overcoming shame in borderline personality disorder (bpd) using compassion focused therapy...

Runninghead: Overcoming Shame in BPD Using CFT 1

Overcoming Shame in Borderline Personality Disorder (BPD) Using Compassion

Focused Therapy (CFT)

Masters in Clinical Mental Health Counseling

Capstone Project

Kenneth Smith

Union Institute and University

December 2014

Overcoming Shame in BPD Using CFT 2

Abstract

Shame and Borderline Personality Disorder (BPD) interact in profound ways. BPD is a serious

mental health disorder with high social costs and has a reputation of being very frustrating to

treat. BPD seems to be a disorder of emotional regulation, which may explain why some

popular treatment approaches, especially Cognitive Behavioral Therapy (CBT), fail to help or

even worsen BPD symptomology. Shame is a moral emotion that when internalized leads to a

global negative view of self and produces a host of accompanying behaviors in the shamed

client. Some of the symptoms of shame are avoidance, aggression, externalizing blame,

unethical business practices, lack of empathy for self/others, self-harm, feelings of

worthlessness, and marked/extreme self-criticism. Shame and the symptoms of shame readily

explain most/all of the diagnostic criteria of BPD. A recently proposed therapeutic approach by

Gilbert (2009), Compassion Focused Therapy (CFT), has been created to instill in clients the

skill of feeling compassion to self/others and eliminate shame symptoms. CFT is presented as a

promising treatment option when dealing with BPD. To illustrate using CFT in BPD treatment,

a case study with specific approaches of how CFT could be used to treat a client with BPD is

presented.

Keywords: Borderline Personality Disorder (BPD), Shame, Self-criticism, Compassion

Focused Therapy (CFT), Cognitive Behavioral Therapy (CBT)


Chapter I: Introduction

The Significance of Borderline Personality Disorder (BPD)

BPD has high costs to the BPD client, to the ones close to BPD client, and to society at

large (Abdul-Hamid, Denman, & Dudas, 2014; Van Asselt, Dirksen, Arntz, & Severens, 2007).

BPD sufferers often have other major co-morbid mental disorders, especially major depression

(Abdul-Hamid et al., 2014; Baer, Peters, Eisenlohr-Moul, Geiger, & Sauer, 2012). Clients

suffering with BPD tend to have significantly more unhealthy lifestyles and personal morbidity

than those of the general population, with reports of higher incidences of diabetes, obesity,

cardiovascular disease, arthritis, and many other physical ailments (Powers & Oltmanns, 2013).

Finally, BPD is highly associated with an increased risk of suicide and para-suicide

attempts/gestures, with suicide being a leading cause of death in the US (James & Taylor, 2008).

It becomes clear that BPD is a major concern and topic of interest to those treating and

researching mental disorders. BPD is also regarded as a chronic and difficult to treat condition

(Gilbert, 2009), with significant stigma attached to term itself, with many psychotherapists

tending to have negative associations/emotions with people suffering from BPD (Fritz, 2012). In

fact, due to the failure of treatment of BPD using other approaches, some common modalities

used to treat a variety of symptoms/psychological disorders were originally developed to treat

BPD (Gilbert & Procter, 2006); notably Dialectical Behavioral Therapy (DBT).

Despite developments of therapies to specifically deal with BPD, some clients continue

not do well in therapy (Gilbert, 2009). For many BPD clients this does not seem to stem

inability to develop the skills therapy seeks to imbue, but that the skills learned do not seem to

sooth or improve the emotional drivers of maladaptive and destructive behavior. For instance,

Gilbert (2009) observes that some BPD clients in cognitive and behavioral approaches to BPD


treatment “become skilled at generating…alternatives for their negative thoughts and beliefs, but

who still do poorly in therapy…They are likely to say, ‘I understand the logic of my alternative

thinking but it doesn’t really help me feel much better…” (p. 199). This lack of improvement in

some BPD clients suggests that new modalities and approaches to treatment of BPD sufferers

warrant development and research into underlying factors of BPD and a focus on these factors to

improve treatment outcomes.

One aspect of BPD and many other mental disorders is a presence of the

emotion/experience of shame and its consequences: self-criticism, disgust, personal

worthlessness, personal emptiness, etc. (APA, 2013; Gilbert, 2009). Shame and its offspring

have been of interest in much recent research into BPD (e.g. Abdul-Hamid et al., 2014; Brown,

Linehan, Comtois, Murray, & Chapman, 2009; Gilbert, 2009; Peters, Geiger, Smart, & Baer,

2014). Focusing on shame may be advantageous to treatment of many disorders, including BPD,

as failure to deal with it appropriately has been linked to negative therapy outcomes (Parker &

Thomas, 2009). In fact, some therapies seem to strengthen the stimuli and exacerbate the

symptoms of shame, including Cognitive Behavioral Therapy (CBT) (Gutierrez & Hagedorn,

2013). CBT’s focus on counteracting the present, (e.g. thought suppression, focusing on the

problem), seems to have an effect counter to the desired outcome on shame, as the more you

avoid the thought of shame, the more the thought occurs.

Shame and related emotional factors may well explain the lack of success for some BPD

sufferers in psychotherapy, since a logical approach to dealing with cognitions (e.g. CBT) may

not meet the emotional need of the BPD client (Gilbert, 2009). Indeed, a necessary hallmark of

BPD is a marked instability of emotions and mood (APA, 2013), so that dealing with emotions

and mood may be the most effective approach to BPD treatment. It may also be important to


remember, as pointed out by Chesterton (1908) long ago, that most mental disorders are not a

defect of logic, but a defect in the assumption that leads to logical or hyper-logical conclusion

by the individual; in the BPD client this can be manifested in the maladaptive actions (e.g. self-

injury) making sense if the client believes that s(he) is truly worthless and shameful.

Defining Shame and Its Effects

Shame, as many phenomenological emotions, can be difficult to define. Firstly, it is very

important to differentiate between shame and guilt, which are often confused (Gutierrez &

Hagedorn, 2013). They are distinct psychological phenomena (Parker & Thomas, 2009) with

guilt being the attempt to make a reparative response to a behavior a person regrets, e.g. “I did a

bad thing”. Shame is a more global experience in the ego of having done bad things, e. g. “I am

a bad person that’s why I do bad things”. Gutierrez & Hagedorn (2013) conceptualize that

“shame… has greater self-awareness, making it difficult for an individual to differentiate [her]

actions from her sense of self…there is a notable lack of empathy [in shame]…guilt consists of

greater awareness of how their own behavior created the distress (p. 45).” This motivates the

person feeling shame to withdraw from others, while guilt feelings cause a desire to make

amends caused by feelings of regret. Werkander-Harstäde, Roxberg, Andershed, & Brunt (2012)

categorize guilt as being caused by action and “sin”; while shame is a thing that gives rise to

shameful feelings and the experience of feeling shame. It is often easier to identify the causes of

guilt, while shame is much more elusive and general in character (Gutierrez & Hagedorn, 2013).

