Soler et al. Borderline Personality Disorder and Emotion Dysregulation (2022) 9:34 https://doi.org/10.1186/s40479-022-00204-x RESEARCH Open Access Advancing the treatment of long‑lasting borderline personality disorder: a feasibility and acceptability study of an expanded DBT‑based skills intervention Joaquim Soler1,2,3, Elisabet Casellas‑Pujol1,2,3, Juan Carlos Pascual1,2,3*, Carlos Schmidt1, Elisabet Domínguez‑Clavé1,3, Ausias Cebolla4,5, David Alvear6, Anna Muro2,7 and Matilde Elices3,8 Abstract Background: Long-term follow-up studies in patients with borderline personality disorder (BPD) consistently show persistent impairment in psychosocial adjustment, although symptoms tend to decrease over time. Consequently, it might be better to deemphasize symptom-oriented interventions and instead promote interventions that incorpo‑ rate patient perspectives on recovery. In this study we aimed to examine the feasibility and acceptability of a novel intervention (dialectical behavioral therapy combined with positive psychology and contextual-based skills) in the clinical treatment of long-lasting BPD difficulties. Methods: This was a qualitative study. We developed an initial 8-week group intervention for long-lasting BPD. Upon completion of the 8-week program, the participants were asked to participate in a group discussion to provide feed‑ back. Based on that feedback, the intervention protocol was modified and then offered to a second group of patients, who also provided feedback. The protocol was revised again and administered to a third group. A total of 32 patients participated in the group interventions; of these, 20 provided feedback in the qualitative study. The main outcome measure was acceptability. Results: The following overarching themes emerged from the group interviews: helpful, unhelpful and neutral prac‑ tices; internal/external barriers; facilitators; and effects. Participants reported difficulties in imagining an optimal future and self-compassion. By contrast, positive skills were associated with an increase in positive emotions. The main inter‑ nal barrier was facing difficult emotions. The main external barriers were language-related issues. The group format was perceived as a facilitator to success. Dropout rates, which were assessed as an additional measure of acceptability, decreased substantially in each successive group, from 60 to 40% and finally 20%. Conclusions: The intervention was feasible to implement in the clinical setting and participants rated the final set of skills highly. Most of the skills were considered useful. Participant feedback was invaluable to improve the interven‑ tion, as evidenced by the large increase in the retention rate from 40 to 80%. Randomized clinical trials are needed to test the efficacy of this intervention in promoting well-being in participants with long-lasting BPD. *Correspondence: jpascual@santpau.cat 3 Institut d’Investigació Biomèdica-Sant Pau (IIB-NTPAU), Centro de Investigación Biomédica en Red de Salud Mental, CIBERSAM, Barcelona, Spain Full list of author information is available at the end of the article © The Author(s) 2022. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. 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Borderline Personality Disorder and Emotion Dysregulation (2022) 9:34 Page 2 of 14 Keywords: Borderline personality disorder, Long-lasting BPD, Feasibility, Acceptability, Skills training, Positive psychology, Dialectical behavior therapy, Contextual approach Background employment, and a decrease in symptoms such as suici- Borderline personality disorder (BPD) is a severe mental dality and self-harm. disorder characterized by pervasive emotion dysregula- Psychotherapy is recommended as a first-line treat- tion, impulsivity, identity disturbances and conflicting ment for BPD [56, 72]. Several psychological inter- interpersonal relationships [1, 8]. In the general popula- ventions are available to treat BPD, although the most tion, the prevalence of BPD is around 2% [76], although extensively studied and well-established approach is dia- it is substantially more common in clinical populations, lectical behavioral therapy (DBT), whose effectiveness with a reported mean point prevalence across studies of has been demonstrated in multiple studies [8, 19, 72]. 28.5% [73]. BPD often presents with other mental disor- Standard DBT is a highly structured treatment based on ders, including mood, substance use, and eating disor- cognitive-behavioral principles, integrating mindfulness ders, as well as post-traumatic stress disorder (PTSD) [1]. and dialectical-based strategies into four different treat- Despite the severity of BPD, remission rates within ment modes (i.e., individual therapy, skills training [ST], 10 years of diagnosis are as high as 85% [34, 77]. How- phone contact, and consultations team) [49]. DBT offers ever, high remission rates do not necessarily indicate a stage-specific treatment approach that is determined by the absence of suffering or impairment, rather remission the severity of the disorder. Treatment according to the simply means that the patient no longer meets diagnostic stage, which ranges from stage 1 to 4, is important and criteria for BPD. Some authors argue that BPD progresses necessary given the high complexity of BPD and related in stages, starting with an “at-risk” stage that eventually comorbidities. The main goal of stage one treatment is leads to clinical manifestations [42]. Clinical improve- to reduce life-threatening behaviors (i.e., parasuicidal ment appears to come at the cost of social isolation and behavior, severe eating disorder and substance abuse). a significant reduction in general activity. A relevant pro- The focus of stage two is to help patients learn to experi- portion of patients suffer from persistent impairment ence emotions appropriately. Exposure-based strategies in psychosocial adjustment [2]. Follow-up studies have for treating intrusive symptoms, which may be related to consistently found that some core BPD traits, such as comorbid PTSD, are recommended once the patient has impulsivity-related behaviors, resolve more quickly while improved stage one behaviors. Stage three treatments other traits, such as those related to affective instabil- focus on improving problem-solving related to activi- ity and anger, tend to be more enduring [54]. Crucially, ties of daily living, increasing self-respect, and improv- only a small percentage of patients with BPD achieve ing relationships. The aims of interventions for stage remission of comorbid clinical conditions, most notable four include reducing the sense of incompleteness while affective symptoms, which reflect loneliness, feelings of increasing connectedness, and enhancing full participa- emptiness, and impaired psychosocial functioning [2]. In tion in life, and acceptance [52]. this regard, “long-lasting BPD” refers to patients that pre- Research in DBT has focused mainly on stage one sent