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Table 1 Main differences between Dialectical Behavior Therapy (DBT) and Schema therapy (ST)

From: PRO*BPD: effectiveness of outpatient treatment programs for borderline personality disorder: a comparison of Schema therapy and dialectical behavior therapy: study protocol for a randomized trial

Case conceptualization Focus on connection between emotion regulation skills deficit and dysfunctional behavior; emotion dysregulation is the central problem Case conceptualization uses the mode concept; the frustration of basic needs and trauma in childhood leads to the development of maladaptive schemas and modes. For each individual, there is a case conceptualization in schema mode terms that fits the patient’s profile.
Focus on childhood experiences Primary focus on the present, focus on childhood experiences mainly in the context of validating emotional difficulties (level 4 validation) Full integration: Current problems are associated with childhood experiences; psychoeducation for basic needs, the development of schemas and modes, emotionally processing aversive childhood memories to change the meaning of early experiences that underlie the schemas
Trained skills Emotion regulation, stress tolerance, mindfulness, interpersonal skills Awareness of one’s own needs, schemas and modes. Although the functional expression of emotions, needs and assertiveness is encouraged, there is no explicit skill training in these areas.
General therapeutic strategies Validation strategies
Commitment strategies
Dialectical strategies (balance between acceptance and change, pro-contra lists)
Major use of cognitive and behavioral techniques
Special focus on experiential (esp. imagery rescripting and chair-dialogues) and relational techniques (limited reparenting, empathetic confrontation)
Mode-specific use of cognitive and behavioral techniques
Analysis of problem behaviors Chain analysis based on the DBT model for each type of problem behavior; hierarchy of problem behaviors; focus on obvious and threatening problem behaviors, such as suicide attempts, self-harm and impulsive behavior Mode analysis/chair dialogues or imagery work to understand problematic situations from the perspective of the mode model, focus on obvious problem behavior, as well as “hidden” problem behaviors, such as avoidance or surrender
Structure of the individual therapy session Fixed structure with a “crisp beginning” that includes a diary card, processing topics according to the DBT goal hierarchy, and focusing on emotions No fixed structure specification, flexible hierarchy depending on the dominating mode and the frustrated needs
Structure of the group session Homework and goal-related opening and closing rounds, teaching skills from the DBT modules with a fixed manual; focus on cognitive and behavioral therapeutic techniques Begins with safety imagery, topics depend on the dominating mode; designed as a “group family” to create corrective experiences; a primary focus on experiential and relational techniques
Addressing self-injury Fixed procedures according to protocol based strategies, top priority in goal hierarchy; self-injuries are usually discussed with behavioral analysis before addressing other issues No fixed structure specification, and does not need to be treated as a first priority (only if highly threatening); therapeutic intervention is directed at the mode that underlies the self-injury
Addressing interpersonal problems of the patient Psychoeducation for interpersonal skills; behavioral training with standard and individual role-play exercises Understanding interpersonal problems by using the mode model; interpersonal problem patterns normally also arise in the therapeutic relationship and are directly addressed, focus on expressing ones’ own needs and emotions; role-plays as needed but often in a later stage of therapy
Addressing emotional problems Comprehensive psychoeducation in the modules for emotional management; mindfulness and acceptance of emotions; decisions about whether one should act according to or opposite from the emotion; emotion processing with the help of emotion protocols (cognitive approach) Promotes experiencing emotions in a safe way; focus on needs (e.g., “What do I need when I’m sad?”); validating emotions and needs, when possible, fulfilling the need through limited reparenting, the empathetic confrontation of experiential avoidance that is displayed in the coping modes, experiential interventions, primarily imagery rescripting and chair dialogues, aim to develop corrective experiences
Developing the working alliance Therapist acts as a ‘coach’ for the patient; the therapeutic team is at eye level with patient Therapist acts, to a limited extent, as a ‘good parent’ with ‘limited reparenting’; uses the working alliance to change modes
Mindfulness training Central role; non-judgmental attitude is promoted Not included in ST
Skills training in distress tolerance High priority; psychoeducation, developing a skills chain for stress regulation Limited use, primarily for emergency situations at the beginning of therapy