The American borderline guideline names no winning psychotherapy
- The American Psychiatric Association published an updated practice guideline for borderline personality disorder on December 10, 2024; its executive summary appeared in the American Journal of Psychiatry, 2024;181(11):1024–1028.
- The guideline holds eight statements, six recommendations and two suggestions. Five are rated 1C, two 2C and one 1B.
- The single 1B statement concerns psychotherapy: the patient should be treated with a structured approach to psychotherapy that has support in the literature and targets the core features of the disorder. The statement names no specific method; APA's training slides for the guideline list schema-focused therapy among seven structured approaches they compare.
- Writing group chair George Keepers said that several structured psychotherapies were found effective, that no therapy emerged as a "gold standard" and that no pharmacotherapy was found effective for the core symptoms. Medication is to be time-limited, adjunctive to psychotherapy and reviewed at least every 6 months.
A schema therapist reading the new American guideline on borderline personality disorder will not find a sentence that puts any one method first. The psychotherapy statement asks for structure and published support and leaves the method open.
Eight statements, one on therapy
Of the eight statements, six are recommendations and two are suggestions; the letter after the number grades confidence in the evidence, from A for high to C for low. Five carry 1C, two 2C and one 1B: treat the patient with a structured psychotherapy that has support in the literature and targets the core features of the disorder.
The initial evaluation includes the patient's goals and preferences for treatment, a quantitative symptom measure is suggested, and the plan is documented, person-centred and discussed with the patient. Any medication is time-limited, adjunctive to psychotherapy and reviewed at least every 6 months. The writing group chair, George Keepers, summarised the review: several structured psychotherapies were effective, none emerged as a gold standard, and no drug worked on the core symptoms. APA's training slides for the guideline compare schema-focused therapy with six other structured approaches and print its format as individual therapy "2hrs/wk for 3 yr" or group therapy "90min/wk for 8mo". APA puts prevalence at 1.4%–2.7% of the US population and notes that evidence-based treatments are often not available.
A conversation about structure and reach
With no gold standard, the first conversation shifts. "Which therapy is best" has no answer to offer, so the work moves to what this person wants from treatment and what structured help is actually within reach. Schema therapy enters it as one structured option among several, explained through its structure and target in the patient's own terms.
For the first meeting I would bring three things: the patient's goals written into the plan, an honest list of structured programmes available locally, and a symptom measure taken before treatment starts. If the nearest structured programme uses another method, a referral there fits the guideline.
The only 1B statement in the American guideline asks for a structured psychotherapy aimed at the core of the disorder and names no method.
Five of the eight statements are rated on low-confidence evidence (C). The guideline addresses practice in the United States. This note relies on the APA announcement, the executive summary record and APA's training slides, not on the full text.