some degree of clinical improvement, but in whom (keeping patients alive) and stage two (emotional repro- low mood, poor psychosocial adjustment, and feelings of cessing) [8, 35, 52, 62]. Although follow-up studies emptiness persist over time. suggest mood and interpersonal difficulties, evidence In recent years, the concept of good mental health has regarding stages three and four is scarce. been expanded to comprise more than simply a reduc- Studies on DBT skills training (DBT-ST) in BPD have tion in symptoms. Good mental health involves several evaluated the effectiveness of training four skill modules: domains, including meaningful living, the establishment mindfulness, emotion regulation, interpersonal effec- of significant relationships and self-management strate- tiveness, and distress tolerance [50]. Those studies show gies [27, 43, 46]. This broader conception of good mental that standard DBT (including all treatment modes) and health matches the perspective of patients with BPD with DBT-ST mode alone are both effective in reducing self- regards to recovery. Katsakou et al [45] conducted a qual- injurious behavior, suicide attempts, and depression and itative study involving 48 patients with BPD receiving anxiety [12, 48, 71]. treatment in secondary mental health services. The inter- Positive psychology (PP) has emerged as an interest- views showed that patients associated recovery with an ing, evidence-based approach to improving well-being increase in several factors, including self-acceptance, self- [12, 21, 47]. PP interventions focus on selecting and confidence, control over emotions, better relationships, amplifying positive emotions, in some cases by replacing Soler et al. Borderline Personality Disorder and Emotion Dysregulation (2022) 9:34 Page 3 of 14 negative with positive emotions, based on the idea that Accordingly, we performed the present qualitative positive experiences can attenuate or damper negative study to examine the feasibility and acceptability of an ones [65]. Within the PP framework, an individual who expanded skills DBT-based intervention targeting long- is capable of choosing how to act or what to pay atten- lasting BPD. Acceptability was assessed through group tion to at a given point in time is more likely to act in a discussions designed to obtain extensive feedback from wiser, more virtuous manner, thus increasing well-being the participants. [67, 68]. Mindfulness is crucial to achieving those aims. Mindfulness and compassion-based interventions have Methods been associated with increased positive affect, improved Participants quality of life and pro-social behavior [4, 18, 20, 24, 28, A total of 32 outpatients with long-lasting BPD partici- 38, 59]. Some mindfulness practices, such as loving-kind- pated in the novel treatment program (see below). All of ness (LK) and self-compassion (SC), are part of a set of these patients were recruited from the BPD unit at a pub- DBT skills named “other perspectives on mindfulness” lic hospital in Spain. For the purpose of this study, “long- [50]. LK and SC, along with mindfulness, have proven lasting” BPD was defined as the presence of some clinical useful to alleviate suffering and promote well-being ([26, improvement (no life-threatening behaviors or trauma- 33]; ​ ​[53, 57]). Nevertheless, most DBT skills training pro- related symptoms for at least 12 months) accompanied by grams [10, 25, 50] focus on the “core mindfulness skills”, persistent low mood, poor psychosocial adjustment, and/ which teach participants how to practice mindfulness. or feelings of emptiness. Since LK and SC are not considered “core” skills, they Inclusion criteria were: adults of either sex between 18 are often left out of these programs as explicit teaching and 65 years of age; primary diagnosis of BPD according skills, even though some authors have suggested that they to DSM-IV-TR criteria and the structured Diagnostic can be woven into the teaching of the “core” mindfulness Interview for Borderlines Revised (DIB-R) (Barrachina skills [50]. Data from a pilot study showed that adding et al., 2004); previous participation in two DBT-ST inter- LK and SC practices to the traditional mindfulness skills ventions and signed informed consent. Exclusion cri- resulted in greater levels of acceptance than mindful- teria were: presence of life-threatening behaviors in the ness skills alone [26]. That study also observed significant last 12 months; PTSD or related symptoms; diagnosis of improvements in BPD symptoms, self-criticism, and self- drug-induced psychosis, organic brain syndrome, bipolar kindness [26]. A feasibility study performed to assess the or psychotic disorder; intellectual disability; participation value of PP exercises for patients with suicidal behavior in any other psychotherapy treatment during the study. found that exercises designed to increase gratitude and A subgroup of 20 participants participated in the quali- personal strengths were positively evaluated by the par- tative study, which was conducted to assess the partici- ticipants; conversely, forgiveness-focused exercises were pants’ perception of the intervention. rated poorly [39]. Although numerous studies have demonstrated the Procedure value of DBT for the treatment of stage one and two BPD, First, we reviewed the available literature to identify there is a notable knowledge gap regarding the value of interventions designed to treat long-lasting BPD symp- DBT for stages three and four. Although some prelimi- toms. This review showed that PP exercises and compas- nary evidence suggests that positive psychology, loving- sion strategies seem to be useful for enhancing well-being kindness and self-compassion exercises might be useful, [17, 26, 33, 47, 5 ​ 7]. Consequently, we developed an inter- more data are needed to support their use. In addition, vention based on PP and contemplative practices (for published studies on patient perspectives on recovery in more details see the Wellbeing Training Based on Con- BPD are scant, and more data are needed to make treat- templative Practices [WTCP]) manual: [13, 15, 26]). The ment and outcome targets more relevant to patients. skills trainers were directly trained in the WTCP protocol In this context, there is a need to perform feasibility by the creator of that program. Next, we recorded a series studies to determine whether an intervention is appro- of guided meditations aimed at facilitating the practice priate for further testing [9]. These type of studies are val- of the skills in the WTCP and we created a workbook uable because they reflect the reality of clinical practice, describing the skills presented in the intervention. The thus providing external validation by testing whether the intervention was led by three experienced therapists (all feasibility of the intervention in real-world setting [9]. An with PhDs) who had both research and personal experi- important area of focus addressed by feasibility research