What Do Individuals With Borderline Personality Disorder Want From Treatment? A Study of Self-generated Treatment and Recovery Goals

Outcome measurement has progressed in the field of personality disorders. While the majority of trials have evaluated outcomes on the basis of symptom and diagnostic indices, what is considered a meaningful and valued outcome to individuals has seldom been investigated. Self-generated treatment goals were collected from 102 individuals seeking treatment for borderline personality disorder and independently coded by 2 raters. Responses were content-analyzed to determine the categories of goals people want for treatment. A total of 464 individual goal units across 4 main goal types emerged in the content analysis: reducing symptoms, improved well-being, better interpersonal relationships, and having a greater sense of self. Although the reduction of symptoms was the most commonly reported goal, 88.2% reported wanting better psychosocial functioning, including improvements in relationships, vocation, and self-understanding. The existence of the wide range of goals suggests that there is a need for clinicians to establish a collaborative formulation of treatment goals with individuals to ensure that treatment is personalized and meaningful.

symptomatic difficulties known to be experienced by individuals with personality disorder, this finding 23 also provides an indication of the domains that require greater investigation. 24 One approach to personalizing treatment and focusing on the goals generated by service users has 25 been through understanding the target complaints of individuals at the start of therapy. Measures such as 26 Battle's Target Complaints Measure 11 provide an opportunity for individuals to spontaneously formulate 27 and identify their own goals to guide the direction of therapy. The use of personalized treatment goals has 28 been identified as producing larger effect sizes than symptom checklists when evaluating the 29 effectiveness of psychotherapy in clinical trials. 12 The identification of specific categories of goals that 30 individuals value may be important in understanding treatment needs and developing new ways of 31 personalizing treatment. The goal of this study was to examine the personally meaningful treatment goals 32 of individuals seeking treatment for BPD. 33

Study Design and Participants 2
This qualitative study utilized data collected from individuals who were seeking treatment for BPD at a 3 community-based psychotherapy program. Individuals were assessed for suitability for the program and 4 were only admitted if they were over 18 years of age and had a primary diagnosis of DSM-IV BPD, 5 diagnosed using the Structured Clinical Interview for DSM (SCID-I and SCID-II) 13,14 by 2 trained 6 doctoral level clinical psychologists. Individuals were excluded from the program if there was indication 7 of substance abuse, or they met criteria for a primary diagnosis of schizophrenia, schizoaffective disorder, 8 bipolar disorder, major depressive disorder with psychotic features, or a history of neurological disorder. 9 All participants were fluent in English and gave explicit informed written consent (including consent for 10 the audio recording of clinical assessments) following approval from the University of Wollongong 11 Social Sciences Human Ethics Committee. 12

Procedure 13
Participants were entering a year-long program of treatment. Individual goals for treatment were self-14 generated by participants at the first assessment session, guided by using the Target Complaints 15 Measure. 11 Goals could be both specific and more general and long-term in focus and were not delimited 16 by clinicians in any way. The Target Complaints Measure is a semi-structured clinician guided interview, 17 which was used as part of the intake assessment session to ascertain each participant's treatment goals or 18 chief complaints. 11 Participants were told "I want you to tell me in your own words the most important 19 problems that you have that you want help with to change by coming here. These are the kind of goals 20 you might have for your treatment" as specified by the Target Complaints Measure. 11 Participants were 21 prompted to provide up to 3 goals and to self-rate how severe these were as an issue or problem for them 22 on a scale of 0 (not a problem/least severe issue for me) to 10 (the worst/most severe issue for me). 23 24