Guilt oftentimes seems to be pro-adaptive in helping the person resolve reactions to negative

behaviors perpetrated on others; e.g. I will apologize to the person I wronged (Tangney, Stuewig,

& Mashek, 2007). As guilt tends to be healthier than shame and because guilt is not a hallmark

of BPD (while it may be observed in some clients), it will not be considered in this paper.


Shame seems to be much more maladaptive to healthy moral and mental functioning in

persons; e.g. causing frustration, depression, etc. (Tangney et al., 2007). Shame also is correlated

to increases in physical stress response, as measured in salivary cortisol levels (Denson,

Creswell, & Granville-Smith, 2012). Shame is often a common emotional factor, sometimes

consciously or unconsciously, noted in mental disorders (Gutierrez & Hagedorn, 2013). Despite

its common occurrence in mental disorders and stress, shame is often over looked (Egan, 2010).

Articles/ treatment approaches to shame are scarce (Gutierrez & Hagedorn, 2013), suggesting

that treatment may fail or be less effective that do not take the treatment and recognizing of

shame into account.

A review of the literature by Lawrence & Taft (2013) asserts that many studies have

found that shame is an important variable in mental illness and violence. Some authors go so far

as to suggest that most symptoms of mental illness are driven by shame and the spiral caused by

being ashamed of one’s shame (Scheff, 2012). Shame is extremely painful emotion and many

theorists, starting with Lewis (1971, in Thomaes, Stegge, Olthof, Bushman, & Nezlek, 2011),

posited that in an attempt to escape this very painful situation of shame a person often substitutes

anger (or other emotions); the belief is that anger is a less painful or ego threatening emotional

reaction than shame lashing out angrily after a shameful situation, perception, or experience is

common.

Thomaes et al. (2011) also describe that shamed people feel especially worthless. The

occurrence of constant shaming and the internalizing of this shame may account why some

individuals seem sensitive to what most would consider minor conflicts or slights (another

common fixture of BPD). This hyper-sensitivity to feelings of shame may also explain why

emotional/psychological crisis may be difficult to predict, because a person having large


amounts of shame may find a minor shameful experience completely overwhelming (James &

Gilliland, 2013).

Self-criticism: A Consequence of Shame

A major consequence of shame is self-criticism (Gilbert, 2009). Many people with large

amounts or experiences of shame find it very hard to be kind to self and others (Gilbert &

Procter, 2006). In client’s suffering BPD symptoms, self-criticism may lead to self-harm,

suicidal gestures, and completed suicide (Abdul-Hamid et al., 2014). The BPD client is very

negative to self and self-worth. This self-criticism makes it difficult to treat many mental

disorders (Gilbert & Procter, 2006; Gilbert, 2009).

One of the difficulties of addressing self-criticism is that many clients with mental

disorders seem to fear the emotion of compassion for a variety of reasons (Gilbert, McEwan,

Matos, & Rivis, 2011): feeling good about self will lead to worse things in the future, aversive

conditioning (especially in childhood), feeling good is taboo, etc. This may well lead many

clients to avoid feeling compassion or respond to therapy that makes them experience it.

Compassion, as opposed to criticism, has been linked to healthy mental functioning (Neff, Rude,

& Kirkpatrick, 2007). Therefore, it becomes evident that finding a way to deal with self-

criticism and fears of compassion could be an effective treatment for high shame clients,

including those with BPD.

Compassion-Focused Therapy (CFT)

Gilbert (2009) has recently proposed therapeutic technique of Compassion-Focused

Therapy (CFT) to train clients to experience and access compassion emotions. CFT seeks to be

both integrative and multimodal, drawing from a variety of theoretical perspectives. The focus

in CFT is actually learning to feel compassion, not just learning to be mindful of shameful/self-


critical thoughts and their contingent behaviors, which may be the case in other approaches like

DBT (Gilbert et al., 2011; Gilbert & Procter, 2006). Gilbert (2009) further proposes that CFT

may be a more effective therapy choice in treating high shame individuals.

Capstone Driving Questions on BPD, Shame, and Self-criticism

From the brief introduction above, the concepts of shame and self criticism in

relationship to BPD becomes an area worthy of exploration; both from a theoretical and clinical

view. This capstone has three driving questions:

1. What is the relationship and development between shame and BPD?

2. What are symptoms of shame in the BPD and how to they affect treatment?

3. Is CFT as an effect tool in treating shame and self-criticism in BPD?

Exploring these questions may lead to insights on how to approach certain BPD clients and

strategies to achieve better outcomes for both client and therapist.


Chapter II: Review of Literature

BPD Features, Theories of Development of BPD, and Clinical Approaches

Diagnostic Criteria and General Features of BPD. In the DSM-5 (APA, 2013, p. 663)

there are nine diagnostic criteria to BPD. The symptoms of BPD seem to cluster into three

general themes: (A) emotional instability, (B) self-destructive behaviors, and (C)

disassociation/lack of stable personality. The first group (A) includes diagnostic criteria (2)

unstable social relationships with ideation or devaluation, (7) enduring feelings of hollowness,

and (8) frequent intense anger/lack of emotional control. The second cluster (B) contains criteria

(1) desperate efforts to avoid social abandonment, (4) dangerous behavioral impulsivity, and (5)

reoccurring self-harm/suicide attempts. Finally, the last cluster (C) include the criteria (3)

unstable self-identity, (6) severe reactivity due to mood, and (7) paranoid ideation or extreme

dissociative/feelings of different personalities. These conceptual clusters will be used to show

strong possible links to all the features and diagnostic criteria of BPD. Indeed these general

features have elements of impulsivity (Links, Heslegrave, & Reekum, 1999) and strong

relationships to shame as concept of self (Razsch et al., 2007).

Theories of the Development of BPD and Clinical Implications. There are several

theories of the development of BPD which illuminate concepts of why self-criticism and shame

have such a profound influence on the emotional and cognitive function of a person with BPD.

