A total of three superordinate themes were generated from the data: 1) DBT is Life Changing but not a Magic Wand: A Foundation to Build From; 2) “And to have that control is, oh god, it’s like a miracle”: Responding Versus Reacting to Problems; and 3) “I have really good friends now, which is something that I probably would have never really of had”: Meaningful and Healthier Relationships with Others. A thematic map of the superordinate and subthemes is outlined in Fig. 1.
Theme 1 - DBT is life changing but not a magic wand: a foundation to build from
DBT not a magic wand or miracle cure
Participants reflected on the life changing impact DBT had on their lives. However, for many participants, completion of the DBT programme did not mark the end of their therapeutic journey but rather a starting point for further development. Some participants explained that prior to starting the programme, DBT had been pitched by referral agents as almost like a panacea or a “miracle cure” but that this was not the case. However, although it was not the “be all and end all”, it did provide participants with a life changing experience from which to build on. As one participant described:
“But I mean, you know, DBT, it's not the magic wand but I have to say, I wouldn't be here without the course. I really wouldn't like, do you know.” (P3)
Another participant spoke about how they became aware after completing the programme that “this isn’t the end of it”, while another participant acknowledged that DBT required continuous effort even after completing the programme:
“But it’s, DBT is not a miracle cure, it’s something that you have to work at” (P11)
Although participants highlighted the positive impact of DBT on their lives, there were still issues to be explored and it was clear that further support was still required after completing the programme. As one participant noted:
“Yeah so it's kind of been, my life has definitely changed an awful lot since DBT. I would say, definitely for the better. DBT really did change my life … Like obviously DBT was great and it helped me learn loads but I still had problems after it.” (P4)
A lot done, more to do
Participants described engaging in a wide variety of supports in the years after completing DBT. For example, some participants continued to engage in work with their DBT Individual Therapist for a period of time after completing the programme. This included a number of ‘booster sessions’, which are offered to participants in the months following programme completion, or a formal extension in the 12 months post-completion. A small number of participants also described engaging with the psychologist on their community mental health team, who had also been their DBT Individual Therapist, for psychological intervention around other issues at times during follow-up. Participants noted finding this work beneficial, both in terms of the therapeutic relationship and connection they had with their therapist, and consolidating the skills learned on the programme:
“Think I definitely needed the extension. Like I think it hammered home the last bit of the skills and the bit of, the building blocks of whatever was going on in my head.” (P1)
Similarly, another participant noted:
“I have been so privileged and I honestly believe that having (DBT Therapist) as a follow-up to DBT, I have been very fortunate. Because it is very easy to forget about certain aspects or forget to use your skills” (P8)
Following completion of DBT, many respondents continued to engage with mental health supports and services including trauma services, peer groups, and further individual therapy. Some participants also took part in a post-DBT coaching programme called GLOW – Goals for Life: Opting for Wellness [32]. With regards engagement with their mental health service, some participants noted that it was difficult to find further therapeutic support within the service once they finished DBT due to them no longer being in crisis. In some cases, their only engagement with their service was brief outpatient medical review appointments every few months. Some participants noted their frustration with this, for example, one participant described:
“Like you know, I feel like from the psychiatrist's point of view, I've done DBT now so that's as far as they can, that's all they can offer me” (P2)
With regards to peer groups, although some participants did have the opportunity to engage in such groups in the years following the programme, the difficulties associated with sustaining such groups were also highlighted:
“I did some support groups in the years after but you know, difficult, you know, if people are going to attend or not, that kind of stuff” (P6)
Building with DBT
Where participants did go on to receive further therapeutic supports, it was clear that they felt DBT had given them a strong foundation which helped facilitate this further development. As one participant noted,
“I would say that as a certainty, I would say that DBT was a beginning point. So a start point.” (P6)
For example, several participants spoke about how they were able to use the skills when completing future trauma work that could not be done in DBT (DBT Prolonged Exposure [33], a protocol developed specifically for treating trauma, was not available in Ireland pre-2018). Some participants went on to engage in other therapeutic work such as schema therapy and highlighted how the skills learned in the DBT programme benefitted them while engaging in the work:
“Because you had the skills, DBT is so good for, I suppose what it is built for is, just bringing you back to a kind of baseline from which you can then work. And I think having had that foundation, being able to delve into schema was much easier. And much more beneficial because of the stabilising effect of DBT” (P12)
In addition to further development of self, participants also spoke of how the skills learned in DBT enabled them to develop professionally in terms of furthering their education or careers. A number of participants went on to pursue academic courses in the years following DBT and spoke about how the skills have helped them:
“So, I think they’ve, the skills I’ve learned have helped. If I didn’t have the skills, I don’t think I would’ve been able to go into the course” (P1)
Similarly, participants spoke about how this helped facilitate their return to work:
“So yes there were positives, it gave me a confidence, I went off and did that course, I did another course, you know, a course about getting back to work and stuff like that” (P3)
DBT refresher would be helpful
Finally, almost all participants expressed the wish to see some form of a brief DBT refresher or follow-up take place. Although there was a DBT Skills Review Group available in some services within the region in which this study took place, some participants indicated that this was not well attended. Although almost all participants indicated that they would like some form of a refresher, suggestions on what this might consist of and how it could be delivered varied. Participants acknowledged the possible logistical difficulties of a follow-up refresher, with one participant suggesting it could even take place online. Other participants proposed that a follow-up check-in become a mandatory part of the programme. Some suggested how between one to four group check-ins would be helpful to see how people are getting on and share follow-up experiences:
“Because you have invested, and the tutor has invested so much time and energy, and you have as well, and it would be nice to catch up with your group and see, you know, have things changed for you. Or someone might come up with, oh, I used this skill or that skill. Those things like that and I think it would give you more, em, confidence I think in yourself as well if you are using it.” (P8)
Other participants noted that a refresher would be helpful to “brush up” on aspects of the skills that they may have forgotten and to ensure they are still using skills correctly:
“And those are the pieces that I think, would be very nice to get a refresher course on. You know, just to kind of, I suppose it's like everything, if you learn a new skill and if you're only using half of it, well you are going to forget the other half” (P5)
While most participants expressed their wish to see some form of a refresher group occur, two participants had a contrary view noting their preference for a refresher with an individual DBT therapist as opposed to with a group.
Theme 2: “And to have that control is, oh god, it’s like a miracle”: responding versus reacting to problems
Control
The theme of participants now having control of their lives was evident across the interviews, with participants highlighting how the programme gave them skills to cope with setbacks and difficult situations. Several participants reflected on the differences between how they would cope with problems in the years prior to completing the programme, where crises would often lead to hospitalisations, and how they would now. For example, one participant noted how hospitalisation was a default way of coping for them for decades prior to DBT:
“Because in the early days I would be admitted there for crisis intervention at the drop of a hat. And nobody ever sort of sat down with me and said, "Oh you should try and cope". If I couldn't cope I would just go running up to that psychiatric hospital. You know, it could be in the middle of the night or sort of 3 in the morning. And they would admit me and would discuss the paperwork later. Normally it involved a sort of increase in medication and long stay until you felt ready to go home.” (P9)
Similarly, another participant spoke about how they were “continually in and out of hospital” prior to DBT and how that has changed since:
“No you were always hospitalised. Whereas now, I am not being hospitalised” (P7)
Participants reflected on their experiences of frequent hospitalisations in the years preceding DBT and it was clear that they now felt a greater sense of control over their lives:
“And I suppose I would kind of feel that my life is, to some extent anyway, within my own capacity to deal with” (P10)
Participants described how they had experienced a number of setbacks in the years after DBT, such as serious medical diagnoses or the death of a loved one and had been able to use their skills to effectively cope with them. For example, one participant described their experience of receiving a life changing medical diagnosis a number of years after completing the programme. They spoke about how in the past, they would have been devastated and seen it as a personal punishment, whereas now they were able to manage it effectively:
“The following year then I found out I had (medical diagnosis) … But the fact I didn't have a big breakdown when I was told … Em, I got on with it, I got on with things, do you know, I didn't need to ring the doctors, I didn't need to ring the nurse to say I was upset or anything, I just told them at our next meeting and I, I took it very well (laugh)” (P11)