Data Analysis 25
An inductive conventional content analytic approach to understanding the goals of individuals and the 26 development of goal categories was used. This followed a 3-step approach as described by Hsieh and 27 Shannon. 15 28 29 Participants' descriptions of goals were audio-recorded and transcribed verbatim. Researchers immersed 30 themselves in the data by reading and reflecting on participant responses to gain an overall understanding.
First, participant responses were tagged with codes, referred to as goal units, to accurately describe the 1 data. Due to the recognition that multiple goals could be present within an individual goal, some goals 2 could be represented by more than one code. Thus, although the Target Complaints Measure 11 specified 3 up to 3 goals, some participants provided more than 3 goals within their descriptions. Second, similar or 4 related codes were condensed into goal categories that allowed for both homogeneity within the group 5 and heterogeneity between groups. Lastly, goal categories were grouped into meaningful themes to 6 represent participant responses. The coding process was supported by the use of the NVivo 10 software 7 for qualitative data analysis. The data was initially independently coded and categorized by 2 researchers, 8 this was followed by the discussion and review of codes by a third researcher who is an expert in 9 personality disorders. The trustworthiness of the data was ensured by having consistent discussion about 10 codes and findings emerging from the data with the wider research team to ensure that concepts were not 11 overlooked within the data. Through multiple discussions and reviews, the coding and categorization of 12 codes were refined. Discrepancies among the coding and the subsequent categories between researchers 13 were discussed and resolved through consensus. Illustrative quotes of the goals were provided to support 14 and provide evidence for the interpretations of the researchers. The researchers analyzing the data were 15 independent from the clinicians providing psychological care to the participants. 16

Characteristics of Participants 19
A total of 102 consecutively recruited participants seeking treatment who met criteria for a primary DSM-20 IV-TR diagnosis of BPD were invited to participate. All participants gave written informed consent to the 21 study. Table 1 outlines the demographic characteristics of the participants. 22

Treatment Goals Identified by Participants 23
Overall, participants identified a total of 268 goals, with an average of 2.8 goals per participant. All 24 participants (100%) were able to report 1 goal, 100 participants (98%) reported 2 goals, and 86 25 participants (84%) were able to report 3 goals. The majority of goals identified had multiple components. 26 The goals reported were then analysed into constituent units, for a total of 464 individual goal units (See 27   Table 2) or 4.5 goal units per participant. Reported goals could include the same individual goal unit on 28 multiple occasions in their descriptions, however, this was only counted once. Therefore, goal units 29 identified in Table 2 are indicative of the number of participants endorsing a specific goal unit. 30 Findings from the content analysis reveal 4 key themes associated with treatment and personally 1 meaningful goals for recovery. The reduction of symptoms was the most commonly reported goal by 2 participants (n=88, 86.3%), followed by the desire to improve wellbeing (n=64, 62.7%), having better 3 interpersonal relationships (n=54, 52.9%), and having a greater sense of self (n=40, 39.2%). Although 4 reducing symptoms was the most commonly reported theme, 90 participants (88.2%) also reported at least 5 one goal pertaining to a psychosocial goal category. Goals reported by participants were identified as not 6 being mutually exclusive, so that achievement of goals in one area could contribute to improvements in 7 other areas. 8

Goal theme 1: Reducing symptoms 9
The goal of reducing symptoms was the most commonly cited theme in the study, where reducing 10 suicidality and impulsivity and depressive and anxiety symptoms were some of the most highly reported 11 goal categories. Participants discussed the impact of symptoms on daily functioning and self-perceptions. 12

"I'd certainly like to manage my depression better, so that I don't end up back in hospital again. I'd like 13
to be able to explore things that may be affecting me as an adult so that I can understand why I feel the 14 way about things that don't make sense. I just want to get on with my life, be a whole person rather than 15 be in fragments." (Individual 5091) 16 The experiences of symptoms were sometimes interrelated so that the experience of depressive or 17 anxiety symptoms corresponded with a desire to engage in self-harming behaviors or increased was recognized that participation in a structured vocation may not be suitable for all individuals, so that 9 assisting individuals to take part in personally meaningful activities would be a valued target of treatment. 10 "I really want to do dancing. Dancing used to really help me… I think it is teaching myself to go there 11 and not matter whether I will be put down for it." (Individual 5151) 12 13