These different theoretical bases each seem to focus on different aspects. Three will be briefly

reviewed to give insight into how BPD seems to affect sufferers. Most theoretical approaches

tend to have commonalty in theorizing that BPD has a strong base in childhood trauma, failure to

properly bond in early years (Fonagy & Luyten, 2009; Reinecke & Ehrenreich, 2005),

maladaptive emotional concepts of self and others (Pinto-Gouveia & Matos, 2011), and fears of


abandonment (Gormley, 2004; Intili, 2012). These different theoretical approaches lead to

divergence of opinion to the best treatment approaches to BPD.

Developmental-Cognitive Theory of BPD. Perhaps the most widely known theory of

BPD is a developmental-cognitive theory. This model of BPD development focuses on two

facets in its development: that of a genetic tendency to emotionally deregulate and failure to

develop a nurturing and working relationship with parents/care-givers (Reinecke & Ehrenreich,

2005). These two failures interact and create two general consequences in the BPD client: (1) a

disorganized social and emotional attachment schema in behaviors and (2) a “maladaptive

schema regarding loss, abandonment, and personal worth…” (Reinecke & Ehrenreich, 2005, p.

152).

For Reinecke & Ehrenreich (2005) the best treatment of BPD is cognitive therapy that

involves (by careful examination of and perhaps historical development) the complex and varied

cognitions leading to maladaptive behavior. The authors’ central focus using this orientation is

to change specific emotional and behavioral actions, which seem very classically CBT, in

agreement with other authors (e.g. Clarke et al., 2008; Zlotnick et al., 2003). Of secondarily

focus is the underlying mechanisms of maladaptive cognitions and behaviors. Central therapist

skills are patience and radical neutrality in treatment (Reinecke & Ehrenreich, 2005). This

approach (Intili, 2012) is perhaps the most common in BPD treatment, but may have a powerful

weakness in only focusing on the cognitive/behavioral, while making the emotional and

underlying mechanisms of BPD secondary. Some authors have posited that CBT or related

approaches might make symptoms of mental disorder worse and lead to a failure to adequately

treat some mental disorders (Gutierrez & Hagedorn, 2013).


Mentalization Theory of BPD. Based on over two decades of BPD treatment, Fonagy &

Luyten (2009) have proposed a mentalization-based theoretical understanding of BPD. They

focus on a conception referred to as mentalization. Mentalization is a multifaceted way of

understanding social interactions and contexts by a person imagining social situations/what it is

to be another person in order “…to perceive and interpret human behavior in terms of intentional

mental states (e.g., needs, desires, feelings, beliefs, and goals…)” (Fonagy & Luyten, 2009, p.

1357).

Although the rationale for the development of mentalization is complex, one important

aspect is the neurological/cognitive based idea of two pathways of forming understandings of

social/relational aspects. These two pathways are called TOMM and TESS. TOMM acts as a

pathway that make simple logical and black/white statements of what an individual observes,

while TESS seems to frames the contexts of mind/emotion (empathizing rightly or wrongly) on

what is going on in the social relational context. In other words, TOMM describes a person,

what the person believes, and the action causing the belief such as “Mother–believes Johnny–

took the cookies” (Fonagy & Luyten, 2009, p. 1360) and (b) the empathizing system, TESS, uses

self-affective state-proposition such as “I am sorry–you feel hurt–by what I said” (p. 1360). In

the BPD client, TOMM seems overly used while TESS is under used or the two pathways are

completely disintegrated, leading to a breakdown in effective mentalization and often a

disintegration of self-concept (Fonagy & Luyten, 2009; Intili, 2012).

The conclusion of Fonagy & Luyten (2009) suggests that more research into ways of

retraining mentalization may arrive at a very effective treatment of BPD. The author’s give very

little practical clinical application. They suggest that attending to the malfunctioning


mentalization aspect of BPD symptoms for treatment and on finding a balance between

attachment and mentalization may be helpful.

Much more concretely, the authors lay out areas of treatment which may be counter-

indicated or need special emphasis in BPD. In the BPD client, trying to activate mentalization

(which Fonagy & Luyten point out is often a first step in many therapists of diverse modality

preferences) may be very difficult as a basis of treatment due to the complete malfunctioning of

the mentalizing process. E.g. clients with BPD often have a hard time empathizing with self and

others. Also, psychological techniques that rely on insight to underlying drivers or causes may be

counter-indicated due to the unacceptable angst and failure to draw on proper attachment

relationships for new understandings. Such stimulation might also cause the activation of some

neuro-pathways that repress personal insight when treating a client with BPD.

Fonagy & Luyten (2009) point out two other concepts to keep in mind when working

with BPD sufferers. As treatment progresses, the client may actually lose some insight and

understanding of where the therapist is coming from a loss of self (or childlike regression) due to

the development of a perceived dependent child/parent relationship in the client. BPD clients

seem to feel some emotions/thoughts more vividly and have greater effect on them than the

normal population or other clients (Fonagy & Luyten, 2009). It is important to note that this

proneness to greater emotional feeling or vividness seems especially true of shame; “…women

with BPD not only report higher levels of proneness to shame and guilt, but they also show

greater shame proneness … Shame is felt as “more real” by these patients than anxious patients

or normal controls…” (Fonagy & Luyten, 2009, p. 1363).

Adult Attachment Theory of BPD. Gormley (2004) proposes adult attachment theory to

illustrate the symptomology common in the BPD client. Adult attachment theory provides a


framework to look at a client’s formative relationships and working schemas of personal

relationships (Gormley, 2004). It further proposes that there are three general styles of working

attachment schemas, simply described: (1) optimal (most individuals), providing an attachment

schema that helps deal with stressors, (2) insecure (common), an attachment schema marked by

anxiety in adult relationships, often manifested by excessive help seeking or self-reliance, and

(3) disorganized (rare), a style marked by a complete breakdown in understanding of proper

attachment and often leading to odd reactions to many situations (e.g. dissociation) (Gormley,

2004). Individuals in this disorganized category tend to have a history of trauma.

The disorganized style is often seen in women with suicidal and self-harming behavior

(as is common in BPD), often preventing affective treatment. Gormley (2004) points out that

CBT therapy is often the first line of treatment for these chronically self-harming/help-seeking

individuals and fails because “these clients [disorganized] refuse to cooperate. They could not

give up self-destructive behaviors until they felt cared about [by someone else]” (p. 139). Self-

destructive behavior is seen by Gormley (2004) as an attempt to elicit care/ help or a protest

against not being loved or thought about by others; client eating shards of glass to anger a mental

health worker can be seen as “a final attempt to get important others to think about them” (p.

139). Thus, self-destructive behavior can be seen as an attempt to adapt and/or to get help/seek

attachment to others or a punishment or reparation for lack of attachment (extrapolated from not

being loved, shame?).