Another participant spoke about experiencing a setback and attempting suicide but used their DBT skills to pull them back and seek appropriate support:
“And then just in the back of my head I was like, you know, what am I doing? And then I was like, I am not thinking clearly. And then I tried to use the skills to kind of pull me back and thankfully it did … Do you know what I mean, like before the DBT, my self-harming and the suicidal tendencies and all that, I would have to be hospitalised, do you know what I mean? Whereas now, okay even though it came so close last year, I know that if I didn't have the skills, I actually genuinely mean this from the bottom of my heart, I wouldn't be here today if I didn't have the skills from the DBT programme, do you know.” (P3)
Some participants also spoke about how the skills have helped them “bounce back” quicker from setbacks in the years after DBT. For example, one participant noted:
“I took a bad turn there about twelve months ago but even at that, when I was down at my lowest, I was still using the skills from DBT. And I found that, well what I found with the DBT, you might have a bad day before, and the bad day meant I'm not fucking even getting out of bed like, you know. Whereas with the DBT and stuff, it might only be a couple of hours” (P5)
While almost all participants spoke about how DBT helped them to manage various setbacks in the years after the programme, a small number of participants spoke about how experiencing setbacks made them feel like they were “a failure at DBT” or that “all the hard work was gone down the drain”. However, these participants spoke about how they were able to remind themselves of their progress, challenge their negative thinking, and re-engage with the skills.
In addition to being able to manage major setbacks in their lives, participants also spoke about how they are better able to manage difficult emotions and situations in the years after completing the programme:
“I feel, em, an ability to self-soothe and mind myself, which I think is all I ever really needed. And everything else can happen or not happen … Yeah, it's something I was never able to do. It's something I always, I used to drink, I used to find boys, I used to do anything else” (P12)
Participants also expressed their confidence in managing future difficulties by using the DBT skills:
“I mean I have had no hospitalisations since. For the last two years. And I don't intend to be, because I use my skills to, if I ever feel, I mean I do get my days and there might be days where I feel, you know, but I am able to stop it. I am able to hold it in its tracks” (P8)
Responding versus reacting
Participants identified how being able to respond rather than react to difficult situations has helped them to cope with problems in their lives now. Many participants spoke about how they now stop and take a step back before responding to these situations rather than reacting impulsively, which has allowed them to manage the situation more effectively and prevent the situation from getting worse. As one participant noted:
“Because I do find that the times I do act on my impulses, usually aren't good. Without thinking. So I suppose, a lot of what I learned from DBT is to not act as much, take a step back and think for a second.” (P4)
Similarly, another participant said:
“I step back first. Before I would have gone into my own little shell or bubble, and just stayed there. And like I might have gone head first into situations not knowing what was going on. But now I will step back first, breath, and then if necessary, go head first into the situation (laughs). But I definitely step back first” (P1)
Participants also spoke about how they were able to respond rather than react to situations by stopping themselves getting to the point where they would usually become dysregulated:
“I suppose there is a lot of things you know how to do, but in the spur of the moment you kind of can’t, sometimes you kind of go from 0 to 60 in milliseconds. But it's trying to catch yourself before you get to 60 and that's what DBT kind of helped with.” (P2)
Using the skills automatically
Almost all participants commented on how they now use the skills as part of their typical coping repertoire. For example, one participant explained:
“You are using the tools without knowing you are doing them, you know, most of the time … if you read all the files again you realise, ‘Oh god I am doing those everyday’” (P11)
Some participants spoke about how they cannot remember most of the names of the skills but have generalised them to the extent that they have become a natural part of their everyday behaviour where they “just do it automatically”, and they no longer need to a make a mindful choice to select them:
“And I find even to this day with the stuff from the DBT and things, it's when you sit down at the end of the day and you recall your day. You can see the parts you have used … That they automatically just become part of you.” (P5)
Theme 3 - “I have really good friends now, which is something that I probably would have never really have had”: meaningful and healthier relationships with others
The final theme generated from the data relates to the connection that participants described with other people in the years following DBT. This theme was evident throughout the interviews across participants.
