Overcoming Barriers to Skills Training in Borderline Personality Disorder: A Qualitative Interview Study

Despite evidence suggesting that skills training is an important mechanism of change in dialectical behaviour therapy, little research exploring facilitators and barriers to this process has been conducted. The study aimed to explore clients’ experiences of barriers to dialectical behaviour therapy skills training and how they felt they overcame these barriers, and to compare experiences between treatment completers and dropouts. In-depth qualitative interviews were conducted with 40 clients with borderline personality disorder who had attended a dialectical behaviour therapy programme. A thematic analysis of participants’ reported experiences found that key barriers to learning the skills were anxiety during the skills groups and difficulty understanding the material. Key barriers to using the skills were overwhelming emotions which left participants feeling unable or unwilling to use them. Key ways in which participants reported overcoming barriers to skills training were by sustaining their commitment to attending therapy and practising the skills, personalising the way they used them, and practising them so often that they became an integral part of their behavioural repertoire. Participants also highlighted a number of key ways in which they were supported with their skills training by other skills group members, the group therapists, their individual therapist, friends and family. Treatment dropouts were more likely than completers to describe anxiety during the skills groups as a barrier to learning, and were less likely to report overcoming barriers to skills training via the key processes outlined above. The findings of this qualitative study require replication, but could be used to generate hypotheses for testing in further research on barriers to skills training, how these relate to dropout, and how they can be overcome. The paper outlines several such suggestions for further research.


Introduction
Dialectical behaviour therapy (DBT) has been found effective in numerous randomised controlled trials for reducing suicide and self-injury, and for improving global outcomes in borderline personality disorder (BPD) [1,2,3].
DBT is based on the biosocial theory of BPD. A major premise is that BPD develops when emotionally sensitive individuals encounter invalidating environments that ignore, suppress or punish their emotions, which further compounds their emotional sensitivity and prevents development of the behavioural and cognitive skills required to self-regulate emotions. DBT therefore has five essential functions: 1) to teach skills for more effective emotional and behavioural regulation, 2) to enhance client motivation to use these skills, 3) to ensure clients can use the skills in a wide variety of situations, 4) to help shape an environment that reinforces skill use and 5) to enhance the therapist's own skills and motivation to keep working effectively with the client. These functions are fulfilled via five modes: 1) group skills training sessions, 2) individual therapy, 3) telephone skills coaching, 4) case management and 5) therapist consultation meetings [4,5].
The frequency with which clients use the DBT skills is positively associated with self-harm reduction [6,7] improvement in other features of BPD [8] and completing treatment [6]. In qualitative interviews, many clients have reported finding the DBT skills helpful for regulating their emotions and behaviour [9,10,11,12]. However, little research on barriers to treatment progress in DBT has been conducted [13,14]. Such research is important in order to optimise treatment delivery and clinical outcomes [15,16]. Given the evidence base for skills training as a treatment mechanism, it may be particularly important to explore what factors facilitate or act as barriers to DBT skills training. Qualitative interviews with clients who have received DBT could provide a rich source of experiential data, whilst comparing experiences between treatment completers and treatment dropouts could enable generation of hypotheses about processes contributing to dropout.
The present study therefore used thematic analysis of qualitative interviews with clients receiving DBT to address the following questions: 1. What factors do clients experience as barriers to DBT skills training? 2. How do clients experience overcoming barriers to skills training? 3. How do experiences of barriers to skills training, and overcoming such barriers, differ between treatment completers and dropouts?

Inclusion Criteria
The inclusion criteria were: 1. Diagnosis of BPD 2. Having initiated in the past twelve months a twelve-month course of DBT, consisting of once-weekly individual therapy, once-weekly group skills training, telephone skills coaching and team consultation.
All participants were concurrently taking part in quantitative evaluations of DBT [6,17], which required a recent history of self-harm (past 12 months).

Measures
Participants' Axis I and Axis II diagnoses were established at the beginning of treatment using the Mini International Neuropsychiatric Interview [18] and the Structured Clinical Interview for DSM-IV Axis II (SCID-II) [19]. Frequency of self-harm in the twelve months before beginning DBT was established using a structured interview based on the definitions of self-harm used in the Suicide and Self-Injury Interview [20], whilst BPD severity was assessed using the Zanarini Scale for BPD [21]. These measures were administered in the course of quantitative evaluations of DBT, in which all participants were concurrently participating, separately to the current study [6,17].