Using the conceptualization of adult attachment theory and illustrated by two case studies

with very “difficult” clients, Gormley (2004) suggests some approaches when dealing with

clients with a disorganized attachment style. Frist developing a close working relationship with

the clients is paramount and is based on properly showing the clients that the therapist


understands them. This is often more important than treatment of symptoms and protests that

past or traditional therapy has failed may be accurate. For some clients, such a close

interpersonal relationship may provide the first relationship that the client might be willing to

live for (Gormley, 2003, p. 141).

The therapist should see all self-harming/maladaptive behaviors as survival mechanisms (and

as sources of action that the client has taken, giving the client power to change?) and teach the

client to view actions as such, eliminating the humiliation of such self-harm (p.140) (also see

Wiklander, et al. 2003). Constant and immediate reflections on client states by the therapist (e.g.

anxiety, distractibility) to the client, teaching them to notice such states in themselves is

important. In conjunction with this reflection on client states, it is important to give the client

clear choices for how to react or what to do (and not getting frustrated/angry) when they choose

“bad” options in response to these states.

Most at odds with other clinical approaches to BPD treatment (and despite a preference for

maintaining distance, denying powerlessness, or devaluating traumatic experiences in both the

therapist and client) Gormley (2003) holds the best way to deal with underlying trauma in BPD

is to confront it directly. When directly confronting trauma the therapist-client

attachment/relationship provides the basis to deal with the inner pain experienced by the client.

The therapist should expect such direct confrontation of trauma to often elicit anger (at self or

others), since anger is often perceived as more self-reliant than other emotions (such as shame or

sadness).

Divergent Treatment Approaches to BPD. As has been presented, these three

theoretical descriptions provide different conclusions for how to approach BPD. One striking

difference is the criticism of the prevailing practice using CBT to treat personality disorders from


both the mentalization and adult attachment theory perspectives (at least as a first approach),

while it is advocated as the first option in the developmental conception of BPD. Evidence

seems to indicate that the CBT approach to treating BPD is often ineffective or makes symptoms

worse (Gutierrez & Hagedorn, 2013). Since CBT is a very common modality in treating BPD, it

may add to the reputation of BPD to be very difficult to treat and clients with BPD being

manipulative or dangerous (Fritz, 2012; Gilbert & Procter, 2006).

Shame and Its Manifestations

Some major aspects that make BPD so hard to treat include: (a) complete instability in

emotions and extreme negative self-image, (b) a lack of self-control, and (c) the need for external

bonding and dependence in social context. While these aspects can be characterized as distinct

phenomena, all can be seen as actions on the part of a client with BPD to deal with external

factors which affect self-concept and/or attempts to escape feelings of abandonment. These

commonalities can be readily explained by the emotion of shame.

Differences Between Shame and Guilt. Shame and guilt are different concepts

(Tangney et al., 2007). Shame is characterized by a global feeling of worthlessness (e.g. I used

drugs, because I’m a bad person), drives anti-social behavior (such as avoidance, externalization

of blame), and seems very maladaptive. Guilt seems pro-social and focuses on making

reparation for bad actions done. There are two traditionally competing schools of thought in the

conception of shame and guilt (Cohen et al., 2011). Self-behavior theory posits that chronic

focus on negative/bad behavior done by a person creates a stable and global negative view of

self; the person has committed transgressions that show that s(he) is a bad person (Tangney et al.,

2007). The public-private theory of shame and guilt is that transgressions that have been


publically exposed tend to lead to shame, while transgressions that are kept secret tend to lead to

guilt (Tangney et al., 2007).

These seemingly different theoretical approaches to shame may both accurately capture

its aspects. Two common methods used to assess shame and guilt are the Test of Self-Conscious

Affect-3 (TOSCA-3), for the self-behavior school, and the Dimensions of Conscience

Questionnaire (DCQ), for the public-private school, (Cohen et al., 2011). Despite these two tests

having very different theoretical bases, Cohen et al. (2011) report that past studies have found

that both the TOSCA-3 and DCQ are strongly positively correlated with each other for

measuring shame and guilt. This suggests that both of these schools capture valid aspects of the

experience of shame and guilt. Both tests rely on self-reporting of how a person would react in a

given situation to assess whether a person was more given to avoidance/shame or to action/guilt

in moral situations where they did a bad action. Avoidance and action responses are used to

indicate the differences between shame and guilt feelings.

A newer assessment of shame and guilt proneness is the Guilt and Shame Inventory

(GASP) which attempts to combine both of these theoretical approaches into one assessment

tool. GASP was found to be highly positively correlated with both the TOSCA-3 and DCQ

(Cohen et al., 2011). Cohen et al. (2011) report that people exhibiting more shame-proneness in

personality are at higher risk for negative outcomes (e.g. higher risk of experiencing trauma,

poor ethical decision making, unstable affective states, et al.) than persons that are assessed as

more guilt prone (also see Pinto-Gouveia & Matos, 2011).

Shame Proneness as a Feature of Personality. Shame and shaming experiences may be

so powerful that they form a central feature in the development of personality (Pinto-Gouveia &

Matos, 2011). As they are so important in personality formation, shame experiences often serve


to provide central points to personal identity. Proneness to feeling shame or guilt after doing a

“bad” action seems to drastically change people’s behavior and social/personal outcomes

(Tangney et al., 2007).

The Pro-Social Purpose of Shame. The positive purpose of shame is to prevent people

from doing negative actions in the first place (Tangney et al., 2007), as all emotions regulating

moral action are. Shame is an extremely strong emotion (Lawrence & Taft, 2013; Tangney et

al., 2007) which causes avoidance of certain action or thought. The strength of the emotion of

shame may account for it as a strong driver of mental health pathology. Indeed the need to avoid

shame or doing shameful things (so as to not be alone/ostracized) often cause clients to express

other emotions that are perceived as less painful than feeling shame; this seems especially true in

substituting anger or self-criticism for feelings of shame (Gilbert, 2010; Parker & Thomas, 2009;

Tangney et al., 2007; Thomaes et al., 2011).

Internalized Shame: Psychological Manifestations. As illustrated earlier, shame itself

can often be hard to show directly in a client (Gutierrez & Hagedorn, 2013). However, signs of

shame feelings can be quite marked. Below are some of the major symptoms and results of

shame.

Failure to Separate Self and Emotions of Shame/Fusion of Self and Shame. Parker &

Thomas (2009) point out, that shame is self-aware and hard to separate from concept of self.

