Six dominant themes and ten subordinate themes were identified in the data (see Fig. 3). These themes are considered to represent the participant’s experience of the CC workshop.
The need for training
While reflecting on their experiences, there was complete agreement among the participants that there was a need for the CC workshops. Participants identified several areas of need and three subordinate themes were developed which elaborate this further.
Feeling helpless
Participants were asked to reflect on the need for continuing professional development (CPD). They expressed experiencing feelings of “helplessness” and “incompetence” during interactions with clients presenting to the ED or CMHTs with severe emotional dysregulation.
P2: “The sense of helplessness, getting swallowed up and becoming almost dysregulated yourself.”
There was a sense of agreement in the groups that as a practitioner, it can be difficult to stay calm and to regulate one’s own emotions when confronted with someone in crisis. This feeling is exacerbated when practitioners feel they don’t have the skills required to support the person presenting in crisis. Participants expressed concerns of “not knowing what to say” (P3) and wondering “what do I do?” (P5).
Lack of knowledge
The theme of having limited knowledge about the DBT programmes offered in the service was apparent across all three focus groups. Participants reported knowing that the DBT programme existed but having little specific awareness of the skills taught in the programme or levels of support offered. Participants stated that they frequently inquire if their clients are using the skills learned on the DBT programmes but noted that they feel they are “bluffing” during the interaction:
P8: “when you tell people to use their DBT skills you are just shooting in the dark.”
P13: “asking…but not having a clue what they are”.
How can I help?
Participants wondered how they as practitioners can help clients presenting with emotional dysregulation. All participants expressed the desire to further their skillset to support clients in distress:
P2: “what can I do right now to help this person?”
P11: “I’d love to be able to learn this to help people when we do meet them”.
A new understanding
Participants appeared to develop a new understanding of emotional dysregulation and reflected on the fact that the training changed their perception of the person with whom they were interacting. The majority of participants also noted how their developing awareness is changing their practice. Several aspects of the training contributed to this and are further illustrated in the following subordinate themes.
Understanding emotional dysregulation
Participants in the three focus groups reflected on the benefits of the psychoeducation component of CC. This component aimed to create a better understanding of the mechanisms involved in emotional dysregulation. Some participants described having previously felt frustrated during challenging interactions with clients presenting to the ED or CMHT. This frustration appeared to occur as a result of not knowing why the client was expressing intense emotions and extreme behaviours. Since attending CC, the practitioners reported developing a greater awareness for the individual and their situation:
P6: “There’s patterns from their childhood… people can’t help being that way”.
P3: “there’s something deeper going on”.
Participants developed the ability to make sense of the client’s current presentation by considering the underlying mechanisms of how emotional dysregulation develops, and the client’s past history. This in turn impacted upon how practitioners felt about their client. Participants noted that this new understanding of emotional dysregulation and its implications on interactions has had a positive impact on their practice:
P6: “It takes away the impatience and the lack of empathy you can sometimes have”.
Participants noted an increase in empathy and a resulting reduction in their previous experience of frustration towards some clients with whom they worked.
Clinician impact on interactions
The CC workshop facilitated discussions regarding mindfulness and self-awareness. The clinician’s role in interactions was subsequently discussed across the three focus groups. The majority of participants reflected on their new learning regarding the necessity of being aware of their internal states and how their experience of the client or their own emotions can affect the interaction. Two participants outlined this further:
P4: “Understanding what is happening to me as well, you tend to blame them but your own facial expressions can make it worse.”
P8: “Being mindful of where you are on a given day, that has huge implications for how the interactions can go”.
In addition to this, several participants expressed a sense of relief when they were reminded during the workshop that they are “human” and thus fallible:
P11: “Learning that you are a human being yourself…it’s good to be mindful of yourself and know that you have a threshold.”
Alternative perspective
CC aimed to foster a deeper understanding of the processes involved in severe emotional dysregulation. After attending CC, practitioners reflected that it changed the way they perceived their clients and difficult interactions:
P9: “Helped me see a different way of looking at an interaction with my client.”
P10: “People aren’t just purposively trying to be difficult.”
Participants recognised that while it sometimes appeared that the client was behaving in ways which practitioners found challenging, it wasn’t always intentional or directed personally towards the practitioner. A consistent observation across the focus groups was that having an alternative understanding reduced practitioner’s own anxiety about working with the population:
P1: “There’s less dread meeting the person because you are approaching it differently.”
