=1 No evidence No No evidence

supportive therapy n = 40 n = 40 evidence
(Clarkin et al., 12 months 12 months
2007) Depression, anxiety, suicidal behaviors Global functioning
VERY LOW for similar effects VERY LOW for similar effects
DBT vs. supportive No evidence K=1 K=1 No evidence No No evidence

therapy (Clarkin et n = 39 n = 39 evidence
al., 2007) 12 months 12 months
Depression, anxiety, suicidal behaviors Global functioning
TFP vs. supportive No evidence K=1 K=1 No evidence No No evidence

therapy (Clarkin et N = 45 n = 45 evidence
al., 2007) 12 months 12 months
Depression, anxiety, suicidal behaviors Global functioning
MBT vs. No evidence K=1 K=2 K=2 K=2 No evidence No No evidence

supportive therapy n = 85 n = 219 n = 206 n = 219 evidence
(Bateman et al., 24 months 18–24 months 18 months 18–24 months
2021; Bateman &
Fonagy, 2009; Anxiety Depression Severe self-harm, General Global functioning
Carlyle et al., 2020; suicide attempts psychopathology,
Jørgensen et al., interpersonal
2013) functioning
VERY LOW VERY LOW for LOW for VERY LOW for LOW for greater
for similar inconsistent effects inconsistent inconsistent effect with MBT
effects effects effects
TFP vs. schema- K=1 No evidence K=1 No evidence No No evidence

focused therapy n = 88 n = 88 evidence
(Giesen-Bloo et al., 36 months 36 months
2006; Spinhoven et
al., 2007) Severity of BPD Quality of life
VERY LOW for greater VERY LOW for similar effects
effect with schema-
focused therapy
Similar effects Favors first psychotherapy Favors second psychotherapy Inconsistent findings
Note. K = number of studies; n = number of participants; BPD = borderline personality disorder; DBT = dialectical behavior therapy; MBT =
mentalization-based treatmen; STEPPS = systems training for emotional predictability and problem solvingt; DDP = dynamic deconstructive
psychotherapy; TFP = transference-focused psychotherapy. See the online article for the color version of this table.
severity, including the number of suicidal episodes and the number evidence from these same two studies prevented us from drawing
of nonsuicidal self-injuries. With respect to depression, there was no meaningful conclusions related to general psychopathology and
significant difference between groups in Beck Depression Inventory interpersonal functioning (Bateman & Fonagy, 2009; Jørgensen
scores at the end of the 12-month treatment phase. However, at 36 et al., 2013).
months (24-month posttreatment), mean Beck Depression Inventory
scores were significantly lower among patients in the general
psychiatric management group than in the DBT group (17.4 vs. Transference-Focused Psychotherapy Versus
12.7; p = .004; McMain et al., 2012). Supportive Therapy and Schema-Focused Therapy
One three-armed RCT (N = 62) rated as high risk of bias

Global Impression and Functioning compared DBT, transference-focused psychotherapy, and sup-
portive therapy (Table 3 and Supplemental Material; Clarkin et al.,
The study reported no significant differences between treatment 2007). Treatment duration was 12 months. Another RCT (N = 88)
groups on the Symptom Checklist–90–Revised and the Inventory of rated as high risk of bias compared transference-focused
Interpersonal Problems.
psychotherapy with schema-focused therapy over 36 months