This agrees with findings that suggest that shame and shaming experiences are central to

formation of identity, personality, and self (Pinto-Gouveia & Matos, 2011). Taking a concept

from Acceptance and Commitment Therapy (ACT), a very shameful person cannot see self-as-

context. Self-as-context is the perception of self that is universal and detached from behaviors


and private thoughts/experiences (Hayes, Luoma, Bond, Masuda, & Lillis, 2006). In other

words, it is the area in which people examine their lives and know themselves.

The lack of self-awareness of shame feelings causes a person not to be able to recognize

shameful feelings as feelings, but see shame as self (Pinto-Gouveia & Matos, 2011) or see shame

as making a person who s(he) is. This leads to having a lack of empathy with self (and as an

extension, others). The lack of empathy in shame also contributes to the notion that, since there

is normally no one action, event, amalgamation of events, or specific action associated with the

notion of shame, the emotion integrates itself in to the mind of the client (Tangney et al., 2007).

Externalizing Blame and Lack of Self-Control in Emotions. It has been noted that

shameful people tend to externalize blame and/or blame others for feelings they have or actions

they do (Cohen et al., 2011; Parker & Thomas, 2009; Tangney et al., 2007). This often seems

due to a feeling of powerlessness in a shame-prone person (Fonagy & Luyten, 2009). This author

presents a personal experience to illustrate how externalization manifests itself. Drawing on

conversations with a person who is seems very shame-prone (and having other quite marked

psychological/interpersonal challenges), this person related that he had been in psychological

treatment when he was a child. One thing the therapy sought to do was to change how he

perceived his emotions. This person very much tends to view others and their actions as ruining

his life, even in what seems to be very short and cursory exchanges. This is manifested in his

language as “that person made me feel…” This kind of conceptualizing was present in his

childhood therapy and the therapist sought to change his outlook by substituting references to

feelings as “I feel…” instead of “that person makes me feel…”, to no doubt to empower this

person to have control and to avoid blaming others for his feelings.


The externalizing of blame can account for many other symptoms of shame, such as

avoidance or anger. Frustration for not being able to have control in life due to shame has been

linked to aggression (Thomaes et al., 2011). Externalization of blame may also explain why

Cohen et al. (2011) report that shame-prone people tend to be less honest in business dealings,

because they perceive others forcing them to do bad things or that they are just bad and can’t

help being dishonest.

Anger and Aggression. Differing amounts of anger linked to shameful events have been

presented as two different categories (Lawrence & Taft, 2013), those related to occasional

instances of shame which happens to all persons (e. g. I do stupid things sometimes) and those

persons who experience shame as repeated incidences of ridicule, humiliation, or experience

shame a majority of the time (e.g. a subject exposed to constant bulling). This occurrence of

constant shaming and the internalizing of this shame may account why some individuals seem

very sensitive to what most would consider minor conflicts or slights. Lawrence and Taft (2013)

conducted a review of the literature linking shame to violence and aggression and concluded that

shame is an important variable in PTSD and Intimate Partner Violence (IPV). Furthermore, the

authors propose that shame regulation may be useful in clinical interventions with violent

perpetrators. Teaching a client to make a dichotomy between perceptions of shame and who the

person is may well be very effective in treating some violence behavior.

Avoidance of Shame Feelings and Treatment. Avoidance is also a hallmark of shame

(Parker & Thomas, 2009; Tangney et al., 2007). Feelings of shame might also be responsible for

the poor participation rates and seeking help for negative behaviors. Like anger, avoidance

behaviors might be substituted for shame and avoid shameful feelings/situations.


Statements of self-reliance may be used to mask shame. Indeed, shame and avoidance

are often drivers of suicide, in an attempt to escape (Wiklander et al., 2003). In a study about the

use of mental health hotlines by teenagers (Gould, Greenberg, Munfakh, Kleinman, & Lubell,

2006), two factors suggests that statements of self-reliance as an objection to seeking help may

be masking feelings of shame in individuals with severe mental distress. In this small study, the

teenagers who most needed mental health help were (1) most likely to object to using the hotline

and cited (2) the need to be self-reliant as a reason not to call to a higher degree than those in the

general cohort (Gould et al., 2006). This seems to strongly suggest that those with the worst

psychological problems may use the term self-reliance to hide the shame for not being able to

deal with their problems themselves.

Self-Harm/Suicide/Homicide. Shame is also a critical factor in suicide (Wiklander et al.,

2003) and homicide; and perhaps even more importantly in those who commit homicide then

commit suicide (Anderson, Sisask, & Varnik, 2011). One important way of determining the

chances of suicide in a correctional setting is “shame attenuation”; that is looking for shame (and

the pain caused by shame) beyond the defense mechanisms of a client (Knoll, 2010). Treatment

of shame also seems to have important implications for those suffering BPD with suicidal or

self-injuring behaviors (Harned, Korslund, Foa, & Linehan, 2012).

A strong predictor of future suicide attempts are a record of past attempts. Shame may be

a factor in subsequent suicide attempts since some individuals will have shame for failing to

commit suicide or that the attempt to harm self is seen as shameful (Gormley, 2004; Harned et

al., 2012). Many suicides in correctional settings have no warning signs (Knoll, 2010) and shame

is a major factor in suicides (Anderson, Sisask, & Värnik, 2011). This hiding of a client’s


suicidal thoughts seems influenced by shame and could be a major factor in the lack of warning

in many suicides.

References to Self in a Chronic Self-Critical Manner. As can be directly inferred,

internalized shame can lead to very negative views of self. This in turn can lead to clients who

refer to self in very negative ways and express feelings of worthlessness (Parker & Thomas,

2009; Tangney et al., 2007). Indeed Parker & Thomas (2009) point out that a central way in

determining differences in underlying causes of depression between shame and guilt are that

“guilt-laden depression would be evident in talk about actions taken…shame-laden would be

characterized by reports of worthlessness or badness of the person (the self) rather than deeds”

(p.218). Also evident in chronic self-critical references is a distinct lack of empathy and

compassion for the self. By extension, highly self-critical people also seem to have difficulty

empathizing or being compassionate to others (Gilbert & Procter, 2006; Gilbert, 2010). It is also

important to recall that self-criticism and feelings of worthlessness are diagnostic features of

BPD (APA, 2013).