ence in mindfulness practice. Two of the therapists (J.S is examining acceptability, which refers to participant and M.E) had received prior training in DBT, self-com- perceptions of the novel intervention [9]. passion programs, and CBT. The third therapist (A.M) had experience in CBT and PP. Soler et al. Borderline Personality Disorder and Emotion Dysregulation (2022) 9:34 Page 4 of 14 We developed an initial 8-week intervention designed of the ten participants completed the entire 8-week inter- to treat long-lasting BPD. Ten patients were assigned to vention, a 60% dropout rate. a group intervention. Upon completion of the 8-week To address this high dropout rate and dissatisfaction program, the participants were invited to participate in with certain elements of the intervention, the interven- group discussions to explore their experience with the tion was modified based on feedback from the partici- training and the particular practices offered in those pants. The “My best possible self ” skill was reduced to 1 sessions. Two group discussion sessions were con- year (instead of 10) and we also modified the sequence of ducted by two independent researchers, who were not skill presentation. In addition, during the post-interven- involved in the treatment of patients. The information tion interviews, participants reported experiencing high obtained during these interviews regarding the value levels of distress during the intervention. Consequently, of each specific practice was then used to improve we moved the presentation of self-compassion skills to and refine the content of the intervention. The revised session 1, and also extended training in self-compassion treatment protocol was then offered to a second group to four sessions. The “regulating negative emotions” of patients, who also participated in a group discus- model session [15] was replaced with self-compassion sion after completion of the 8-week intervention. This strategies. Instead, participants were encouraged to prac- process was repeated to develop the third and final tice the skills covered in the emotion regulation module intervention, which included only the skills/practices of DBT-ST. References to “happiness” were avoided. considered most useful by most patients. Practices that A second group of patients (n = 10) that met the inclu- had an aversive effect (i.e., increased distress) were dis- sion criteria were recruited from the BPD Unit to par- carded; only those practices considered useful by par- ticipate in this revised intervention. Upon completion ticipants were retained. of this second 8-week intervention, feedback from the The initial intervention was based on a combination of participants confirmed difficulties with the “Best Possi- PP and mindfulness-based frameworks (see WTCP man- ble Self ” practice. Consequently, we decided to eliminate ual: [15]). The treatment format consisted of eight 2-hour this skill in the next version of the protocol. Participants sessions offered weekly in a group setting (minimum 10 also reported difficulties with the concept of “self-com- participants). The structure of the sessions was similar to passion”, which some perceived as sorrow or self-pity. the DBT-ST format. At the first session, the norms and Importantly, six of the ten participants completed full goals were presented and participants received the work- intervention, a dropout rate of 40% (versus 60% in the book and recorded meditations. The therapists empha- first group). Both patients and therapists agreed that sized that the goal of the intervention was not to achieve eight sessions were insufficient to introduce and train all “instant” happiness, but rather to learn and practice evi- of the content. dence-based skills to promote well-being. Starting with Based on these data, the protocol was again revised the second session, a new skill was introduced each week. and expanded from eight to 12 weekly sessions. The Practical exercises and/or a meditative practice were also revised protocol included new strategies to work on self- practiced during the session. Participants were instructed compassion as a form of self-care. In terms of sequence to practice the skills learned at the session during the of skills, the revised protocol began with self-care skills, week. These skills and the homework assignments were based on the observation that a minimum degree of lov- reviewed at the start of the next session. ing kindness and compassion towards the self is essen- The first eight-week intervention was entirely based on tial before training in positive emotion strategies. These the WTCP program [15]. This program included training self-care skills were based on the DBT practice of “Please in the following skills: 1) Best Possible Self (participants Self-care” (see PLEASE skills: [49, 50]), which consists of were instructed to write a letter about the best version of practicing self-compassion by performing “self-care acts”, their self-projected self over the next 10 years); 2) Mind- defined mainly as behaviors involving taking care of the fulness (breath and body meditations); 3) Identification body under the premise of “fake it until you make it”. and development of personal strengths; 4) Empowering In addition, we detected a need for strategies to defuse positive emotions (savoring and gratitude); 5) Regulat- cognitive barriers for self-care training. Consequently, ing negative emotions; 6) Contribution (compassion and we developed and included a new module, which we altruism); and 7) Multi-Self (including compassionate called “Cognitive Self-Care”, to address different polari- self ). In this first intervention, most participants strug- ties of thought. Defusion strategies played a key role in gled with the concepts of “happiness” and “self-compas- these practices. Additionally, we incorporated a practice sion”. In addition, most of the patients considered the called “Wise-Matrix”, which combines “the Matrix” from practice of projecting oneself into the long-term future Acceptance and Commitment Therapy (ACT) [60] and (i.e., Best Possible Self strategy) to be aversive. Only four the “Wise Mind” skill from DBT [50]. The aim of this Soler et al. Borderline Personality Disorder and Emotion Dysregulation (2022) 9:34 Page 5 of 14 combined practice is to promote new perspectives for (standard deviation [SD]) age was 40.3 (6.1) years (range, problematic thoughts and emotions to lower emotional 27-45). Twenty of these patients were interviewed in reactivity. Most patients rated the savoring and gratitude the post-intervention feedback groups. The educational practices as useful and thus these were retained. This level was as follows: university studies (56.3%), second- third and final intervention group had the lowest drop- ary studies (37.5%), and primary education (6.3%). At the out rate of the three groups (20% vs. 40 and 60%). Ten evaluation, 37.5% of the sample was unemployed, 31.3% patients out of twelve completed