(Giesen-Bloo et al., 2006; Spinhoven et al., 2007). The certainty of
MBT Versus Supportive Therapy evidence across outcomes was graded as very low for transference-
focused therapy versus supportive therapy, as well as for
Three RCTs, described in four articles, compared MBT with transference-focused therapy versus schema therapy, thereby
supportive therapy (Bateman et al., 2021; Bateman & Fonagy, 2009; making meaningful conclusions impossible.
Carlyle et al., 2020; Jørgensen et al., 2013). Together, these studies
provided data on 317 participants. Supportive therapy was not
identical across the studies, but all included group sessions that Harms
focused on supportive techniques, such as problem solving. We
rated two studies as some concerns for risk of bias (Bateman & Incidence of treatment-related adverse events, serious adverse
Fonagy, 2009; Carlyle et al., 2020) and the other as high risk of bias events, and withdrawal due to adverse events were poorly reported,
(Jørgensen et al., 2013). with just two studies reporting any data (see Tables 2 and 3). One
study comparing MBT with TAU reported no adverse events in any
arm (Beck et al., 2020); another study reported no differences in
Severity of Symptoms Associated With Borderline withdrawals due to adverse events between participants treated with
Personality Disorder DBT and TAU (0% vs. 0%; Gregory & Sachdeva, 2016).
All three studies assessed symptoms associated with BPD and
reported mixed findings. Following 18 months of treatment, a some
Discussion
concerns for risk-of-bias study by Bateman et al., 2021 (N = 134)
reported a significant reduction in suicide attempts (0.03 vs. 0.32; Although multiple recent systematic reviews have been published
p < .001) and life-threatening self-harm (0.38 vs. 1.66; p < .001) in the on the use of psychotherapies to treat BPD, all were limited to RCTs
previous 6-month period, along with improvements in interpersonal (Cristea et al., 2017; Oud et al., 2018; Storebø et al., 2020). To the
functioning (1.28 vs. 1.65; p < .001) among patients receiving MBT best of our knowledge, this is the only recent systematic review to
compared with supportive therapy and case management (Bateman include RCTs, nonrandomized trials, and observational studies in an
& Fonagy, 2009). A 6-year follow-up of 97 participants revealed investigation of the comparative effectiveness of a broad range of
that, compared with the supportive treatment and case management commonly used psychotherapies. While RCTs provide the best
group, significantly more of the MBT group who had achieved the quality evidence for determining the comparative effectiveness of
primary recovery criteria (i.e., free of self-harm, suicide attempts, interventions, non-RCT’s can provide important complementary
and inpatient hospital stays) remained well over that 6-year period evidence including about the effectiveness of interventions in
(Bateman et al., 2021). In contrast, a similar study, rated some populations excluded from RCTs, and on the risk of harms of
concerns for risk of bias, that attempted to replicate findings by interventions.
Bateman et al. found no significant differences between groups in The certainty and direction of evidence for the effectiveness of
incidents of severe self-harm and suicide attempts in the previous 6 psychotherapies compared with TAU varied across psychotherapies
months (Carlyle et al., 2020). Studies also reported on depression and often varied across outcome measures for each psychotherapy.
(Bateman et al., 2021) and anxiety (Jørgensen et al., 2013) but the Overall, TAU and nine included psychotherapies were effective in
certainty of evidence for these outcomes was very low, preventing treating the severity and symptoms of BPD. Moderate-to-low
meaningful conclusions. certainty of evidence suggests that DBT, STEPPS, schema therapy,
transference-focused psychotherapy, ACT, MACT, and CBT were
Global Impression and Functioning more effective than TAU for the treatment of one or more BPD-
related outcomes. Head-to-head comparisons of psychotherapies
Two studies reported significant improvement in independently were limited to single studies, with mostly very low certainty of
rated global assessment functioning among patients receiving MBT evidence preventing us from drawing meaningful conclusions from
compared with patients receiving supportive therapy (60.9 vs. 53.2; the findings. Low certainty of evidence suggested similar effects
p < .001 and 56.7 vs. 51.3; p = .007, respectively; Bateman & between DBT and manualized general psychiatric management for
Fonagy, 2009; Jørgensen et al., 2013). Very low certainty of the treatment of BPD and similar effects between MBT and
18 CROTTY ET AL.
supportive treatment. Treatment-related harms were very poorly meta-analysis did not meet criteria based on established guidance
reported, with no obvious differences across psychotherapies. (Gartlehner et al., 2012) and could be misleading.
DBT was the most studied psychotherapy for the treatment of Because we did not combine results, our findings are less
BPD; it was included as a study arm in 12 of the 25 studies meeting definitive than other recent systematic reviews in terms of the
inclusion criteria. Low strength of evidence suggests that DBT is effectiveness of psychotherapy versus TAU but are very similar to
more effective than TAU in reducing symptoms associated with other systematic reviews in that we found no significant differences
BPD and improving functioning, but mixed findings suggest that across various psychotherapy treatments. A 2020 Cochrane meta-
TAU may be as effective as DBT in improving the severity of BPD. analysis of findings from 16 different psychotherapies in RCTs
Due to very low certainty of evidence, we were unable to draw published through March 2019 found moderately good quality
conclusions from studies comparing DBT with MBT, transference- evidence that psychotherapy reduces BPD symptom severity
focused psychotherapy, supportive therapy, STEPSS, and dynamic compared to TAU; SMD: −0.52, 95% confidence interval (CI)
deconstructive psychotherapy. Overall, despite its dominance and [−0.70, −0.33]; 22 trials (Storebø et al., 2020). The review also
popularity as a first-line psychotherapy treatment for BPD, we did found low-quality evidence that psychotherapy may be more
not find DBT to be superior to other psychotherapies. effective than TAU at reducing self-harm and suicide-related
MBT is arguably the second most popular line of psychotherapy outcomes and may be more effective than TAU at improving