Validation
Validation skills were referred to by all 13 participants as being the most useful component of CC and the most influential in terms of changing their practice:
P12: “Validation skills encouraged me to stick with it and try harder and not give up with the person.”
The majority of participants explained previous difficulties they experienced when empathising with and validating people engaged in harmful or destructive behaviours. Following the intervention, they could validate the person’s emotion and experience, without condoning the behaviours:
P7: “Validation stuck in my mind a lot, how to validate some part of what the person is experiencing even if you don’t agree with a behaviour.”
Others noted that it changed the way in which they approached their sessions. They previously adhered to agendas and their session goals. Following CC, there is an awareness of letting the person feel heard. This included being flexible with the session: balancing the validation of the person’s emotional experience with change-based strategies.
P5: “It changes that expectation of getting through the agenda but the most important thing is she is heard.”
It was acknowledged that this positively affected interpersonal interactions and the therapeutic relationship for both parties.
Moving forward in transactions
The subordinate theme of moving forward in transactions emerged from the groups’ discussion of using validation skills. Several participants had been using validation in the month prior to the focus groups. Practitioner’s reflected on how validating the person’s emotional experience helped them progress both their relationship and their planned intervention. They noted that clients who are dysregulated frequently ruminate on a difficult interaction or event and this can be a barrier to therapeutic progress. They noted how validation can be used to overcome this:
P9: “They can see that you are trying to acknowledge it and then can move forward rather than getting stuck on it”.
P3: “It allowed us to move past it a little bit, once they feel ok they know where I’m coming from. Acknowledge and validate it you can move forward rather than just getting stuck in a rut with it.”
Barriers to applying new skills
Each focus group was asked to highlight barriers they face in using the skills learned at CC. While lack of confidence was cited as a reason, this appeared to originate from a lack of knowledge regarding the core skills taught in DBT.
Not knowing
The majority of participants expressed the desire to learn more specific DBT skills. While their new knowledge has been beneficial, gaps still remain. Several participants stated similar concerns about “putting a foot in it” (P4) or “making things worse.” (P5). One individual expressed her fear about contradicting the DBT programme and this appeared to be shared by other participants:
P2: “Not knowing what do to is the main barrier.”
P8: “I would be afraid for saying something opposite to what they are learning [on the DBT programme]”.
Practitioner’s agreed that knowing more about the DBT skills plus DBT structure could alleviate these fears.
Overcoming barriers to skill application
Practitioners reflected on possible solutions to the barriers discussed and highlighted the need for further training and increased communication.
Further training
Practitioners across the three focus groups agreed that further training and practice could help increase their confidence in utilising skills and improve their knowledge base.
P10: “Having the information can overcome barriers”.
P6: “I would like more practical skills maybe roleplays on how to use the skills on a practical level.”
Knowing the specific skills and how to practice them with an individual experiencing emotional dysregulation was highlighted as a training need. The importance of further training was recognised in terms of having an effect on both practitioner and client well-being:
P7: “It takes a certain amount of patience and there’s a high level of burn out towards some clients but the training and the discussion part of the training helped with that”.
Further communication
The need for increased communication among peers and across teams was discussed in terms of overcoming barriers. In general, the practitioners found the peer support element of CC reassuring and normalising. One group generated the idea of forming peer support groups at work:
P4: “Peer support stuff was reassuring…that others experience these difficulties too.”
P13: “Forming support groups among staff to practice the skills.”
When reflecting on their concerns about “doing the wrong thing” (P7) or giving conflicting advice to the DBT programme, several practitioners suggested the need for more communication regarding an individual’s progress in the DBT programme and information about their care plan:
P3: “More communication on the team about what works for the person”.
P6: “To be better linked…who is their telephone contact for phone coaching – whether they are attending the group”.
The DBT programme offers a number of supports to clients attending the group (e.g. phone coaching outside working hours). Practitioners agreed that knowing more about this process and others like it would be beneficial in terms of providing improved care.
Future direction for CC: practical application of skills
The predominate theme towards the end of each focus group was the need for further training in the practical skills of DBT. Many participants echoed the desire to obtain tangible skills that can be applied in the moment when clients are in extreme distress:
P13: “I would like to know more about the practical applications of the skills.”
P8: “I’d love to be able to learn this to help people when we do meet them.”
This learning included the development of a knowledge base of the various concepts used within DBT (e.g. chain analysis) to support clients using their skills:
P12: “I just know the words but I don’t know what it is, we should probably know how to do it to support them…how to go through it with them.”