Recruitment and Sampling
Forty interviewees were purposively sampled from a group of 89 individuals participating in a process-outcome study of DBT [6], some of whom were also concurrently participating in a randomised controlled trial [17], between 2009 and 2012. The purposive sampling [22] selected both treatment completers and treatment dropouts to be interviewed, where treatment dropouts were those missing four or more consecutive sessions of group and/or individual therapy [5]. This aimed to facilitate maximum variation sampling [22], whereby a range of experiences was captured, and to enable comparison of treatment completers and dropouts. Completers were consecutively selected to be interviewed once they had completed treatment, until data saturation had been achieved i.e. a subjective judgement by the study authors that additional interviews were not contributing new ideas to the analysis [23]. Selection of dropouts for interview was also consecutive until the point of data saturation, but some dropouts lost contact with the research team before they could be interviewed. More completers were sampled (N = 27) than dropouts (N = 13). This was because completers by definition had lengthier and more complex experiences of skills training to draw on, so saturation took longer to achieve in this subgroup.

Study Setting
Sample Characteristics. The sample was predominantly female (85%) and unemployed (67.5%), and spanned a range of ethnic groups (55% white, 45% black or other ethnic minority). The average age was 33 years (SD = 10.2). On average participants met criteria for 3 personality disorders (SD = 1.3) including BPD, and co-morbidities included substance dependence (33%), alcohol dependence (36%) and post-traumatic stress disorder (50%). In the 12 months before beginning DBT, the average rate of self-harm was 7.6 days (SD = 10.1) per month. The treatment completer subgroup (N = 27) had all completed 12 months of DBT, whilst the treatment dropout subgroup (N = 13) had completed an average of 6.1 months (SD = 3.2, range: 1-11 months).
Treatment Setting. Participants were recruited from a community DBT service in an inner city area in the United Kingdom. The service provided a twelve-month course of DBT, including weekly individual therapy, a weekly group skills teaching session, telephone skills coaching and team consultation. Since this paper focuses on barriers to treatment, it is important to establish treatment adherence. A DBT therapist was trained in adherence rating by the Behaviour Research and Therapy Clinics (BRTC), University of Washington, and rating was conducted according to BTRC protocol. All individual and group sessions were audio recorded. Ten percent of individual sessions and five group sessions were randomly selected for adherence rating. A further 10% of the selected individual sessions and one group session were also rated by a BRTC adherence rater to establish inter-rater reliability. The individual sessions received a mean score of 4.1 (range: 3.6-4.5), demonstrating good adherence. The skills teaching groups received a mean score of 4.1 (range: 4.0-4.4). The two raters rated all sessions within a 0.3-point margin of difference.
Interview Setting. Participants were interviewed as soon as possible after ending DBT. The interviews were conducted, following informed consent, in a private research office or the client's home, lasted 20 to 90 minutes and were audio recorded for later transcription.

Reflexivity
The background, research roles and potential influences on each of the authors is detailed in Table 1. The authors aimed to approach data collection and analysis without a priori hypotheses. However, they also aimed to cultivate an attitude of 'mindful inquiry', i.e. to notice, accept and transcend the influence of their own beliefs, knowledge and experiences on interview conduct, interpretation and analysis [24].

Materials
The topic guide for the interviews was developed in collaboration with DBT clients and therapists, and was modified, following piloting, to reflect areas which emerged as important in early interviews. The topic guide was semi-structured, with key questions followed by suggested probes for further exploration [22]. The order and wording of questioning was flexible in response to the interviewee's language and the natural course of the conversation [25,26]. The guide prompted interviewers to explore participants' experiences of learning, using and benefiting from the skills, what factors had acted as barriers to this process and how they had overcome them. The topic guide is available as supplementary material (S1 Topic Guide).

Thematic Analysis
The analysts (KB, LC and SS) took a critical realist approach to the data, viewing participants' accounts of their experiences as grounded in reality, but acknowledging the influence of subjectivity and the social context on data collection and analysis [27]. The interview data was analysed inductively using thematic analysis [28,29]. Analysis and data collection occurred concurrently in an iterative process whereby early analysis informed conduct of subsequent interviews [23]. The analysts first coded the data i.e. in each interview, sentence(s) of potential relevance to the research questions were tagged in MAXQDA software [30] using brief phrases ('codes') that summarised the content [28,29]. Once all interviews had been coded, credibility checks were conducted by a researcher external to the study team, who independently coded a randomly selected ten percent of the transcripts against the code list. Any discrepancies in coding were discussed and used to modify the list of codes until all raters agreed on code application. The codes were sorted into preliminary themes and sub-themes, which were repeatedly reviewed and refined by all analysts to maximise internal homogeneity and external heterogeneity, until all analysts agreed that the themes and sub-themes accurately reflected the overall 'story' told by the data [29]. Once the themes and sub-themes had been finalised, all analysts worked together to develop an analytic narrative for each sub-theme, which summarised what participants had said in each sub-theme and encapsulated the analysts' interpretation of what each sub-theme meant in relation to the research questions [29].