Goal theme 3: Better interpersonal relationships 14
Better interpersonal relationships were another key theme associated with developing a sense of 15 connectedness with others, improving current relationships, and developing interpersonal skills. The theme of developing a greater sense of self was associated with improving attitudes toward self and 32 increasing personal awareness. The goal of increasing personal awareness was expressed as achievable 33 through developing greater self-understanding and being able to conceive of what might be a meaningful 34 life direction or goal, and have motivation to move in that direction. "Be more of a whole 1 person…learning some tools that will help me be motivated to get out and do things and enjoy life instead 2 of dragging myself through it, all the time." (Individual 5091) 3 Some participants broadly discussed goals to "get to know who I am," while others discussed a 4 desire to shift away from a "victim persona" developed from experiences of trauma and to no longer be 5 viewed only through the lens of their BPD diagnosis. "I have childhood issues and I'm hanging onto 6 them. I'm dealing with them really well… but still need help to deal with some of those issues, how to not 7 be a victim" (Individual 3054). Goals pertaining to the development of self-esteem and self-worth were 8 discussed, as were the negative consequences of poor self-esteem and self-worth "If I consciously self-9 harm, it is because of my self-esteem. I just hate myself" (Individual 5090). 10 Some participants recognized that improving self-esteem may be an ongoing journey, and that a 11 person's attitude toward him-or herself is inextricably linked with increasing personal awareness. The 12 ability to separate oneself from others in order to develop a sense of who one is and a sense of 13 genuineness was also identified by some participants. "Getting to know me… I want to be more 14 Camberwell Assessment of Need. 9 Domains of psychopathology in BPD were also reflected in the 27 identified goals, 20 including difficulties in relational functioning, emotion dysregulation, and 28 understanding self and others. However, the identified goal themes and categories expand on the work to 29 date in the literature by providing greater insights into the specific aspects that may be important to 30 individuals that could be potentially targeted during treatment. 31

consistent. I've gotten to the point where I push people away because I can't be me and I am sort of
The identification of symptom reduction as the most cited theme was not surprising given the 1 severe nature of BPD and that individuals were at the start of treatment. Interestingly, studies of the lived 2 experience of personality disorders have conceptualized recovery as the reconciliation of self and other 3 representations through the development of a sense of self that could be achieved through the engagement 4 of interpersonal relationships and the community. 6,21 Although these themes are reflected in the findings 5 from our study, fewer than half the participants reported goals associated with developing a greater sense 6 of self. This may be associated with the sample being at the start of treatment, in contrast to other studies 7 where participants were engaging in a specialist intervention and therefore were more aware of their 8 underlying difficulties. This finding may also reflect the shifting nature of treatment goals and suggest 9 that routine monitoring of goals may be required. 10 The treatment goals that were reported were not mutually exclusive, so that participants believed 11 that improvements in one goal would contribute to the achievement of other goals. This suggests that 12 there may be multiple processes and challenges involved in achieving desired recovery outcomes in a 13 personally meaningful manner. Although the identification of these processes and challenges were 14 beyond the scope of this study, understanding these will have implications for clinical practice and can 15 provide guidance for the development of recovery-oriented mental health services for BPD. 16 17

Implications for Clinical Practice 18
The narrow treatment targets of interventions for BPD have been reported as a limitation to care by 19 individuals with BPD. 6 Although this study identified similarities between individual treatment goals and 20 the typical targets of interventions, some identified goal categories and units did reflect that a wider focus 21 may not be captured in psychotherapeutic interventions and treatment manuals for BPD. Given the 22 findings reported here, there is room for treatment manuals to focus more broadly on goals identified by 23 individuals. Having broader treatment targets may also have the effect of generating greater motivation 24 for behavioral change and improving treatment engagement. In addition, the therapeutic alliance between 25 clinicians and individuals could also profit from greater awareness of individual goals. 26 The development of new methods of integrating existing psychotherapeutic evidence-based 27 approaches with psychosocial interventions may be important in assisting individuals with BPD achieve 28 their desired outcomes. 22 The findings from this study provide a basis for understanding areas of 29 importance to individuals with BPD. Evidence-based social interventions and psychosocial rehabilitation 30 interventions such as illness management and recovery, 23 assertive community treatment, 24 or individual 31 placement and support 25 may help support individuals with BPD in achieving goals that extend beyond 32 the scope of the current manualized interventions with an evidence base. In addition, developing the 33 capacity of individuals with lived experience to become peer support workers may also present a unique 1 opportunity for individuals with similar experiences to learn from each other. 26 2 The development of enhanced therapeutic interventions that target specific goals of interest to 3 individuals with BPD may also be relevant. One recent example of such an intervention pertains to 4 improving the parenting capacity of individuals with BPD who are parents. 27 Continual evaluation of the 5 integration of these interventions with evidence-based interventions should be completed using multiple 6 measures and methodologies. 7 8

Limitations and Future Research 9
Treatment goals reported by participants in our study were framed in a clinically oriented manner, so that 10 goals predominantly focused on the symptoms and problems participants wanted to overcome. Although 11 this can be attributed to the context in which goals were formulated, the identified goals may also be 12