the full intervention. All were receiving an invalidity allowance, and 25% were the practices and skills used in the final intervention are employed. Most patients (75%) were single. Most patients described in Table 1. lived alone (43.8%) or with their birth family (31.3%). Data analyses Participants’ experiences In this study, we used a mixed-methods approach, which Six overarching themes were explored in each group consisted of a quantitative description of the partici- discussion, as follows: 1) helpful practices, 2) unhelpful pants’ characteristics and attendance rates, together with practices, 3) neutral practices, 4) barriers, 5) facilitators, a qualitative description of the participants’ experience and 6) effects. Later, several sub-themes were identified with the intervention obtained through group discus- based on an analysis of the transcribed text of the discus- sions led by experienced clinicians. sions (Table 2). We evaluated the opinions and experiences of the par- A central theme was the distinction between helpful, ticipants as a result of the process. We obtained qualita- neutral, and unhelpful practices, which was based on the tive data by means of a clinician-led discussion within participants’ experience with these different skills during the established groups. These discussions were based on training. Among the helpful practices, practicing grati- a series of semi-structured questions designed to inves- tude and savoring, and mindfulness were associated with tigate the participants’ experiences around six different an increase in positive emotions in 15 of the 20 partici- themes established by the research team (these themes pants (75%), as evidenced by the following comments: were selected prior to conducting the group discus- sions) (Table 2). First, participants were asked to give “I noticed that being grateful for the things that I their opinion on each theme. If any contradictory state- have lifts my mood. At night, instead of thinking ments or disagreements emerged, the discussion mod- about everything that goes wrong, I do the grati- erator asked the participants to clarify their statements. tude practice, and I feel much better for all the good The data obtained in the discussion groups were analyzed things I do have in my life”. using an interpretative phenomenological approach (IPA [];). Since the individual’s perspective cannot be directly “It has helped me to accept that I will have negative accessed in IPA, the researcher interprets the partici- feelings, and that I can feel the pain and continue pant’s interpretation through a double hermeneutic pro- with my life (mindfulness with emotion)”. cess [23]. This process allows the researcher to reflect on the participant’s insider perspective in the broader con- Some participants (6/20; 30%) reported that complet- text, informed by scientific publications and research on ing the Strengths Questionnaire was helpful to become the topic/experience under study. Following IPA guide- more aware of their strengths. The questionnaire helped lines [70], the participants were encouraged to express raise awareness of some personal characteristics that themselves freely; when necessary, the researcher asked they had not noticed before or shifted how they per- for clarification. The researchers encouraged participants ceived some of these characteristics. to express their opinions as naturally as possible. The “I already knew I had these characteristics, but per- recorded discussions were transcribed verbatim and were haps I did not see them as strengths. There are things read several times, line-numbered, and organized by that people say about me that I do not believe. The codes into subthemes [23]. Disagreements between the questionnaire has helped me to see them as good two researchers were resolved by consensus between the things about myself ”. researchers and the first author. Analysis was supported by Atlas.ti, (v.22). For some, being more aware of their strengths was also related to decreasing self-criticism: Results “According to the questionnaire, some of my Sample characteristics strengths are equanimity, honesty, and appreciation A total of 32 outpatients participated in the group inter- of beauty and excellence. At first, I could not believe ventions. Most patients (95%) were female. The mean age it because I have always been in touch with the neg- Soler et al. Borderline Personality Disorder and Emotion Dysregulation (2022) 9:34 Page 6 of 14 Table 1 Summary of the final 12-week intervention: skills and strategies and order of presentation Session number and content/goals Skill or Strategy Description 1. Introduction Emphasis on self-care: biology, behavior, Presentation of the goals of the intervention as well as thoughts, and emotions the norms, framework and skills trained. 2. Activating and maintaining self-care behaviors Please Self-care The aim of this skill, from DBT (see PLEASE skills: [49] [50];), is to facilitate behavioral changes through self-care. It consists of five components: (i) address‑ ing physical illness; (ii) balancing eating; (iii) avoiding mood-altering substances such as alcohol, drugs, non-prescribed medications or misuse of prescribed medications; (iv) balancing sleep; and (v) exercising. 3. a) Identify internal and external barriers that keep Wise-Matrix The Matrix is a therapeutic tool created by Polk and us away from what is important to us Schoendorff [60] and used in the context of ACT [36] to provide a contextual view of problematic behaviors. The aim is to explore the following: values, obstacles/ barriers, inflexible behaviors, and valued actions. This tool is useful to generate cognitive defusion, although it can generate elevated distress when applied in patients with severe BPD, especially when internal obstacles are identified. To avoid distress, participants were instructed to answer the MATRIX questions from the DBT “wise mind” skill ([49], [50]), which helps to generate a defused perspective of inner experience while avoiding the extremes of “emotional mind” and “rational mind”. This skill was named “Wise-Matrix”, as it combines both strategies. b) Orient towards values and define goals to be Values Based on the emotion regulation skills of DBT (see achieved Emotion Regulation Handouts: [50], p. 388), partici‑ pants were asked to answer the question “what is most important to me right now?”, to identify their main values. Once these values were identified, goals and concrete actions were defined to help the participants put each value into practice on a daily basis. 4. Identify personal strengths Personal Strengths The freely available VIA Character Strengths Survey (https://​www.​viach​aract​er.