Sub-Group Comparisons
The proportion of participants endorsing each sub-theme was compared between treatment completers and dropouts using Fisher's Exact Test.

Quality Assurance
In conducting and reporting the results of the study, Elliott and colleagues' guidelines for qualitative research [31] and the consolidated criteria for reporting qualitative research (CORE-Q) [25], were adhered to.

Ethics Statement
This qualitative study was approved on 18/02/2009 by the Camden and Islington Research Ethics Committee as a substantial amendment to the DIALECT trial (ref: 07/H0722/98). Participants provided written informed consent to participate. Only participants with capacity to consent were included, after checking they had understood the information provided.

Results
The analysts derived themes and sub-themes under two key domains pertinent to the research questions: Participant Experiences of Barriers to Skills Training (Domain 1), and Participant Experiences of Overcoming Barriers to Skills Training (Domain 2). Examples of verbatim quotes from participants coded under each sub-theme are given in Tables 2 to 5. Additionally, for each sub-theme an analytic narrative is presented, encapsulating the authors' interpretation of the meaning of each sub-theme in relation to the research questions.

Domain 1: Participant Experiences of Barriers to Skills Training
Theme 1. Difficulties learning the skills: too much to take in. Participants reported difficulties learning the skills linked to two key sub-themes: Anxiety during the skills groups (Subtheme 1.1.) and Difficulty with the presentation of the skills material (Sub-theme 1.2). Examples of supporting quotes for each of these sub-themes are given in Table 2 below.
Sub-theme 1.1 Anxiety during the skills groups: For twenty-five participants, attending the skills groups was at times an anxiety-provoking experience. Elements leading to anxiety included worrying about being judged by the therapists or other group members, judging themselves when they did not understand the material, or concern that the treatment would not work. For a few, the therapists were perceived as authoritarian and strict, whilst the school- like environment triggered traumatic childhood memories. This interfered with participants' ability to learn the skills in various ways, including interfering with their ability to concentrate on the material being taught, feeling too embarrassed to ask for help when they did not understand, or having urges to escape the room or end therapy. Sub-theme 1.2 Difficulties with the presentation of the skills material: Twenty-five participants reported that certain aspects of the way the skills material was presented made it difficult to understand and learn. These included being faced with a lot of information presented at a rapid pace, the use of specialist DBT jargon that was difficult to understand, and the use of acronyms which were difficult to remember.
Theme 2. Difficulties putting the skills into practice: overwhelming emotions. Thirtytwo of the forty participants explained that feeling overwhelmed by intense emotions at times prevented them from putting the skills into practice, by leading them to perceive a loss of control over their behaviour (Sub-theme 2.1) or leading to negative thoughts about using the skills (Sub-theme 2.2). Examples of supporting quotes for each of these sub-themes are given in Table 3. Sub-theme 2.1 Loss of control: Twenty-six participants explained that at times intense emotions seemed to 'take over' their mind, such that they felt a loss of control over their own thoughts and behaviour. They explained that their emotions could overwhelm their thoughts to such an extent that it felt like "blackness" [Participant 22, DBT dropout] or a "massive fog"  2 Negative thoughts about the skills: Thirty-two participants explained that at times they would have negative thoughts about the skills, such as thinking that they did not want to try to use them, and that using them was too difficult, pointless or would not work. They emphasised that continually trying to use the skills in the face of distressing experiences could be a difficult struggle and was often emotionally exhausting. For some, negative thoughts were linked to feelings of defiance or rebellion against having to use the skills. For others, the thought of using the skills was highly anxiety-provoking, forcing them to confront things they would rather avoid, take risks and let go of their 'safe' coping behaviours.