Shame Leading to the Failure of CBT. CBT can be effective on some clients with

BPD (Clarke et al., 2008), but there are many examples where CBT seems not to help or can

worsen symptoms in BPD clients (Fonagy & Luyten, 2009; Gilbert & Procter, 2006; Gormley,

2004). Using CBT, the prevailing treatment option in BPD (Gutierrez & Hagedorn, 2013;

Reinecke & Ehrenreich, 2005), examples of how shame thwarts psychological treatment

intervention can be illustrated. There is a tendency for clients to transfer shame into other

emotions or behaviors: anger, avoidance, self-harm, violence to others, disassociation,

sabotaging success, and many others (Tangney et al., 2007). These substitute emotions/

behaviors can make CBT very difficult. Some of these substitute emotions/behaviors include:


client refusal to participate, uncontrollable painful feelings, attempts by the clients to prove they

are “bad”; all of which can stop treatment. The focus on the here and now in CBT can also be

problematic for BPD treatment due to the fusion of self and shameful behaviors, because, at least

from the client’s perspective, s(he) is a shameful person in the here and now (Gutierrez &

Hagedorn, 2013).

As touched on earlier, shame often causes a fusing of self and actions. This fusion

interferes with thought and causes the failure of key techniques in CBT. Techniques such as

thought suppression or dealing with the problematic cognitions that requires the client to judge

the cognition as irrational/rational, good/bad, etc. (Gutierrez & Hagedorn, 2013) may even make

client symptoms worse. CBT often attempts to label thoughts that interfere with function as

irrational. Proving to a client with BPD that s(he) should not feel shame or feeling shame is

irrational can be very difficult. Gutierrez & Hagedorn (2013, p.45), use a metaphor that trying to

suppress shame in CBT is akin to telling a person not to think about a pink elephant; the more

you try not to think about it, the more it comes up. Also, relaying to a BPD client that her/his

cognitions are causing distress or problems may not be new to the client (Gutierrez & Hagedorn,

2013).

Furthermore, Gutierrez & Hagedorn (2013) have cited evidence that acceptance based or

mindfulness techniques, such as ACT, have success where clients have been resistant to CBT. A

major reason reported for this success is that the client simply learns to accept the

emotion/cognition s(he) experience’s with no initial judgment (Gutierrez & Hagedorn, 2013).

Acceptance in ACT is the set of techniques to overcoming avoidance; it helps clients to stay

aware of private memories, thoughts, and feelings without feeling the need to alter the amount

and form of the experiences (Hayes et al., 2006).


It has also been noted that clients suffering BPD and other disorders often will not/cannot

participate in CBT (Fonagy & Luyten, 2009; Gormley, 2004; Gutierrez & Hagedorn, 2013).

This can be due to a variety of reasons, but two come to the fore: (1) the therapy is too painful to

sustain and (2) the focus on the here and now in CBT can be difficult to use because the here and

now might be awful. Focusing on the cognition of shame is very difficult and distressing

(Tangney et al., 2007; Thomaes et al., 2011).

Client refusal to participate due to shame using CBT techniques is illustrated in a small

controlled study (Arntz, Tiesema, & Kindt, 2007). The study was done to compared the success

rate between Imaginal Exposure (IE) (focusing on the fear inducing images in a client with

PTSD to lessen the fear, a common approach in CBT (Clarke et al., 2008)) and the use of IE plus

Imagery Rescripting (IR), which focuses on changing the beliefs in the experiences culminating

in PTSD during IE (e.g. I should not feel shame for not being able to save my friend in the

accident, because I was trapped in the car and it was not my fault I could not do anything). Arntz

et al. (2007) found that people having the IE+IR as compared to IE alone were much more likely

to stay in treatment (many found IE alone too painful). The authors also reported a reduction in

hostility and guilt feelings, with a trend in shame reduction with IE+IR. While the size of the

study may influence the results, the concept that changing the feelings during IE using IR is

superior to only experiencing the images in IE would be consistent with the concept that shame

without modification is too difficult to deal with for many clients.

Compassion-Focused Therapy

As the evidence presented strongly suggests, both from a practical and theoretical view,

BPD suffers seem to have features of internalized shame. It has also been shown that some

treatment approaches dealing with or ignoring the feeling of shame will not work for many


clients, specifically CBT. In response to the observation of self-criticism and shame in many

clients, Gilbert (2009) introduced Compassion-Focused Therapy (CFT). Research has supported

CFT effectiveness (Gilbert & Procter, 2006; Gilbert, 2009; Neff & Germer, 2013) in clients who

have failed past therapeutic interventions and seems to be effective in teaching compassion for

self and others. While a recently formulated therapeutic approach, the Compassionate Mind

Foundation-USA has been formed to promote training and use of CFT (CMF-USA, 2014).

Gilbert (2009) has noted that compassion to self and others can be learned; CFT is a

multi-modal approach aimed at teaching self-compassion to over-come feelings of self-

worthlessness, shame, and attending features. To conceptualize what is needed to develop

compassion, Gilbert (2007) has constructed a diagram (Fig. 1) which shows what skills (outer

circle) need to be trained/strengthened to develop the attributes (inner circle) which form the

basis for feeling and practicing compassion. In CFT, skill-training takes place always in the

context of strong personal warmth from the therapist.

Figure 1. Diagram of CFT key concepts and compassion attributes developed by Gilbert (2007)


The focus of CFT is to develop the feelings of compassion and empathy to self (Gilbert, n.d.) as

compared to logically considering changing maladaptive cognitions and behaviors, as in CBT

(Gilbert, 2009).

Briefly, CFT seems not so much to be a rigid approach to treating self-criticism and

shame, but provides a frame work on approaching clients dealing with such issues. The

attributes of CFT are the signs of compassionate development and skills training. Gilbert (2009,

pp. 203-205) proposes six skills (see Fig. 1) to focus on teaching clients to be self-

compassionate:

1. Compassionate attention involves focusing the attention on feelings that help the

clients to deal with the world around them. Gilbert (2009) specifically mentions

teaching the client to remember times when s(he) felt safe and supported when

dealing with shameful feelings and situations.

2. Compassionate reasoning is teaching the client to reason in a compassionate way

about self and others. Fundamentally, it is about the client thinking of alternative

thoughts to situations, much like in CBT or mentalizing (Gilbert, 2009), with a

constant focus on the alternative thought being supportive and kind.

3. Compassionate behavior educates the client into developing behaviors that alleviate

stress (not avoidance) and facilitating personal growth. E.g. when a client has to

engage in a stressful behavior, “they will try to create an encouraging, warm tone in

their minds…as a reference point to move into more frightening activities.” (p. 204)

4. Compassionate imagery is a technique/exercises to help clients produce

compassionate feelings. E.g. the client might be asked to explore what a

compassionate person might act like.


5. Compassionate feeling is about experiencing compassion from/for others and self.

This may take place in the context of the therapeutic relationship or past experiences.