for the treatment of BPD. However, we found low strength of psychosocial functioning (Storebø et al., 2020). Similar to our
evidence from just one study of 112 adolescent participants, which findings, the review found no clear differences between the various
suggests no difference between MBT and TAU for severity of BPD, psychotherapies for the treatment of BPD. A 2018 meta-analysis
severity of symptoms, or global impression and functioning (Beck combined findings from studies that compared DBT, MBT, or TFP
et al., 2020). In terms of comparative effectiveness, the evidence was to TAU or community treatment by experts and also found
inconsistent and generally of very low certainty, preventing moderate-quality evidence that these psychotherapies are effective
meaningful conclusions. Overall, the evidence does not support in reducing overall BPD severity (SMD: −0.59; 95% CI [−0.90,
recommending MBT over TAU for the treatment of BPD in −0.28]; Oud et al., 2018). The analysis found no differences for
adolescents and does not support the use of MBT over other almost any outcomes when comparing the selected psychotherapies
psychotherapies. to other protocolized psychological treatments, including general
Low-to-moderate certainty of evidence suggests that STEPPS is psychiatric management, structured clinical management, client-
more effective than TAU for improving BPD severity, severity of centered therapy, and supportive psychotherapy (Oud et al., 2018).
A 2017 systematic review and meta-analysis of adults with BPD
symptoms associated with BPD, and global impression and
found that, compared with TAU, DBT and psychodynamic
functioning. There is insufficient evidence comparing STEPPS to
approaches were effective in improving BPD symptoms and self-
other psychotherapies for the treatment of BPD.
harm and suicide outcomes; like the other reviews, it found no
Low-to-moderate certainty of evidence suggests that schema
difference between types of psychotherapies (Cristea et al., 2017).
therapy is more effective than TAU for improving BPD symptoms,
There are several notable limitations to this systematic review.
global functioning, and quality of life. However, findings were
We limited study populations to those diagnosed with DSM-IV or
inconsistent for the effectiveness of schema therapy compared with
later, thereby excluding some early trials. We did not require
TAU for treating the severity of BPD, and low strength of evidence
included studies to have a registered published protocol—
suggests that TAU is as effective as schema therapy for treating
consequently, selective reporting bias is a possibility. Discerning
depression and anxiety among patients with BPD. There is
which comparators to categorize as TAU was sometimes challeng-
insufficient evidence comparing schema therapy to other psy-
ing. We defined TAU as interventions that were explicitly described
chotherapies for the treatment of BPD. as TAU, had a flexible approach, and did not adhere to a manualized
Multiple factors, including overlapping treatment components or prespecified regimen. However, TAU varied broadly across
across the various psychotherapies, variations in the provision of studies, introducing substantial heterogeneity and making synthesis
TAU, variations in treatment protocols across studies, and and comparisons challenging. Similarly, psychotherapy compo-
significant challenges in studying patients with BPD, contribute nents, intensity, and duration often varied across studies, which
to the lack of robust evidence for the comparative effectiveness of introduced further heterogeneity. Added to differences in BPD
psychotherapies to treat BPD. Characteristics of the disorder make it symptomatology among participants, as well as differences in
particularly difficult to retain participants in trials. In addition, therapist type and expertise, these likely explain some of the
treatment implementation, level of therapist expertise, and patient observed inconsistencies. In addition, the small number of trials for
symptoms can vary tremendously across studies, making cross- each psychotherapy lowered the overall strength of evidence,
study comparisons difficult and open to misinterpretation if studies particularly for examining head-to-head studies comparing a
are inappropriately combined. commonly used psychotherapy to another psychotherapy. A wide
Since this review was focused on the comparative effectiveness of range of outcome measures with varying scales were employed
individual psychotherapies, we did not combine findings across across studies to measure the severity of BPD, BPD-specific
psychotherapies for a meta-analysis of “any psychotherapy” versus symptoms, global clinical assessment, and functioning, which
TAU. Where sufficient information was available (e.g., for DBT, further complicated and limited comparisons.
STEPPS, and schema therapy), we did consider meta-analysis for In clinical practice, patients with BPD are often treated with
each psychotherapy versus TAU, but given substantial heterogene- medication alone or in conjunction with psychotherapy. In a
ity across studies in terms of the patient populations studied, previous systematic review we conducted, which analyzed the
outcomes measured, and intervention fidelity, we determined that comparative effectiveness of pharmacological treatments for BPD,
we found that there is insufficient evidence to support the efficacy of Bateman, A., Constantinou, M. P., Fonagy, P., & Holzer, S. (2021). Eight-
pharmacotherapies alone in reducing the severity of BPD year prospective follow-up of mentalization-based treatment versus
(Gartlehner et al., 2021). Therefore, considering these findings, structured clinical management for people with borderline personality
psychotherapies should be a more frequently utilized option for disorder. Personality Disorders, 12(4), 291–299. https://doi.org/10.1037/
treating BPD. Our findings also suggest that generalized psy- per0000422
Bateman, A., & Fonagy, P. (2009). Randomized controlled trial of outpatient
chotherapies may be as effective as intensive specialized BPD
mentalization-based treatment versus structured clinical management for
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borderline personality disorder. The American Journal of Psychiatry,
confirmed with additional higher quality evidence it provides new
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possibilities to address the shortages of providers available to treat Beck, E., Bo, S., Jørgensen, M. S., Gondan, M., Poulsen, S., Storebø, O. J.,
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bmj.i4919 Accepted June 12, 2023 ▪