​org) was used to iden‑ tify personal strengths. This questionnaire assesses 24-character strengths classified into six broad categories of virtues: wisdom, courage, humanity, justice, temperance, and transcendence [61]. Partici‑ pants were told to complete the questionnaire and to identify their five main strengths. The main goal of this strategy was to define and generate behaviors linked to personal strengths. For example: “activating the strength of kindness by acting kindly towards co-workers”. As a way of motivating concrete actions, the personal strengths were associated with the values previously identified in session 3. 5. Identify levels of self-care: cognitive Cognitive Self-carea The goal of this session was to foster the understand‑ Loving ­kindnessa ing of the importance of self-care through loving kindness. This skill focuses on identifying polarities of thought (i.e., “fusion vs. defusion”, “kindness vs. hostility”, “shared humanity vs. isolation”, “impermanence vs. per- manence” ...) in order to generate more flexible ways of relating to one’s own experience. Some of the main targets are to generate perspective, identify forms of experiential avoidance, facilitate a connection with others, and to foster acceptance that the world, like our experiences, is changeable. The goal is to defuse rigid rules such as “my life will always be the same” or “I can’t trust others”. Soler et al. Borderline Personality Disorder and Emotion Dysregulation (2022) 9:34 Page 7 of 14 Table 1 (continued) Session number and content/goals Skill or Strategy Description 6. Identify levels of self-care: behavioral Body Self-care The main target of this session is for participants to learn to calm themselves as a prelude to compassion. This skill consists of using body-related practices to facilitate self-compassion and self-calming. The skills used were “half smile” and “willing hands” (DBT: [49] [50];), “compassionate gesture and tone”, and “calming touch”. 7. Identify levels of self-care: emotional Self-compassion The aim of this session is to appreciate the difference between self-care and self-criticism, as well as how to use meditations to facilitate self-compassion (e.g., “safe place imagery, compassionate color, interconnection meditation …”). Some of the meditations are available in many mindfulness-based interventions (e.g., MSC: [30]). The goal is to facilitate self-care skills and a kinder relationship with one’s own experience. Participants were encouraged to practice self-com‑ passion by talking to themselves as they would talk to a loved one. They were also encouraged to identify self-critical phrases and to replace them with self- compassionate ones. 8. a) Identify internal parts of the mind (multi-self ). Multi-Self This strategy is widely used in compassion-focused b) Generate a perspective of the different multi-self. therapy (WTCP; CFT: [31]: [15]). It consists of exploring the possible multiple selves that can appear in the same situation and their relationship with different emotions such as anger, anxiety, and sadness. The goal is to show the participants that there are different possibilities of experiencing a situation and not just a “single self”. This skill allows the participants to practice perspective-taking to create “a compassionate self”. 9. Enhancing positive emotions Savoring To practice intensifying and prolonging positive emo‑ tions in a deliberate way. Participants can be trained in savoring by increasing awareness of something posi‑ tive from the present, remembering something from the past or anticipating something good in the future [5, 6, 64]. Listing their favorite experiences using the five senses and then experiencing them in daily life or bringing this to mind during a meditation practice were examples of savoring-training. Specific tasks were: 1) Identify favorite sensory experiences; 2) Iden‑ tify thoughts and behaviors that boycott positive moments; and 3) Record three positive events in the day and savor them. 10. Enhancing positive emotions I Gratitude The goal of this skill was to pay attention to valued things in daily life that are not usually appreciated. For example: “Find three things during your day that you are grateful for and savor them for 20-30 seconds”. These practices included: thinking about supportive relationships, what others have done for us, a gift you have appreciated, feeling grateful for something or to someone … Participants were also asked to make a record of self-critical or judgmental thoughts and then turn them into a gratitude sentence. 11. Enhancing positive emotions II Contribution This practice consists of taking concrete actions to help others (i.e., “perform 5 kind acts during the week”). The aim is to increase self-esteem through helping loved ones and nurturing old and new relationships. This skill is commonly used as a distraction and dis‑ tress tolerance strategy in DBT ([49] [50];). Contribution allows individuals to redirect attention from the self to others and can be useful to interact with others. Soler et al. Borderline Personality Disorder and Emotion Dysregulation (2022) 9:34 Page 8 of 14 Table 1 (continued) Session number and content/goals Skill or Strategy Description 12. Motivate daily practice of learned skills Summary of skills and strategies learned The final session focuses on underscoring the impor‑ tance of continuing to practice the skills learned. Suggestions are given on how to facilitate practice in daily life. a Note: The terms self-care and loving kindness were used instead of “self-compassion” Table 2 Topics and example questions Topic Definition Example questions Helpful practices Practices associated with increasing positive emotions and/ Of all the practices and exercises we have done during the course, or self-awareness; and/or decreasing negative emotions and which were helpful (if any)? self-criticism. Unhelpful practices Practices identified as unhelpful because they increased nega‑ Of all the practices and exercises we have done during the course, tive emotions, and/or generated self-criticism. which were unhelpful (if any)? Neutral practices Practices not related to any particular effect. Of all the practices and exercises we have done during the course, which had a neutral effect (i.e., neither helpful or unhelpful)? Barriers External and/or internal factors that interfered with the learning In your opinion, did anything interfere with your learning process process and practice. (e.g., the group format, the therapist’s embodiment of the skill, your previous training …)? Facilitators External and/or internal factors that facilitated the learning In your opinion, did anything facilitate your learning process process, skills-training, and the homework assignments. (i.e., the group format, the therapist’s embodiment of the skill, your previous training …)? Effects Consequences related to the intervention. Internal effects on Did you experience any changes during the training? mood, self-awareness and/or self-dialogue. Has the course had any effect on you? External effects on social functioning. Has anything changed for you since you finished the course? ative side. Now, I do not see myself as bad as I used “Just realizing what is the internal world and