6. Compassionate sensation is about exploring how the feeling of compassion affects

biological response. This seems closely related to other modern therapy approaches,

such as mindfulness.

Many of the six skills seem to have overlap with other therapeutic techniques. What

differentiates CFT from other approaches is that the central focus is always on the development

of feeling and being compassionate. Despite its relative novelty, CFT has been successfully used

to treat clients with very marked psychological difficulty and to which past attempts at therapy

have failed (Gilbert & Procter, 2006).

CFT Treatment in BPD. CFT is a promising approach to the treatment of clients with

symptoms of BPD. As this paper has presented, there seems to be very strong links to shame and

BPD. The focus in CFT on dealing with shame directly (Gilbert, 2009) may be a very useful in

dealing with BPD. Also, since shame seems to defeat treatment (e.g. CBT) of many BPD

sufferers (Gutierrez & Hagedorn, 2013), it provides a novel way of dealing with clients to whom

past therapy interventions have failed. Finally, since BPD seems to primarily be a disorder of the

emotions, the direct use of emotional feeling in CFT for treatment may prove effective. CFT

also seems to fit very well in the theoretical concepts of Fonagy & Luyten (2009) and Gormley

(2004) in the treatment of BPD and help alleviate the difficulty BPD sufferers in having empathy

with self and others.

Conclusion


The evidence presented traces the strong relationship, both practically and theoretically,

between BPD and shame/the symptoms of shame. Research also shows that some approaches

(particularly CBT) to dealing with shame and BPD symptoms do not produce successful

treatment outcomes for many clients. CFT provides an interesting approach to dealing with

shame and maladaptive thoughts and behaviors noted in clients with BPD. The next chapter will

focus on a practical application and provide a treatment program using CFT to treat BPD.


Chapter III

Application of CFT as BPD Treatment Using a Case Study

Using CFT as a treatment for BPD is best demonstrated using a case study. This allows a

demonstration how specific aspects of CFT would be used to treat a client with BPD symptoms.

CFT treatment adapts to each client according to past experiences and outlooks.

Case Study: Margaret. The case study used to demonstrate CFT technique is taken from

Gormley (2004, pp.139-140) about a client the author had treated named Margaret. Margaret

had a long history of severe childhood abuse and was constantly being admitted into inpatient

mental health facilities. In addition, Margaret had a prolonged history of self-harming behaviors,

suicide attempts, drug addiction, and hallucinations commanding that she kill herself. Margaret

was perceived by most clinical staff as being very needy, not being responsive to psychological

interventions, and using suicide/self-harm attempts to elicit attention from others. Margaret

reported one positive relationship with a grandmother, who had died. Furthermore, Margaret

admitted to using self-harm to get medical attention to prove that she was worth saving, but

when in therapy sessions, continually told the therapist [Gormley] that she [Margaret] was not

worth the therapist’s time. Finally, Margaret had little control over emotional regulation,

especially anger. Margaret’s symptoms are consistent with the diagnostic features of BPD

(APA, 2013).

Treatment Plan using CFT. As illustrated from Margaret’s case history, statements of

worthlessness and past interventional failure make her a good candidate for CFT treatment

(Gilbert & Procter, 2006). The central focus of CFT is to help the client develop a

compassionate way of thinking and behaving to treat feelings of worthlessness and shame

(Gilbert, 2009). The treatment plan for Margaret will be to develop the six skills innumerate in


CFT. Also important in the treatment using CFT is constantly conveying warm feelings to the

client in the therapeutic context, both to provide support and behavioral modeling for the client

(Gilbert, 2009). Special attention on the therapist’s part should be on client references to the

attributes of compassion as proposed by CFT, namely: sensitivity, care for well-being, non-

judgment, empathy, and distress tolerance (Gilbert, 2007). When expressed by the client, these

attributes can indicate specifically useful areas to help the client using CFT.

Establishing Assessment of CFT Treatment. Assessing the effectiveness of the CFT

intervention is important. Means of assessing the effectiveness of CFT could include depression

inventories, inventories of suicide risk, ability to continue therapy, and number of psychiatric

hospitalizations. However, two seem especially well adapted for this case. Firstly, Margaret will

be asked to keep journal or chart of the time, number, and duration of self-critical, self-harming,

and compassionate feelings/thoughts/behaviors (Gormley, 2004). This method will allow the

recording of any changes in Margaret’s feelings and behaviors; it also affords opportunities to

Margaret to reflect when negative thoughts and behaviors occur and what a more compassionate

way of dealing with them in the future might look like. Charting/journaling also allows Margaret

to notice and be mindful of her feelings/actions (not just acting on them or they being automatic),

an important component to CFT (Gilbert, 2009).

Secondly, the GASP (Cohen, Wolf, Panter, & Insko, 2011), a measurement of shame and

guilt-proneness will be periodically administered. The GASP is a short, easily taken, and scored

assessment tool. The first assessment using the GASP will likely indicate that Margaret is very

shame-prone (a hardly surprising outcome). However, since the GASP uses moral situations

where the subject is asked to rate how much they agree with a proposed feeling (e.g. GASP

question 1 “After realizing you have received too much change at a store, you decide to keep it


because the salesclerk doesn’t notice. What is the likelihood that you would feel uncomfortable

about keeping the money?” (Cohen et al., 2011, p. 966)), the assessment would be very likely to

capture changes in personal outlook for the likelihood of feeling shame due to CFT treatment. It

would also provide an objective confirmation along with the subjective assessment of Margaret’s

journaling/charting.

Course of Treatment/Specific CFT Skill Development. To show how a treatment plan

may develop in Margaret’s case, each of the six skills developed in CFT can be applied to

Margaret’s situation. Using the client’s own ways of understanding and correctly empathizing

with the client may change the course of CFT skill development focus. At all times and skill

development attempts, the therapist must be careful to consistently show the attributes of

compassion to the client. Also since feeling compassion can cause fear in some clients (Gilbert,

2009), Margaret should be encouraged to express feelings of fear.

Compassionate Attention. In Margaret’s case, a focus on times that she felt compassion

in the past may be very useful. This is especially indicated because Margaret stated that she felt

cared about by her grandmother. Focusing on how the grandmother showed that she cared about

Margaret will most likely lead to identifying attributes of compassion by the grandmother.

When identified, these compassionate actions can be explored with Margaret so that she can

know the feeling of compassion and eventually learn to access it at times of shameful and

stressful feelings.