Healthy relationships – self-respect and openness with others
Prior to DBT, participants reflected on how their relationships with others were impacted as a result of their difficulties, with some participants describing how they had lost touch with many of their friends. Participants spoke about how their relationships have improved as a result of DBT and how they have continued to improve in the years since completing the programme, where they now experience more positive and open relationships with others and have been able to reconnect with old friends:
“Em, friends, I have gone back to. I mean my anxiety was, I couldn't go into town on my own or anything like that. And I would avoid my friends, I would avoid their calls, I would avoid everything. So now, they all know what's wrong with me and, you know, I am still in contact with all of them.” (P8)
Another contributor to participants’ healthy and more meaningful relationships in the years following DBT was their openness about their difficulties with others. Many participants spoke about how their openness about their difficulties with other people has had a marked impact on their lives and has led to a deeper connection with others:
“Talking to people and you would be surprised how many people that I now know, that are opening up to me about their own problems, because I have opened up to them and I have nothing to hide. And if I see them now, I get on so much better with people than I ever did because I am hiding nothing, they are hiding nothing, and em, you don't feel quite so isolated.” (P9)
Some participants also described how they tended to remain in negative peer relationships prior to DBT. However, in the years following the programme, an important aspect that contributed to healthier relationships was their ability to pull-back or eliminate negative relationships in their lives:
“So when I was with DBT, I would have had a lot of crappy friendships. And people would have used me or just kind of, when there was no one else around they would take me or whatever. And I kind of got rid of all of that.” (P4)
Participants also described how they now engage in more self-compassion and put their own mental well-being first when considering certain relationships. For example, one participant spoke about how they are in the process of pulling back from a friend of many years who has a tendency to be direct and hurtful towards others. Even though the participant knew it would be difficult, and that they would feel bad about it, they realised the effects of this relationship on their own mental health:
“I'm actually, something I wouldn't have done before DBT, I am thinking of myself and what's best for me and my whole family … The whole time gently pulling back because I think it will be healthier for me.” (P11)
Improved awareness and compassion towards others
Related to this improved connection was participants’ improved understanding and compassion towards others, where they described being more aware of other peoples’ difficulties and how they respond to them. For example, one participant explained:
“Yeah, I just I, some people think I make excuses for people now, you know, when someone else is cross or angry and I’m just like, ‘Leave them alone, you just don’t know what’s going on in their head’” (P11)
Another participant described the experience of being in an argument with others and how they respond differently now than how they would have before:
“And if you're listening to it, like you don't have to be a rocket scientist, but if you listen to it and you know people, you can put the truth together to what they are actually angry about. And then it doesn't bother you. What ends up happening then is, you end up in a scenario where you want to help them.” (P5)
Sharing skills with others
Through the improved understanding and compassion towards other people, participants also described how they have been able to help others in the years after DBT. Participants spoke about teaching the skills to others, either individually or when engaging in a peer group:
“But even like, say with friends, I am able to calm them down as well. Calm them down by giving them, saying to them do such and such a thing for a few seconds, do such and such a breathing exercise do you know what I mean? It helps. They would say, ‘Where did you learn that?’” (P1)
Participants also spoke about how being able to help others has also had benefits for them. By teaching the skills to others, participants have been reminded of skills they may have forgotten in the years since DBT. Being able to help others using the skills also provides a rewarding experience for participants:
“I was, like the one thing the DBT has allowed me to do is, in the last two years, I have been able to help three or four people that have suffered panic attacks, anxiety, and the whole lot … You know, and I suppose for me, that was the reward for me.” (P5)
Good support networks
Finally, participants noted that they have strong support networks in their lives now which includes both family and friends. It was clear that these networks have been invaluable sources of support for participants in the years since finishing DBT. For example, one participant described:
“Even if it’s something really, really trivial I will discuss it because, you know, it’s that old saying a problem shared. So I talk more freely and even if it’s not my wife, I will talk to a friend. You know, most of my close friends know my situation so you know, if something is bothering me, I’ll tell the closest person I’m to at the time and you don’t feel quite so isolated” (P9)
The majority of participants also noted that they have continued to stay in contact with people from their DBT group in the years after the programme, with some going on to become close friends:
“So that group they really changed my life. Those people were inspirational beyond inspirational for me … Like I still talk to some of them.” (P4)