Undoing Self‐Contempt in Borderline Personality Disorder: A Controlled Test of Change in Emotion Processing in Psychotherapy

Abstract

ABSTRACT Background Emotion processing has been discussed as a mechanism of change in several forms of psychotherapy for a broad range of psychological disorders. The general conclusions of the field do not allow for a step‐by‐step granularity of relevant emotional experiences in clients. This is particularly important for personality disorders, especially borderline personality disorder (BPD). Using a controlled out‐of‐therapy assessment, we assume that the lessening of expressed self‐contempt by clients gives way to proportionally more expressions of self‐compassion and assertive anger after a brief psychiatric intervention. Methods The present secondary analysis of a randomized controlled trial includes N = 79 participants (n = 27 clients with BPD in the active treatment following the principles of good psychiatric management [GPM]; n = 23 clients with BPD in the treatment as usual [TAU]; n = 29 healthy controls). Both treatments—GPM and TAU—lasted 4 months. All participants underwent out‐of‐therapy experiential two‐chair dialogues focusing on self‐criticism at two time points. The participants' emotional expressions were assessed using the video‐rated Classification of Affective Meaning States and the Self‐Contempt Rating Scale. Results The results indicated that the intensity of out‐of‐session observed self‐contempt as part of a person‐relevant self‐criticism decreased in clients with BPD undergoing GPM, with a large effect, similar to healthy controls. A medium‐sized effect was found for reduction in self‐contempt in clients undergoing TAU. The results also indicated that the proportion of individuals with BPD undergoing GPM accessing self‐compassion and assertive anger increased, which was not the case for healthy controls nor clients in TAU. Conclusions Undoing self‐contempt may be an elusive, yet central task in psychotherapy for clients with BPD. The present study explored the client process of change of undoing self‐contempt and moving towards self‐compassion and assertive anger. These conclusions bear important clinical and research implications.