what to”. is the external world is what helped me the most. Understanding it, integrating it and practicing it In addition to identifying these personal strengths, a is the most important thing. I wouldn’t have been substantial proportion of participants (12/20; 60%) noted able to stand being in this group if it hadn’t been that practicing self-compassion and loving-kindness had for the matrix, because my heart is going super- a positive impact: fast and I can still stay here”. “I am so harsh on myself. Compassion practices help me notice that and decrease the number of self-judg- “The matrix has placed me in the world, it has ments, which has an impact on the way I see others. made me more aware of what I had in my head I do not judge them as much either”. and believed to be real. Now I can distinguish the difference between my inner world and the outside “For me, the best thing has been the work with self- world”. criticism, it has helped me a lot to use the third per- son, to ask myself if I would speak to another person “The matrix is very useful, but I have to keep work- like that”. ing on it. When something affects me, I wonder if it is something from the outside world or from the “Combining self-compassion talk with touch helps inside world. Now I see that difference, but I still me. It didn’t help me as much to tell myself things find it hard not to believe what my mind is telling as it would to someone else, but to put a hand on me. I also am more aware of whether or not I am my chest and feel myself, helps. If I just tell myself I moving away from what matters to me. For exam- don’t believe it, then the reassuring touch helps me ple, with interpersonal relationships, if I am very believe it”. vulnerable, I prefer to take a step back and face another day, instead of saying or doing something Finally, most participants (7/10; 70%) rated the “Wise- that is going to be bad for the relationship”. Matrix” as a useful but complex tool: Soler et al. Borderline Personality Disorder and Emotion Dysregulation (2022) 9:34 Page 9 of 14 By contrast, some of the practices were considered their own feelings. Some participants also noted that unhelpful. For example, being more aware of particu- the therapist’s ability to “embody” these practices and to lar internal processes was associated with an increase in direct the group to prevent deflection from the session’s negative affect. subject. “Trying to practice self-compassion was awful for “You can tell that the therapist practices these skills me because I became aware of how much I criticize … and I wanted to be a little bit like him, if only just myself, not three times a day, but 20 hours a day. a little!” This made me feel like some monster, and it was The role of practice was also considered pivotal to inte- unpleasant for me; it made me angry. It is tough for grating the concepts learned during the sessions. A high me to practice self-compassion". proportion (15/20; 75%) of participants highlighted the In addition, the practice of writing a letter to the future importance of having previously attended DBT-ST before self was perceived as bitter-sweet. While some partici- being introduced to these new skills: pants (3/10; 30%) considered it to be a sort of “roadmap” “Five years ago, I would not have had the necessary for the future, for most (7/10; 70%) the experience of pro- skills to understand these. I could neither under- jecting themselves into the future was unpleasant and stand nor regulate my emotions. I was in a very dark triggered anxiety. place”. “I do not see the point in writing the letter. I find it difficult to survive each day, so I cannot make a plan “Some years ago, I felt that I was living in a storm for the next six months”. most of the time. If somebody had said to me `look at the sun`, I would not have been able to do so. I In relation to internal barriers, many participants (9/20; would have thought: what are you talking about? 45%) identified “moodiness” as the primary obstacle to Some years ago, the content of these practices would practicing the skills presented: have been impossible for me to understand”. “Some days, I am just not open to this. On those Lastly, in relation to the effects of the intervention, sev- days, having to find things to be grateful for is neg- eral participants perceived a decrease in self-judgment ative. If I have a bad day, I prefer to deal with it upon completion of training: rather than feeling forced to find good things in my life”. “Now that we have finished the training, I notice that I am more kind to myself … I have to work on this a “When I feel “normal”, practicing is not a problem. lot, but I am starting to see the effects”. However, when I am having a bad day, it is impos- An increased capacity to notice small things that hap- sible for me to apply self-compassion. I wish I could, pened during the day was also relevant for many: but I simply cannot”. “I have learned that good things happen to me In terms of external barriers, some participants (4/20; despite feeling pain, so I can feel bad about some- 20%) identified the characteristics of the group leader thing and still appreciate good things in my life …” as not being helpful. A few participants (3/20; 15%) also criticized how the content was presented, suggesting that The effects of the practices were also evident in terms it would be better to use a more structured presentation of interpersonal relations, with participants finding during the session, with a booklet to review the content themselves to be “less reactive,” “less judgmental,” and at home. Most participants underscored difficulties in the “more compassionate” towards others: use of concepts such as “happiness” and “self-compas- “Being more self-compassionate and more in touch sion” during the training. with positive emotions is something that has not “Sometimes I thought that the group leader was only helped me, but it has kind of expanded to other oversimplifying this and was being condescend- people in my life”. ing. We have particular problems as a group. We deal with pervasive emotion dysregulation, and the “My daughter and I do not get along. She is going leader must acknowledge that”. through adolescence, and now I am more aware of the details. I sometimes notice that she does things With regard to facilitators, most participants (12/20; that make me happy”. 