Compassionate Reasoning. This skill development may take place in a context of what

Margaret was trying to accomplish when committing acts of self-harm. Some of the self-harm in

Margaret does seem attention seeking to others, which seems to indicate that somewhere

Margaret cares that others should pay attention to her. Adapting Gormley’s (2004) conception of


every act of self-harm to be a kind of coping mechanism, Margaret can be asked to describe why

some people would try to harm themselves in order to elicit sympathy and compassion in others.

Eventually, Margaret may then be able to see her own attempts as self-harm in a context of

needing to be compassionate to herself.

Compassionate Behavior. Modeling compassionate behavior in/to Margaret may take

form in a variety of ways. If specific compassionate behaviors were noted in discussions on

Margaret’s grandmother, Margaret may be asked to do those same behaviors to herself or others

(if appropriate). Another way may be finding a person, animal, or thing that Margaret is

naturally compassionate to and to which she can express compassionate behavior. E.g. if

Margaret naturally likes stuffed animals, she can be asked to hold and stroke the object,

expressing warmth to it (eventually, Margaret may be able to hold and stoke herself in a similar

way, in order to elicit compassion). If Margaret has a very difficult time doing compassionate

behaviors, she may be ask to sincerely smile at someone or herself in a mirror (whether she feels

it or not) once a day, as a model of compassionate behavior.

Compassionate Imagery. Asking Margaret to describe places and times where she felt

safe and warm would form a basis to accessing compassionate imagery. If Margaret said that

she always felt safe and warm in her grandmother’s house, she could be asked to explore the

image in detail and then to notice and attend to the feeling it caused. The purpose is to develop

what the feelings of compassion feel like, so that they can be called upon to contradict feelings of

shame and self-criticism.

Compassionate Feeling. This aspect of CFT focuses on eliciting feelings to self and

others in a compassionate way. This could be done in conjunction with many of the other skill

developments. If Margaret tells a self-critical story about herself and/or others, she could be


asked to retell it in a more compassionate way or reconstruct the story to elicit compassionate

feelings. Once Margaret develops an understanding and recognizes the feelings of compassion,

something as simple as focusing on the feeling for a period of time might allow for continuous

compassion development.

Compassionate Sensation. In Margaret, after she begins to feel compassion, she should

be asked to describe what it does to her body. She might state that it slows her breathing and

creates a warm feeling in her limbs. Attending to the actual bodily sensation of compassion can

then be used to elicit the feeling of compassion in shameful and stressful situations. Also getting

use to and being comfortable with the sensation of compassion is very important to this skill

development.

Conclusion. By exploring how CFT might develop in a client like Margaret with BPD

symptoms, methods for compassionate skill development can be shown. Using Margaret’s own

words, past, and experiences optimize CFT. The first purpose of CFT is to teach feeling

compassion in order to combat feelings of shame and being self-critical. Secondly, it is

important to develop a new world view in the client, to see self, others, and the world in a more

caring and compassionate way. Gormley (2004, pp.140-141) reported that Margaret had marked

improvement after being treated by focusing on developing correct personal attachments, despite

a long history of psychological treatment failures. As was examined in Chapter II,

unquestionably a central component of attachment theory in treatment is compassion. It

therefore strongly seems that Margaret would show improvement and respond well to the CFT

stratagems and orientation as explored above. The specific CFT skill development illustrated by

focusing on Margaret’s own case can also give insight to how to use CFT in other clients.


Chapter IV

Summary

BPD. As has been shown, BPD is a very serious and costly disorder. The clients

afflicted with its symptoms’ tend to have major life difficulties (Zlotnick et al., 2003), form a

large proportion of admissions to mental health faclities, and are costly to society (Abdul-Hamid

et al., 2014). Furthermore, the severity of BPD leads to stigma and even avoidance/negative

outlooks in mental health professionals (Intili, 2012).

BPD is clearly a major disorder in the mental health pantheon and attempts to treat it

have been numerous. Especially examined was the attempt to use CBT to treat BPD. While

some BPD clients seem to be helped by CBT (Reinecke & Ehrenreich, 2005), there is a large

amount of literature that suggests that CBT may not be ideal or even counter indicated with

many BPD suffers (Fonagy & Luyten, 2009; Gormley, 2004; Gutierrez & Hagedorn, 2013). The

problem with using CBT to treat BPD seems to lie in the fact the BPD seems to be a disorder of

the emotions more than that of intellect/logic. CBT focuses on identifying why some cognitions

work in an irrational way in the client, which may not help the client with emotional regulation

(Gutierrez & Hagedorn, 2013).

Shame in BPD. A major (perhaps the major factor) in BPD seems to focus on feelings

of shame which often translate into other actions/emotions, including: anger, self-criticism,

feelings of worthlessness, self-harm and avoidance (Parker & Thomas, 2009; Tangney et al.,

2007) . Shame is a kind of self-hatred marked by global internal feelings of “being bad” or

worthless (Parker & Thomas, 2009). Conversely, the feeling of guilt is marked by a realization

of doing a bad action and trying to make reparations for it (Tangney et al., 2007).

Feelings of shame and its attending symptoms seem to account for the diagnostic criteria

in BPD. In addition, shame feelings have been shown to be major drivers of aggression, self-


harm, and un-ethical behaviors in people (Cohen et al., 2011; Thomaes et al., 2011; Wiklander et

al., 2003). Furthermore, shame seems to be a major player in psychological

treatment/intervention failure in many clients (Gilbert & Procter, 2006; Gutierrez & Hagedorn,

2013).

CFT to Treat BPD. CFT was introduced in this paper as a newer approach when treating

BPD. CFT is focused on teaching the client to view self, the world, and others in compassionate

ways (Gilbert, 2009). CFT focuses on six skill sets to develop (see Fig. 1 in Chapter II) in clients

so that they can have the attributes of compassion (sensitivity, care for well-being, non-

judgment, empathy, and distress tolerance (Gilbert, 2007)). The focus in CFT is to help the

client elicit the feelings of compassion to counteract feelings of shame, worthlessness, and self-

criticism (Gilbert, 2009, n.d.). The focus on using the emotions in CFT certainly seems a

productive approach in the treatment of BPD and CFT has been reported to have success in

clients with long and very difficult psychological problems (Gilbert & Procter, 2006).

To illustrate this view that CFT may be a good treatment option for BPD, Chapter III

showed, in the context of a case study (Gormley, 2004) with client Margaret, how CFT skill

development might be best achieved. Each of six skills to develop in CFT were individually

presented and aspects of Margaret’s case were used to illustrate how to deploy/teach them. The

literature and evidence presented here certainly makes a strong case for the greater education of

the profession in CFT and its uses in the treatment of personality disorders, including BPD.


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overcoming shame in borderline personality disorder (bpd) using compassion focused therapy...

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