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Journal of Consulting and Clinical Psychology

Psychotherapies for the Treatment of Borderline Personality Disorder: A

Psychotherapies for the Treatment of Borderline Personality Disorder:

Mariam Siddiqui1, Roberta Wines1, Piotr Ratajczak2, 3, and Gerald Gartlehner1, 2

What is the public health signiﬁcance of this article?

Supplemental materials: https://doi.org/10.1037/ccp0000833.supp

Karen Crotty played a lead role in writing–original draft and writing–review

Borderline personality disorder (BPD) is the most common Method

protocol for the systematic review addressing both pharmacologi-

Study withdrawal, drug

Author (year) Number of participants

Commonly used psychotherapy versus TAU (K = 17; 18 publications)

provisions and professional mental health care

Author (year) Number of participants

Commonly used psychotherapy versus another commonly used psychotherapy (K = 13)

Author (year) Number of participants

Functioning Adverse Adverse

Dialectical K=2 K=6 K=2 No evidence No evidence K=1

Sachdeva, 2016; and (n = 134)

Dynamic K=1 K=1 K=1 No evidence No evidence No evidence

Schema Therapy K=2 K=2 K=3 No evidence No evidence No evidence

Transference- K=1 K=1 K=1 K=1 No evidence No evidence No evidence

Manual Assisted K=1

LOW for greater effect with MACT

Similar effects Favors psychotherapy Inconsistent findings

TAU group achieved clinically relevant improvements on the months.

Severity of Symptoms Associated With Borderline Global Impression and Functioning

The proportion of participants who engaged in suicidal acts

DBT vs. DDP K=1 K=1 K=1 No evidence No No evidence

DBT vs. TFP vs. No evidence K=1 K=1 No evidence No No evidence

DBT vs. supportive No evidence K=1 K=1 No evidence No No evidence

TFP vs. supportive No evidence K=1 K=1 No evidence No No evidence

MBT vs. No evidence K=1 K=2 K=2 K=2 No evidence No No evidence

TFP vs. schema- K=1 No evidence K=1 No evidence No No evidence

One three-armed RCT (N = 62) rated as high risk of bias

psychotherapy with schema-focused therapy over 36 months

166(12), 1355–1364. https://doi.org/10.1176/appi.ajp.2009.09040539

51(2), 121–141. https://doi.org/10.1111/j.2044-8260.2011.02017.x M. (2013). Outcome of mentalization-based and supportive psychotherapy

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