Domain 2: Participant Experiences of Overcoming Barriers to Skills Training
Theme 3. A personal journey to a new way of life. Participants described the challenging journey they had undergone to overcome initial difficulties in learning and using the skills. As they committed and re-committed to keep working towards change in their lives, (sub-theme 3.1), they gradually began to personalise the way they used the skills (sub-theme 3.2), and to find that the skills became an automatic part of their behavioural repertoire (sub-theme 3.3). Supporting quotes are shown in Table 4.
Sub-theme 3.1 A commitment to keep working towards change: Almost all participants (N = 32) emphasised that overcoming barriers to learning and using the skills was a gradual journey, requiring a continual process of committing and re-committing to working towards change. Participants did this by continuing to attend the group, even when at first they did not understand what was being taught, and did not believe it would help them. They practised using the skills again and again in their daily lives, even when at first it was difficult or did not seem to work. When they felt tempted to give up, they re-committed to maintaining their efforts by reminding themselves of how much they wanted to change their lives, and also of the progress they had made.
Sub-theme 3.2 Making the skills my own: Over the course of DBT, a minority of participants (N = 13) gradually derived their own personal meanings and interpretations of the skills, and learnt to concentrate on using the skills that worked best for them and their personal circumstances. For some, this personalisation was important in enabling them to let go of rigid, perfectionistic and self-critical thinking about their skills use.
Sub-theme 3.3 Using the skills becomes automatic: For nearly half of the participants (N = 18), the end result of this journey was that eventually they became able to use the skills automatically without having to think about it. For a few, the DBT skills became so ingrained that they referred to them as "part of" themselves, an integral aspect of their identity.
Theme 4. An environment that supports change. The second theme concerns the beneficial effect of support from others in learning and using the skills: the skills group (sub-theme 4.1), the individual therapist (sub-theme 4.2) and friends and family (sub-theme 4.3). Supporting quotes are shown in Table 5.
Sub-theme 4.1 The skills group: Many participants (N = 25) found the skills group to be an environment that supported them in overcoming difficulties with learning and using the skills. Participants emphasised the importance of being able to learn from each other's understanding of the skills and experiences using them, and of being encouraged by more experienced group members to persevere through doubts and difficulties. For some, learning from the group therapists about how they used the skills to deal with problems in their own lives gave them a sense of connectedness and made learning the skills a less isolating experience; less of a 'them and us'. Participants found learning much easier when there was a fun, light-hearted atmosphere in the group, with everybody included. This was created through the interactions between group members and through the efforts of the therapists to teach in a fun way using multiple formats, and to keep checking that everybody understood.
Sub-theme 4.2 The individual therapist: Many participants (N = 23) reflected on the importance of their individual therapist in supporting their skill use. The individual therapist was able to explain things they had not understood during group skills training, suggest skills to try during telephone skills coaching and role play skilful behaviour. If target behaviours, e.g. selfharm, had occurred in the previous week, they could use chain analysis to help the participant see where they could have used the skills.
Sub-theme 4.3 Friends and family: A minority of participants (N = 13) reported that their friends and family had supported their skill use in a number of ways: by discussing the skills with them, helping them understand difficult concepts, encouraging them to use the skills, or even using the skills themselves.

Subgroup Comparisons
A comparison of the proportions of participants endorsing each sub-theme in the treatment completers versus treatment dropouts sub-groups is shown in Table 6 below. Dropouts were more likely than completers to have experienced anxiety during the skills groups as a barrier to learning the skills (p = 0.05) and were less likely to report committing to persisting in working towards change (p = 0.02), personalising their use of the skills (p = 0.07) or becoming able to use the skills automatically (p = 0.02). They were also less likely to report experiencing the skills group (p = 0.03), their individual therapist (p = 0.01) or friends and family (p = 0.07) as supporting their skills training.

Summary of the Findings
Based on in-depth interviews with 40 clients with BPD who had taken part in a DBT programme, the study aimed to establish what factors clients experienced as barriers to DBT skills training, how clients experienced overcoming barriers to skills training, and how these experiences differed between treatment completers and treatment dropouts. A thematic analysis of participants' reported experiences found that key barriers to learning the skills were anxiety during the skills groups and difficulty understanding the material. Key barriers to using the skills were overwhelming emotions which left participants feeling unable or unwilling to use them. Key ways in which participants reported overcoming barriers to skills training were by sustaining their commitment to attending therapy and practising using the skills, personalising the way they used skills, and practising them so often that they became an integral part of their behavioural repertoire. Participants also highlighted the importance of other skills group members, the group therapists, individual therapists, friends and family for explaining the skills and exemplifying how to use them, whilst making skills training an enjoyable and collaborative process. Treatment dropouts were more likely than completers to describe anxiety during the skills groups as a barrier to learning, and were less likely to report overcoming barriers to skills training via the key processes outlined above.

