Table 1 Summary of the final 12-week intervention: skills and strategies and order of presentation

1. Introduction

Emphasis on self-care: biology, behavior, thoughts, and emotions

Presentation of the goals of the intervention as well as 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) addressing 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 us away from what is important to us

Wise-Matrix

The Matrix is a therapeutic tool created by Polk and 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 achieved

Values

Based on the emotion regulation skills of DBT (see Emotion Regulation Handouts: [50], p. 388), participants 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.viacharacter.org) was used to identify personal strengths. This questionnaire assesses 24-character strengths classified into six broad categories of virtues: wisdom, courage, humanity, justice, temperance, and transcendence [61]. Participants 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-care^a

Loving kindness^a

The goal of this session was to foster the understanding 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. permanence” ...) 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”.

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-compassion 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).

b) Generate a perspective of the different multi-self.

Multi-Self

This strategy is widely used in compassion-focused 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 emotions in a deliberate way. Participants can be trained in savoring by increasing awareness of something positive 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) Identify 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 distress 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.

12. Motivate daily practice of learned skills

Summary of skills and strategies learned

The final session focuses on underscoring the importance of continuing to practice the skills learned. Suggestions are given on how to facilitate practice in daily life.