60%) pointed to the value of the group format, as see- ing others experiencing difficult times helped to validate Soler et al. Borderline Personality Disorder and Emotion Dysregulation (2022) 9:34 Page 10 of 14 Based on the participants’ feedback, the researchers of DBT in patients with long-lasting BPD are needed, rated each skill and strategy used in the group interven- with a focus on enhancing connectedness and reduc- tions as useful (or beneficial effects reported), neutral, or ing the sense of emptiness. Positive interventions could not useful (or adverse effects reported). Fig. 1 shows the help to promote both of these aims. A strategy designed mean rating of each skill and strategy in terms of their to increase positive emotions would seem appropri- perceived effects. On average, the skills related to self- ate once behavioral decontrol has been overcome when compassion and the My Best Possible Self strategy were further clinical improvement may come at the cost of evaluated as neutral, while the other skills were better social isolation, low mood, and generalized avoidance accepted and generally rated as useful. [2]. Accordingly, we developed and implemented a pilot PP-based intervention (WTCP [15];). Given the need to Discussion align therapeutic goals with patient perspectives on per- This qualitative study was performed to examine the sonal recovery, we used interview groups to obtain feed- feasibility and acceptability of an add-on skills training back from participants, and then used this information intervention involving the combination of DBT-ST, posi- to progressively adapt and improve the intervention by tive psychology, and contextual-based skills. This com- eliminating the least useful practices while retaining the bined intervention was implemented in a clinical setting practices that participants considered helpful. to treat long-lasting BPD in a group of patients who had previously undergone DBT-ST. The intervention was Positive skills feasible to implement in this real-world setting and par- For most participants, practicing positive skills such as ticipants rated the final set of skills highly. Most of the gratitude, savoring, and working with personal strengths practices were considered useful. was associated with an increase in positive emotions, in DBT-ST primarily addresses the first stage of DBT line with the findings described by [39]). This improve- treatment, mostly focusing on reducing life-threaten- ment in positive emotions is consistent with other stud- ing behaviors and provide the emotional regulation and ies that have shown an association between savoring and tolerance required in order to then shift the emphasis decreases in negative affect and self-reported depressive to trauma-related symptoms in stage 2. In this regard, symptoms [40], and between savoring and increased hap- strategies that facilitate the transition to stages 3 and 4 piness and satisfaction [41, 44]. Previous studies have also Fig. 1 Soler et al. Borderline Personality Disorder and Emotion Dysregulation (2022) 9:34 Page 11 of 14 found that gratitude has positive effects in non-clinical perceived mindfulness skills to be more anxiety-pro- populations by reducing repetitive negative thinking [37], voking and less connected to their treatment goals than increasing positive emotions [22], and potentially even IE, which would explain the higher and faster dropout direct reducing suicidal ideation [48]. Interestingly, prac- rate. Interestingly, the patients who received mindful- ticing these positive skills not only had a beneficial effect ness training first and did not drop out showed greater on the participants’ emotions and self-awareness, but improvement in BPD symptoms compared to those in they also had a positive influence on interpersonal rela- whom the sequence of training started with IE skills; in tionships. Overall, the participants reported a decrease addition, relevant changes, such as reduction of judg- in self-judgment and an increase in their ability to notice mental stance and defusion of self-critical thoughts, were small positive things. Participants also reported being only achieved throughout the mindfulness condition [10, less reactive and more compassionate towards others. 25, 63]. Based on our experience, we believe that self- Overall, the effects of these practices are aligned with compassion can cause short-term discomfort (similar important areas of recovery as suggested by [45]). Hence, to that observed with mindfulness), but this practice is it appears that positive strategies (e.g., savoring, grati- likely to reduce self-invalidation, a core feature of BPD, in tude, and personal strengths) may enhance the expected the long-term [26]. effects of compassion-related skills to target the specific Self-criticism and self-invalidation [49] refer to two dif- problems underlying long-lasting BPD. ferent but overlapping concepts. Given that self-invalida- Despite the potential benefits of positive psychol- tion is a core aspect of BPD and that both self-criticism ogy for both nonclinical and some clinical populations and self-invalidation are cause and consequence of high [11, 16], the application of some of these strategies in emotional vulnerability that handicap patients’ capacity patients with BPD may not be suitable. For example, we for joy, it would seem appropriate to target these areas. found that imagining an optimal future was unhelpful, in A recent review found that compassion-based interven- line with the findings reported by Huffman et al [39] in a tions reduce self-criticism and that longer interventions sample of suicidal patients. Similarly, projecting a future were associated with greater effect sizes [74]. Conse- self was problematic for some of the participants in our quently, it is crucial to find ways to ensure that patients sample. continue with the intervention for a sufficiently long period to notice the benefits, despite the transitory back- Self‑compassion skills draft. In this context, the sequence in which different Self-compassion exercises also triggered difficult experi- skills and practices are presented appears to play a key ences, which some patients found hard to regulate when role. For example, training loving-kindness before com- they became aware of their self-criticism. Interestingly, passion appears to be beneficial, especially in participants this finding contradicts preliminary evidence from other with long-lasting BPD because loving-kindness training studies that suggest that compassion exerts helpful effects increases positive emotions and fosters greater openness in patients with personality disorders [26, 51]. However, towards other practices, such as compassion. Our experi- the difference in these results could be attributed to the ence suggests that the transition between the two prac- study cohort, which involved a mixed sample of patients tices is easier than if offered in reverse order, but more with personality disorder. Although training in self- research is needed to test this hypothesis. compassion fosters positive emotions in the long-term, unpleasant emotions (especially grief, shame, and anger) Barriers and facilitators are likely to emerge during the training period, a phe- In our study, some participants described “moodiness” nomenon known as “backdraft” [29, 75]. This “unwanted as an internal barrier to practice. As some participants effect” is similar to those reported in mindfulness-based noted, they did not always feel “open” to the practice, interventions [14], which seem to be transitory. which