Clinical and Research Implications of the Findings
Due to the subjective nature of qualitative findings, which are based on participants' interpretations of their experiences which are then in turn interpreted by the analysts, the present study can only raise tentative suggestions for clinical implications and hypotheses for testing in further research. These are outlined below.
Monitoring problematic thoughts and feelings. Experiences of anxiety during the skills group, difficulties with the skills material, a perceived loss of control over behaviour, and negative thoughts about using the skills, should all be treated as Target 2 "therapy-interfering behaviours" [5], if they interfere with clients' ability to learn and use the skills. However, these experiences may not always be apparent to therapists. It could perhaps be helpful to add "Anxiety during the skills groups", "Difficulties with the skills material", "Feeling out of control" and "Negative thoughts about the skills" to the Diary Card to enable the individual therapist to monitor, explore, validate and target them as necessary.
Skills coaching. Individual therapists may find it helpful to suggest various DBT skills to clients experiencing problematic levels of anxiety during the groups, perceived loss of control or negative thoughts about the skills. These include: considering pros and cons of using the skills to cope versus acting on their urges; 'acting opposite' (e.g. actively participating in group despite urges to withdraw, using the skills despite negative thoughts about them); recognising and letting go of judgemental thoughts about group or the skills; challenging negative thoughts about the group or using the skills; 'cheerleading' (thinking encouraging thoughts); 'Cope Ahead' (e.g. imagining oneself coping with feeling anxious during group); and radical acceptance (e.g. accepting that feelings of anxiety are part of life and must at times be endured) [4,32]. Clients who report becoming so overwhelmed by their emotions that they lose control and "cannot" use the skills, may lack awareness of early warning signs that their emotions are escalating. Therapists may find that coaching clients to scan their bodies regularly could allow the client to notice early indicators of emotional arousal and intervene by using the skills, before reaching the point of feeling overwhelmed [4,32].
Tailored interactional styles. Group therapists may find it helpful to modify their interactions with clients for whom anxiety during the skills groups has been identified as a barrier, by taking a gentler approach focussed on validating clients' answers to questions and feedback on homework practice [32].
Presentation of the skills material. Group therapists may find it helpful to repeatedly define any specialist terminology used (e.g. 'mastery', 'radical acceptance'). Participants in the present study found it particularly helpful when group therapists made the skills teaching interactive and fun, using a variety of teaching techniques including group exercises, diagrams, role plays and self-disclosure.
Reinforcing motivation and commitment. Therapists may find it helpful to draw on Linehan's suggested strategies for reinforcing clients' commitment to maintaining their efforts to learn and use the skills [5]. These include evaluating the pros and cons of making such a commitment, playing devil's advocate, using the 'foot in the door' technique, highlighting prior commitments made by the client, and cheerleading the client.
Suggestions for further research. Further research could monitor state anxiety before, during and after the skills groups and test whether increases in state anxiety during the group predict dropout. If found to be linked to dropout, a feedback system could be implemented whereby state anxiety measures are routinely administered during DBT skills groups, and clients reporting increases in anxiety during the groups are 'flagged up' to their individual therapists as being potentially at risk of dropout. This feedback approach has been shown to improve outcome in mixed diagnosis groups but has not yet been tested in personality disorder [33,34,35,36].
Participants in the present study highlighted the role of support from other group members in overcoming barriers to skills training. Further research could test whether assigning new group members a skills coaching 'buddy' from amongst the more experienced group members, to provide encouragement and share their own experiences of learning and using the skills, could help reduce dropout.

Limitations
The interviews focussed only on the skills training element of DBT, preventing exploration of other aspects of the treatment that may have contributed to treatment dropout. Additionally, participants who dropped out of treatment may have retrospectively adjusted their recall of their experiences in line with their outcome, thus being more likely to recall learning and using the skills in a negative light. The samples were small and not randomly selected-hence, differences between dropouts and completers are not robust findings but can yield plausible hypotheses for testing in further research.

Conclusion
The present study was able to produce novel insights on barriers to DBT skills training and how they can be overcome, through analysis of the rich, experiential data provided by qualitative interviews with DBT participants. Although the findings are subjective and require replication, they could be valuable for generating ideas on how therapists can help their clients overcome barriers to skills training, and also hypotheses for testing in further research.
Supporting Information S1 Topic Guide. Topic Guide for Qualitative Interviews. (DOC)