suggests that a certain degree of emotion regula- tion may be necessary before practicing certain skills. Sequence of skill presentation In this context, it is worth noting that all of the partici- Although the sequence of skill presentation in DBT has pants had previously received DBT-ST before enroll- not been extensively studied, future studies are needed ing in the current study. As a result, their prior training to investigate this aspect in more detail. Elices and col- provided them with the personal resources necessary to leagues [25] found that patients with BPD who partici- face distressing emotions provoked by new skills. Sev- pated in DBT training were significantly more likely to eral internal barriers to practice were detected, making drop out of treatment when the first skill taught was these potential targets for future studies. Indeed, defu- mindfulness versus interpersonal effectiveness (IE). sion strategies were needed to address these barriers, Those authors hypothesized that participants may have Soler et al. Borderline Personality Disorder and Emotion Dysregulation (2022) 9:34 Page 12 of 14 mainly the “wise matrix” tool which we developed for Conclusions this intervention. In this qualitative study, we examined the feasibility and External barriers were mostly related to the attitude of acceptability of a novel 8-week intervention designed to group leaders and language-related issues. For example, treat long-lasting BPD. The intervention was feasible to the use of concepts such as “happiness” and “self-com- implement in the clinical setting and the final set of skills passion” had a negative impact. Talking about “increasing was highly rated by participants, who considered most of happiness” evoked unrealistic expectations, which was these strategies/skills to be useful. By using the partici- experienced by some participants as something that “can- pants’ feedback to modify the intervention, we were able not be achieved”. As a result, this caused frustration and to substantially improve retention rates (an additional was perceived as invalidating for most of the participants. measure of acceptability), which doubled from 40% in The main “facilitating” factor was the group therapy for- the first group to 80% in the final group. More research is mat, as it can reduce feelings of being “weird” or “alone”. needed to test the efficacy of this intervention to promote life fulfillment in participants with long-lasting BPD. Strengths and limitations Acknowledgments This study has several limitations. First, the sample was This study was supported by Centro de Investigación Biomédica en Red de predominantly female and Caucasian, and all partici- Salud Mental (CIBERSAM). The authors would like to thank Bradley Londres for professional English language editing. pants had prior experience with DBT-ST. In addition, only the participants who had completed the full inter- Authors’ contributions vention took part in the post-treatment group discus- JS, JCP, ECP and ME designed the study. JCP and JS recruited the partici‑ pants. ME and CS collected and interpreted the data analyses. AM, JS and sions. Unfortunately, as occurs in many qualitative ECP performed the interventions. AC and DA provided the material and the research studies, we were unable to explore the experi- training for the intervention. All the authors assisted in the first draft of the ences of the participants who dropped out. In addition, manuscript providing critical feedback. All authors approved the final version of the manuscript. due to the preliminary study design (aimed at assessing feasibility and acceptability), we did not use validated Funding measures to assess the impact of the intervention on dif- This study was supported by the Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM) and by a grant from Instituto de Salud Carlos ferent domains. Similarly, we did not track home prac- III (PI19/00087 and PI21/00505) and co-financed by the European Regional tice, and therefore, we cannot make any definitive claims Development Fund (ERDF). about the association between adherence to practice Availability of data and materials and the effects thereof. We used a series of broad ques- The dataset and materials analyzed during the current study are not publicly tions to elicit a wide range of responses. As a result, the available. participants’ statements about the intervention were spontaneously reported. We purposely did not ask Declarations about specific skills, as we assumed that skills not men- Ethics approval and consent to participate tioned were neither helpful nor unhelpful. In retrospect, The study was approved by the conducted according to the guidelines of the it might have been better to specifically ask about each Declaration of Helsinki, and approved by the Ethics Committee of Hospital de skill and it would probably be beneficial in future stud- la Santa Creu I Sant Pau. Informed consent was obtained from all participants. ies to do so. Despite these limitations, the study also has Consent for publication several important strengths. First, the findings broaden Not applicable. our understanding of the feasibility and acceptability of Competing interests a positive-contextual psychology skills training interven- The authors report there are no competing interests to declare. tion in patients with long-lasting BPD. This study also represents an important first-step towards facilitating the Author details 1 Department of Psychiatry, Hospital de la Santa Creu i Sant Pau, Av. Sant transition to stages 3 and 4 of DBT, and towards develop- Antoni Mª Claret 167, 08025 Barcelona, Spain. 2 Universitat Autònoma de ing a targeted program whose efficacy could be evaluated Barcelona (UAB), Barcelona, Spain. 3 Institut d’Investigació Biomèdica-Sant in future research studies. In addition, by examining the Pau (IIB-NTPAU), Centro de Investigación Biomédica en Red de Salud Mental, CIBERSAM, Barcelona, Spain. 4 Departamento de Personalidad, Evaluación y specific skills rather than the final “package”, we increased Tratamientos Psicológicos, University of Valencia UV, Valencia, Spain. 5 CIBER our understanding of the processes of change in psycho- Physiopathology of Obesity and Nutrition (CIBEROBN), Madrid, Spain. 6 Univer‑ therapy, which is congruent with new approaches in the sidad del País Vasco/Euskal Herriko Unibertsitatea, leioa, Spain. 7 Department of Basic, Developmental and Educational Psychology, Universitat Autònoma field such as the process-based framework [16]. de Barcelona Serra Húnter Programme, Generalitat de Catalunya, Barcelona, Spain. 8 Institute Mar of Medical Research, IMIM, Barcelona, Spain. Received: 10 August 2022 Accepted: 12 November 2022 Soler et al. 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Soler J, Pascual JC, Tiana T, Cebrià A, Barrachina J, Campins MJ, et al. Learn more biomedcentral.com/submissions Dialectical behaviour therapy skills training compared to standard group